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Home My WebLink About20040649.tiff RESOLUTION RE: APPROVE FOUR MEDICAL AND HOSPITAL GROUP SUBSCRIBER MASTER CONTRACTS FOR HEALTH INSURANCE AND AUTHORIZE CHAIR TO SIGN - PACIFICARE OF COLORADO, INC. WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with four Medical and Hospital Group Subscriber Master Contracts for Health Insurance between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, and PacifiCare of Colorado, Inc., commencing January 1, 2004, and ending December 31, 2004, with further terms and conditions being as stated in said contracts, and WHEREAS, after review, the Board deems it advisable to approve said contracts, copies of which are attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the four Medical and Hospital Group Subscriber Master Contracts for the Health Insurance between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, and PacifiCare of Colorado, Inc., be, and hereby are, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said contracts. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 3rd day of March, A.D., 2004. BOARD OF COUNTY COMMISSIONERS �/ W D COUNT , COLORADO ATTEST: fatehlk �,%%` IEILa • Y��/�� Robert D. Masden, Chair Weld County Clerk to t an,: ,' %'- 4Z°BY: . William H. J� Pro-Tem Deputy Clerk to the Bo: ` ez `•M. J. Geile APP AS TO EXCUSED David E. Long ounty Attorney AI 342 Glenn V�a� Date of signature: 2004-0649 PE0023 b3-lam rJ�l 2004 Client's Cony PACIFICARE OF COLORADO, INC. MEDICAL AND HOSPITAL GROUP SUBSCRIBER AGREEMENT MID/LARGE COVER SHEET (This Cover Sheet is an integral part of this Agreement) GROUP NAME: Weld County Government GROUP CODE: D6600 SIC CODE: 9111 GROUP COVERAGE EFFECTIVE DATE: January 1, 2004 through December 31, 2004 PLAN CODE: PLAN DESCRIPTION: 10764 Medical Plan 19DW4 Pharmacy Plan E1144 Vision Plan HEALTH PLAN PREMIUMS: EE $313.17 EE + Spouse $626.38 EE + Child(ren) $601.28 EE +Family $997.49 PREMIUMS DUE ON OR BEFORE (refer to Section 3.06): The first of the month of coverage to be paid within 15 days ANNUAL OUT OF POCKET MAXIMUM PER INDIVIDUAL: $2,500 ANNUAL OUT OF POCKET MAXIMUM PER FAMILY: $5,000 CONTINUATION OF BENEFITS ELECTIONS: Yes ELIGIBILITY: Group Eligibility(refer to Section 2) This health plan is available only to employer groups who have 51 or more eligible employees. If at the anniversary date of the Agreement the number of eligible employees is less than 51, this Agreement may not be renewed. However, the Subscribing Group may be offered the small employer health benefit plan(s) as defined by Colorado Insurance Law. Dependent Member Eligibility Dependent children are Eligible through age: (minimum up to age 19) end of the month in which they reach age 26 Students are Eligible through age: (minimum up to age 24) end of the month in which they reach age 26 Start and End date of coverage (e.g. waiting period for Employee, full-time requirement, and termination of coverage date): PC01531 2004-0649 Waiting Period: First day of the month following first full pay period Full-Time Requirement: 20 hours per week Termination of Coverage: Termination of coverage varies by date of termination. If term occurs from the 1st through the 14`h of the month, coverage terms end of current month. If term occurs on the 15`h through end of month, coverage terms at the end of the following month. Eligibility: A retiree who retired from employment with Weld County on or after December 16, 1998, after at least 10 years of service; or was an elected official of Weld County, Colorado, for at least one full four-year term; has attained the age of 55 years; and is now drawing benefits from the Weld County Retirement Plan and on the date of his or her retirement or end of office, retiree and/or his dependents was (were) enrolled and in good standing with Weld County's health insurance program. Continuation: A retiree can continue the health insurance plan until the retiree attains the Normal Retirement Age for Social Security(NRA), or becomes eligible for health insurance coverage with another employer, or becomes eligible for Medicaid or Medicare coverage before attaining the NRA. Such insurance shall be the same as that offered to regular, full-time, current employees of Weld County, through the same health insurance provider. New spouse or children are eligible as set forth in the PacifiCare Combined Evidence of Coverage and Disclosure Form. ATTACHMENTS: (The following Attachments are an integral part of this Agreement) A- Schedule of Benefits, PacifiCare Combined Evidence of Coverage and Disclosure Form B - Schedule of Supplemental Benefits (If Purchased) C- Chiropractic Services (If Purchased) E - Eye Refraction Benefits (Standard Medical) H - Hearing Aid (If Purchased) PAN - Personal Assistant Network (If Purchased) R- Outpatient Prescription Drug Benefit (If Purchased) V- Vision Care (If Purchased) PCOI531 2004 PACIFICARE OF COLORADO, INC. MEDICAL AND HOSPITAL GROUP SUBSCRIBER AGREEMENT PCO1531 MEDICAL AND HOSPITAL GROUP SUBSCRIBER AGREEMENT This Medical and Hospital Group Subscriber Agreement (the "Agreement") is entered into between PACIFICARE OF COLORADO, INC., a Colorado corporation, hereinafter called "PacifiCare," and the employer, association or other entity specified as "GROUP" on the Cover Sheet, hereinafter called "Group." RECITAL OF FACTS PacifiCare is a health care service plan which arranges for the provision of medical, hospital and preventive medical services to persons enrolled as Members through contracts with associations of licensed physicians, hospitals and other health care providers, Group is an employer, union, trust, organization, or association which desires to provide such health care for its eligible Subscribers and family Dependents. PacifiCare desires to contract with Group to arrange for the provision of such health care services to Subscribers and family Dependents of Group, and Group desires to contract with PacifiCare to arrange for the provision of such services to its Subscribers and family Dependents. AGREEMENT NOW THEREFORE, in consideration of the application of Group for the benefits provided under this Agreement, and in consideration of the periodic payment of Health Plan Premiums on behalf of Members in advance as they become due, PacifiCare agrees to arrange or provide medical, surgical, hospital, and related health care benefits subject to all terms and conditions of this Medical and Hospital Group Subscriber Agreement, including the Cover Sheet and Attachments. 1. DEFINITIONS 1.01 Agreement is this Medical and Hospital Group Subscriber Agreement, including, but not limited to, the Combined Evidence of Coverage and Disclosure Form, the Cover Sheet, Attachments and any amendments thereto. 1.02 COBRA Continuation Member is any individual who is enrolled and eligible to receive COBRA benefits under Agreement. 1.03 Coinsurance are fees payable to a health care provider by the Member enrolled in a Point-of- Service (PLUS)plan, at the time of provision of services which are in addition to the Health Plan Premiums paid by the Group. Such fees are a pre-determined percentage of eligible charges that the Member pays after a deductible has been met, as specified under in the Summary of Benefits, depending on the type of service. 1.04 Combined Evidence of Coverage and Disclosure Form is the document issued to prospective and enrolled Subscribers disclosing and setting forth the benefits and terms and conditions of coverage to which Members of the Health Plan are entitled as set forth in the summary of benefits. 1.05 Copayments are fees payable to a health care provider by the Member at the time of provision of services which are in addition to the Health Plan Premiums paid by the Group. Such fees may be a specific dollar amount or a percentage of total fees as specified herein, depending on the type of services provided. PCO1531 1 1.06 Cover Sheet is the Medical and Hospital Group Subscriber Agreement Cover Sheet which is attached to and an integral part of this Agreement. 1.07 Dependent is any spouse, including those as defined as common-law spouse under the state, or unmarried child (including a step-child, court ordered Dependent, or adopted child or child placed for adoption) of a Subscriber who is enrolled hereunder, who meets all the eligibility requirements and definitions as set forth in the PacifiCare Combined Evidence of Coverage and Disclosure Form attached to this Agreement and for whom applicable Health Plan Premiums are received by PacifiCare. 1.08 Eligible Dependent is any spouse or unmarried child(including a step-child, court ordered coverage, or adopted child or child placed for adoption) of an Eligible Employee who works or resides within the HMO Service Area and who is eligible for Enrollment as a Dependent in the Health Plan as defined in the PacifiCare Combined Evidence of Coverage and Disclosure Form. 1.09 Eligible Employee is a Group employee who works a fixed number of hours per week as established by the Group, meets any applicable waiting period required by the Group, and meets the following additional criteria: (a) Is defined as an employee under state and federal law; (b) Consultants, temporary labor, suppliers or contractors are not Eligible Employees. 1.10 Enrollment is the execution of a PacifiCare Enrollment Application form, or a non-standard Enrollment Application form approved by PacifiCare, by the Subscriber on behalf of the Subscriber and his or her Dependents, and acceptance thereof by PacifiCare, conditioned upon the execution of this Agreement by PacifiCare, and either the execution of this Agreement by Group or the timely payment of applicable Health Plan Premiums by Group. In its discretion and subject to specific protocols, PacifiCare may accept Enrollment through an electronic submission from Group. 1.11 Group is the single employer, labor union, trust, organization, or association identified on the Cover Sheet. 1.12 Group Contribution is the amount of the Health Plan Premium applicable to each Subscriber which is paid solely by the Group or employer and which is not paid by the Subscriber either through payroll deduction or otherwise. 1.13 Group Participation is the number of individuals in the Group who are enrolled as Subscribers expressed as a percentage of the number of individuals in the Group who are eligible to enroll as Subscribers. 1.14 Health Plan is the Health Plan described in this PacifiCare Medical and Hospital Group Subscriber Agreement, Cover Sheet and Attachments, subject to modification pursuant to the terms of this Agreement. 1.15 Health Plan Premiums are pre-determined amounts established by PacifiCare to be made on a pre-paid basis to PacifiCare by Group on behalf of Members in consideration of the benefits provided under this Health Plan; such amounts are set forth in the Cover Sheet of this Agreement. PCOI531 2 1.16 Member is any Subscriber or Dependent. 1.17 Open Enrollment Period is the period of not less than 30 days agreed upon by PacifiCare and Group, during which all eligible and prospective Group Subscribers and their Eligible Dependents may enroll in this Health Plan. 1.18 PacifiCare Enrollment Packet is the packet of information supplied by PacifiCare to prospective Members which discloses plan policy and procedure and provides information about Plan benefits. The PacifiCare Enrollment Packet contains the PacifiCare Enrollment Application Form or a non-standard Enrollment Application Form approved by PacifiCare. 1.19 Standard Leave of Absence is the period of time when you are voluntarily absent from work, including but not limited to, sabbaticals and The Family and Medical Leave Act of 1993 (FMLA). 1.20 Subscriber is the individual enrolled in the Health Plan for whom the appropriate Health Plan Premium has been received timely by PacifiCare, and whose employment or other status, except for family dependency, is the basis for enrollment eligibility. 1.21 USERRA Continuation Member is any individual who is enrolled and eligible to receive USERRA benefits as outlined under this Agreement. 2. ELIGIBILITY AND ENROLLMENT 2.01 Enrollment Procedure 2.01.01 Application Form. A properly completed, signed application for Enrollment on a form provided by PacifiCare, or on a non-standard form approved by PacifiCare, must be submitted to PacifiCare by Group for each eligible and/or prospective Subscriber, on behalf of the eligible and/or prospective Subscriber and any Eligible Dependents. PacifiCare may, in its discretion and subject to specific protocols, accept Enrollment through an electronic submission from Group. 2.01.02 Time of Enrollment. All applications for Enrollment shall be submitted by prospective Subscribers to the Group during Open Enrollment Periods, except that prospective Subscribers and their Eligible Dependents who were not eligible during the previous Open Enrollment Period may apply for Enrollment within 31 days after becoming eligible. All applications for Enrollment which are not received by PacifiCare within the 31 days from the first day the prospective Subscriber or Dependent becomes eligible shall be subject to rejection by PacifiCare. Prospective Subscribers and their Eligible Dependents may reapply at the next Open Enrollment Period in the event an application was not received by PacifiCare within such 31 day period. Group shall provide notice to Members of the applicable Open Enrollment Periods. PCOI531 3 2.01.03 Notice and Certification. Group shall provide a written notice and certification, prepared by PacifiCare, as part of the PacifiCare Enrollment Packet to Eligible Employees at the commencement of the initial Open Enrollment Period. The written notice and certification section of the PacifiCare application for Enrollment shall provide notice of the availability of coverage under the Health Plan and indicate that an Eligible Employee's failure to elect coverage, on his or her behalf or on behalf of his or her Eligible Dependents during the initial Open Enrollment Period, permits PacifiCare to exclude coverage for a period of 12 months from the date the Eligible Employee subsequently elects coverage under the Health Plan. Group shall require any Eligible Employee declining coverage under the Health Plan on behalf of himself or herself or any Eligible Dependent, to certify on the written notice and certification prepared by PacifiCare, the reason for declining Enrollment in the Health Plan and that he or she has reviewed the notice and certification and understands the consequences of declining coverage under the Health Plan. Group agrees to submit all completed notices and certifications to PacifiCare for: a. Each Eligible Employee and/or his or her Eligible Dependents who declined coverage at renewal of this Agreement; and, b. Each Eligible Employee and/or his or her Eligible Dependents who became eligible during the term of this Agreement specified on the Cover Sheet of this Agreement and who have declined coverage. 2.01.04 Late Enrollment: Please refer to the section of this Agreement entitled Combined Evidence of Coverage and Disclosure Form for a complete description of Late Enrollment procedures. 2.02 Commencement of Coverage. The commencement date of coverage under this Health Plan shall be effective in accordance with the terms of the Cover Sheet and this Agreement. PacifiCare's acceptance of each Member's Enrollment is contingent upon receipt of the applicable Health Plan Premium payment. 2.03 PacifiCare's Liability in the Event of Conversion From a Prior Carrier. In the event PacifiCare replaces a prior carrier responsible for the payment of benefits or provision of services under a Group contract within a period of 60 days from the date of discontinuation of the prior contract or policy, PacifiCare will immediately cover all employees and Dependents who were validly covered under the previous contract or policy at the date of discontinuation, and who are eligible for Enrollment under this Agreement, without regard to health status. 2.04 Standard Leave of Absence. A Member who elects to take a Standard Leave of Absence shall be eligible for coverage for six months from the first day the Standard Leave of Absence begins. The Family Medical Leave Act of 1993 (FMLA) allows a worker up to 12 weeks of leave under certain circumstances. All time taken by a Member under FMLA shall be applied to the six month limit under this section, Standard Leave of Absence. PC01531 4 3. GROUP OBLIGATIONS, HEALTH PLAN PREMIUMS AND COPAYMENTS 3.01 Non-Discrimination. Group shall offer PacifiCare an opportunity to market this Health Plan to its employees and shall offer its employees an opportunity to enroll in this Health Plan under no less favorable terms or conditions than Group offers enrollment in other health care service plans or employee health benefit plans. 3.02 Notices to PacifiCare. Group shall forward to PacifiCare all completed or amended Enrollment forms for each Member within 31 days of the Member's initial eligibility. Group acknowledges that any Enrollment applications not forwarded to PacifiCare within such 31 day period may be rejected by PacifiCare. Group further agrees to transmit to PacifiCare any Enrollment application amendments pursuant to the Administrative Manual described in Section 8.07 below. Group shall forward all notices of termination to PacifiCare within 31 days after Member loses eligibility or elects to terminate membership under this Agreement. Group agrees to pay any applicable Member Health Plan Premiums through the last day of the month in which notice of termination is received by PacifiCare. Any errors in termination by the Group will not afford a refund to the Group in Member premium, as premium payment will be required up to last day of the month in which notice of termination is received by PacifiCare, whether in practice or in error. 3.03 Notices to Member. If Group or PacifiCare terminates this Agreement pursuant to Section 7 below, Group shall promptly notify all Members enrolled through Group of the termination of their coverage in this Health Plan. Group shall provide such notice by delivering to each Subscriber a true, legible copy of the notice of termination sent from PacifiCare to Group at the Subscriber's then current address. Group shall promptly provide PacifiCare with a copy of the notice of termination delivered to each Subscriber, along with evidence of the date the notice was provided. If, pursuant to this Agreement, PacifiCare increases Health Plan Premiums payable by the Subscriber, or if PacifiCare increases Copayments or reduces Covered Services provided under this Agreement, Group shall promptly notify all Members enrolled through Group of the increase or reduction. In addition, Group shall promptly notify Members enrolled through Group of any other changes in the terms or conditions of this Agreement affecting the Members' benefits or obligations under the Health Plan. Group shall provide such notice by delivering to each Subscriber a true, legible copy of the notice of the Health Plan Premium or Copayment increase or reduction in Covered Services sent from PacifiCare to Group at the Subscriber's then current address. Group shall promptly provide PacifiCare with a copy of the notice of Health Plan Premium or Copayment increase or reduction in Covered Services delivered to each Subscriber, along with evidence of the date the notice was provided. PacifiCare shall have no responsibility to Members in the event Group fails to provide the notices required by this section. 3.04 Indemnification. Group agrees to indemnify, defend and hold PacifiCare harmless and accept all legal and financial responsibility for any liability arising out of Group's failure to perform its obligations as set forth in this Section 3. 3.05 Rates (Prepayment Fees). The Health Plan Premium rates are set forth in the Health Plan Premiums section of the Cover Sheet and supplemental Health Plan Premium notices. PCO1531 5 3.06 Due Date. Health Plan Premiums are due in full on a monthly basis by check or electronic transfer and must be paid directly by Group to PacifiCare on or before the last business day of the month prior to the month for which the premium applies. Failure to provide payment on or before the due date may result in termination of Group, as set forth under this Agreement. 3.07 Modification of Rates and Benefits. 3.07.01 Modification of Health Plan Premium Rates. The Health Plan Premium rates set forth on the Cover Sheet and the PacifiCare Enrollment Packet may be modified by PacifiCare in its sole discretion upon 31 days written notice mailed postage prepaid to Group. Any such modification shall take effect commencing the first full month following the expiration of the 31 day notice period. Modifications may be made for any reason including but not limited to: • Changes to the terms of the Health Plan, including any changes required by federal or state law that affect PacifiCare's liability under the Health Plan or • Failure of the Group maintain any applicable participation or enrollment requirements; or • PacifiCare may adjust premiums, in lieu of terminating coverage, for misstatements of the age, family status, employee status or geographic location of a Member and/or Dependent. If a state or any other taxing authority imposes upon PacifiCare a tax, assessment or license fee which is levied upon or measured by the monthly amount of Health Plan Premiums, membership, claims, or by PacifiCare's gross receipts or any portions of either, then upon 30 days written notice to Group, Group shall remit to PacifiCare, with the appropriate payment, a pro rata amount sufficient to cover all such taxes, assessments and license fees, rounded to the nearest cent. 3.07.02 Modification of Benefits or Terms. The Covered Services set forth in the Combined Evidence of Coverage and Disclosure Form, the Schedule of Benefits, and the Schedule of Supplemental Benefits in the PacifiCare Enrollment Packet, as well as other terms of this Agreement, may be modified by PacifiCare in its sole discretion upon 31 days written notice mailed postage prepaid to Group. Any such modification shall take effect commencing the first full month following the expiration of the 31 day notice period. 3.08 Effect of Payment. Except as otherwise provided in this Agreement, only Members for whom Health Plan Premiums are received by PacifiCare are entitled to health care benefits as described in this Agreement, and then only for the period for which such payment is received. Group agrees to pay entire portion of premium on behalf of the Subscriber to PacifiCare for the first month of coverage for newborn or adopted children who become eligible as provided in the Combined Evidence of Coverage and Disclosure Form of this Agreement. PCO1531 6 3.09 Continuation of Benefits and Conversion Coverage. 3.09.01 Notice Regarding Continuation Coverage. Upon the occurrence of a qualifying event, as defined by the Consolidated Omnibus Budget Reconciliation Act of 1985 (P.L. 99- 272), as amended by the 1986 Tax Reform Act (P.L. 99-514) and the 1986 Omnibus Budget Reconciliation Act (P.L. 99-509) ("COBRA"), Group shall provide affected Members with written notice of available continuation coverage as required by and in accordance with COBRA and amendments thereto. Group shall be solely responsible for collecting Health Plan Premiums from Members who elect to continue benefits under COBRA and shall transmit such Health Plan Premiums to PacifiCare along with the Group's Health Plan Premiums otherwise due under this Agreement. Group shall maintain accurate records regarding Health Plan Premiums for Members who elect to continue benefits, including qualifying events, terminating events, and other information necessary to administer this continuation of benefits. Group may contract with a third party to perform the obligations set forth in this section. However, Group remains liable to PacifiCare for any failure of the third party to fulfill any such duties. 3.09.02 Notice of Individual Conversion Rights. Within 15 days after a Member's coverage terminates, Group shall notify the Subscriber on behalf of the Subscriber and his or her Dependents or, if no Subscriber is available, any terminated Dependent, of the availability, terms, and individual conversion rights as set forth in the Combined Evidence of Coverage and Disclosure Form. 3.09.03 Conversion From Federal COBRA Plan: If a Member is covered under COBRA, the Group and PacifiCare must notify the Member of the option to enroll in all available conversion plans no later than 180 days prior to the expiration date of the Members coverage under COBRA. Notification must include, at a minimum, availability, terms, and individual conversion rights. 3.09.04 USERRA (Uniformed Services Employment and Reemployment Rights Act). Continuation coverage under this Health Plan shall be available to Members through Group under the Uniform Services Employment and Reemployment Rights Act of 1994, as amended ("USERRA"). The continuation coverage under this section shall be equal to, and subject to the same limitations as, the benefits provided to other Members regularly enrolled in this Health Plan and shall be made available to eligible Members absent from employment with Group by reason of service in the United States uniformed services ("USERRA Continuation Members"). Such coverage, including, but not limited to, the maximum period of USERRA coverage, will be provided to USERRA Continuation Members pursuant to the requirements set forth in USERRA. For HMO Coverage Only: To obtain coverage, all care must be provided or arranged in the HMO Service Area by the designated Participating Medical Group, except for Emergency and Urgently Needed Services. Group shall provide written notice to each Member eligible for USERRA continuation coverage of the continuation coverage available to such Member under USERRA. PCO1531 7 The Health Plan Premium for USERRA Continuation Members shall be equal to the Health Plan Premium for similarly situated regular Group Members plus any additional surcharge or administrative fee that can be charged to the USERRA Continuation Member as allowed by law. Group shall be solely responsible for collecting Health Plan Premiums from USERRA Continuation Members and shall transmit such Health Plan Premiums to PacifiCare along with the Group's Health Plan Premiums otherwise due under this Agreement. Group shall maintain accurate records regarding USERRA Continuation Member Health Plan Premium, qualifying events, terminating events and other information necessary to administer this continuation benefit. 4. BENEFITS AND CONDITIONS FOR COVERAGE The attached PacifiCare Combined Evidence of Coverage and Disclosure Form included at the end of this Agreement, is an integral part of this Agreement, and it includes a complete description of the Benefits and Conditions of Coverage of this Health Plan. 5. PARTIES AFFECTED BY THIS AGREEMENT; RELATIONSHIPS BETWEEN PARTIES 5.01 Relationship of Parties. Group is not the agent or representative of PacifiCare and shall not be liable for any acts or omissions of PacifiCare, its agents, employees or providers, or any other person or organization with which PacifiCare has made, or hereafter shall make, arrangements for the performance of services under this Health Plan. Member is not the agent or representative of PacifiCare and shall not be liable for any acts or omissions of PacifiCare, its agents or employees. 5.02 Compliance with the Health Insurance Portability and Accountability Act of 1996. PacifiCare agrees to furnish written certification of prior creditable coverage ("Certificates") to all eligible Members, as required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). PacifiCare and Group acknowledge that PacifiCare's agreement to issue Certificates to all eligible Members relieves Group of its obligation under HIPAA to furnish Certificates. Further, Group acknowledges that PacifiCare must rely completely on eligibility information and data(including, but not limited to, Member's name and current address) furnished by Group in issuing Certificates to Members. Group agrees to notify PacifiCare of all terminations within 30 days of the termination, and to provide PacifiCare with eligibility information and data within 30 days of its receipt or change. Group agrees to indemnify, defend and hold PacifiCare harmless and accept all legal, financial and regulatory responsibility for any liability arising out of PacifiCare's furnishing Certificates to eligible Members under HIPAA. 6. TERM OF AGREEMENT; RENEWAL PROVISIONS Term; Automatic Renewal. The term of this Agreement shall be one year, commencing on the Group Coverage Effective Date set out in the Cover Sheet, unless otherwise indicated on the Cover Sheet or unless this Agreement is terminated as provided herein. This Agreement shall automatically renew for a one year term on each anniversary of the date of commencement of this Agreement or as indicated on the Cover Sheet, unless terminated as provided herein. Renewal of this Agreement shall be subject to modification of rates and benefits pursuant to Section 3.07 and subject to Group underwriting and eligibility criteria as set forth by PacifiCare. PCO1531 8 7. TERMINATION 7.01 Termination by Group. Group may terminate this Agreement by giving a minimum of 30 days written notice of termination to PacifiCare. Group termination must always be effective on the first day of the month. Group shall continue to be liable for Health Plan Premiums for all Members enrolled in this Health Plan through Group until the date of termination and as required under section 3.02 of this Agreement. 7.02 Termination by PacifiCare. 7.02.01 For Nonpayment of Health Plan Premiums. PacifiCare may terminate this Agreement on the last day of the month for which premiums were paid if the Group or its designee fails to remit Health Plan Premiums in full by the required date. Nonpayment of Health Plan Premiums includes payments returned due to non- sufficient funds (NSF) and post-dated checks. In the event premiums are not received, PacifiCare will send the Group a notice of premiums due. Such notice shall specify that payment of all unpaid Health Plan Premiums must be received by PacifiCare within 15 days of the date of issuance of the notice, and that if payment of all unpaid Health Plan Premiums is received within the 15 days of the date specified in the notice, coverage will continue uninterrupted. If premiums are not received within that time period, all coverage will be terminated. PacifiCare will give written notice of final termination of the Agreement via First Class Mail to the Group. In the event PacifiCare has provided notice of non-payment of premium to Group on a prior occasion, and Group again fails to remit payment by the required due date, PacifiCare, at its discretion, reserves the right to immediately terminate Group for non-payment of premium. Termination will be retroactive to the last day of the month for which PacifiCare received full payment of premiums. Notwithstanding the forgoing, Members who receive services beyond their termination date or that of the Group, including but not limited to, cases of retro-termination, confinement or other instances as required under the law, such coverage will continue only to the extent as required under the law, and premiums must be remitted in full by the Group for any month in which services were provided for said Members. 7.02.02 Partial Payment of Premium. If Group submits partial month's premium for the final coverage month, PacifiCare shall have the sole discretion to terminate Group coverage at the end of the previous month as outlined above under section 7.02.01,and refund the partial payment or terminate Group coverage at the end of the final month and pursue collection of the outstanding premium. Negotiation of said partial payment shall not be construed as full payment, nor shall it provide any of the benefits under this Agreement. 7.02.03 Nonliability After Termination. Except as required by law, upon termination of this Agreement for any reason, PacifiCare shall have no further liability to provide benefits to any Member, including, without limitation, those Members hospitalized or undergoing treatment for an ongoing condition. Member's rights to receive benefits hereunder shall cease upon the effective date of termination. PCO1531 9 If a Member is receiving continuing care pursuant to this Agreement at the time Group is terminated, Member shall be responsible for the monthly payment of Health Plan Premiums at the Group rate. Any person receiving benefits or services for which he or she is not entitled will be responsible for all billed charges. PacifiCare and its contracted providers will not be responsible for any portion of the charges incurred during any period for which the Group has not paid premiums. PacifiCare has the right to pend any claims and non- urgent medical authorizations during any period for which premiums have not been received. Pended claims will be subsequently denied if premiums are not paid within the time frames set forth above, except as required by law, and in instances in which premium payment is due as described above in section 7.02.01. Any extension of the time frame in which payment must be made will not be deemed a waiver of PacifiCare's rights under this provision. If PacifiCare agrees to provide coverage during any time period in which the Group is provided to remit payments, the Group will be responsible for premiums during that period even if this Agreement subsequently terminates. Any such agreement to provide coverage must be in writing and signed by both PacifiCare and the Group or its designee. 7.02.04 Reinstatement Following Non-Payment of Premium. Requests for Reinstatement of this Agreement must be received by PacifiCare within 15 days from the date set out on the final termination notice. The termination date will be shown on the Group termination notice sent out by PacifiCare. Group shall be liable for any unpaid Health Plan Premiums. Group shall also pay the current month's premiums. All future premium must be remitted to PacifiCare by the premium due date through an electronic payment. PacifiCare reserves the right to assess an administrative fee of five percent of the monthly premium prorated on a 30 day month for each day premium payment is delinquent thereafter. This fee will be assessed solely at PacifiCare's discretion. Any requests for Reinstatement beyond the period set forth above will not be granted and the Group must submit a new application and undergo underwriting as a new Group. PCO1531 10 7.02.05 Termination for Breach of Material Term. PacifiCare may terminate this Agreement if Group breaches any material term, covenant or condition of this Agreement and fails to cure such breach within 30 days of receiving written notice of such breach from PacifiCare. For purposes of this section, material terms of this Agreement specifically include, but are not limited to, the Sections 3.01, Non-Discrimination and 8.03, Assignment. PacifiCare's written notice of breach shall make specific reference to Group's action causing such breach. If Group fails to cure its breach subject to PacifiCare's satisfaction within 30 days of receiving notice of the breach from PacifiCare, PacifiCare may terminate this Agreement at the end of the 30 day notice period. 7.02.06 For Providing Misleading or Fraudulent Information. PacifiCare may terminate this Agreement upon 30 days written notice to Group if Group provides materially misleading or fraudulent information to PacifiCare in any Group questionnaires or is aware that materially misleading or fraudulent information has been provided on membership enrollment forms. 7.02.07 For Ceasing to Meet Group Eligibility Criteria. PacifiCare may terminate Group upon 30 days written notice to Group if Group fails to meet any of the following Group eligibility requirements: a. Group fails to maintain active Group Participation percentage of 75%; b. For Subscribers without Dependents, Group fails to maintain a Group Contribution equal to 75% of the Health Plan Premium; c. For Subscribers with Dependents, Group fails to maintain a Group Contribution at a minimum of 75% of the employee's cost, or 50% of the employee and Dependent(s) combined premium; d. Group fails to abide by and enforce the conditions of Subscriber Enrollment set forth in this Agreement. 7.02.08 For Changing the Nature of Group's Business. PacifiCare may terminate Group upon 30 days written notice to Group if Group materially alters the nature of its business. "Materially Alters," for the purposes of this section, means a significant change in the business conducted by Group after the commencement of this Agreement. 7.02.09 For Loss of Group's Office Location within Geographic Area of Licensure. PacifiCare may terminate Group if Group no longer maintains an office location within the area in which PacifiCare is licensed as a health care service plan. PacifiCare shall provide Group with 30 days written notice prior to such termination, if possible. Group must notify PacifiCare of changes of the Group's office location provided on the Group application within 30 days of the change. PCO1531 11 7.03 Return of Prepayment Premium Fees Following Termination. In the event of termination by either PacifiCare (except in the case of fraud or deception in the use of PacifiCare services or facilities, or knowingly permitting such fraud or deception by another) or Group, PacifiCare will, within 30 days, return to Group the pro-rata portion of money paid to PacifiCare which corresponds to any unexpired period for which payment has been received, together with amounts due on claims, if any, less any amounts due to PacifiCare. 8. MISCELLANEOUS PROVISIONS 8.01 Governing Law. This Agreement is subject to the laws of the State in which this coverage is sold and to applicable Federal laws including the Employee Retirement Income Security Act of 1974, as amended, (codified at Chapter 18 of Title 29 of the United States Code) and the regulations promulgated thereunder by the United States Department of Labor(codified at Chapter XXV of Title 29 of the Code of Federal Regulations) and title II subtitle F section 261-264 of the Health Insurance Portability and Accountability Act 1996, Public law 104-191, or as amended. Any provisions required to be in this Agreement by any applicable laws and regulations shall bind PacifiCare, Group and Member whether or not expressly provided in this Agreement. Any provisions in this Agreement which, on its effective date, is in conflict with the applicable statutes of the jurisdiction in which is it is delivered, is hereby amended to conform with the minimum requirements of such statutes. 8.01.01 Relationship Of Parties. Group is not the agent or representative of PacifiCare, and shall not be liable for any acts or omissions of PacifiCare, its agents, or employees, or Providers. Member is not the agent or representative of PacifiCare, and shall not be liable for any acts or omissions of PacifiCare, its agents, or employees. Providers, Primary Care Physicians and Contracting Medical Groups are independent contractors and are not the agents, employees or servants of PacifiCare. 8.01.02 PacifiCare Non-Liability As A Health Care Provider. Member and Group agree that PacifiCare is not a Provider. PacifiCare is not responsible for the professional negligence of any Provider, Primary Care Physician or Contracting Medical Group. 8.01.03 Access to Books and Records. PacifiCare and Group shall have the right to access the others books and records for audit of compliance with the terms and conditions of this Agreement. Any such access shall be in compliance with all state and federal laws governing the privacy and security of individual protected health information including HIPAA. Group's access to PacifiCare Member specific data will be limited to de-identified information unless Group uses a third-party auditor who signs a confidentiality statement prior to access and the auditor agrees that all Member specific data or information: a. provided by PacifiCare will be used for auditing purposes only; b. will not be provided to Group or any other party; c. will only be used in a manner and to the extent permitted under federal or state laws, including HIPAA. PCOI531 12 8.01.04 Disclosure of Protected Health Information to Group. In compliance with the Health Insurance Portability and Accountability Act of 1996 ("HIPAA," found at Public Law 94-191) and certain regulations promulgated by the U.S. Department of Health and Human Services to implement certain provisions of HIPAA (the "HIPAA Privacy Regulations," found at 45 CFR, Parts 160 through 164), PacifiCare shall disclose Summary Health Information (as defined at 45 CFR § 164.504) to Group if Group requests such Summary Health Information and only for the limited purpose of(i) obtaining premium bids from health plans for providing health insurance coverage to Group; or(ii) modifying, amending or terminating the Group's Health Plan coverage. PacifiCare shall not disclose Protected Health Information (as defined at 45 CFR § 164.504) to Group unless Group executes an addendum to this Agreement, acceptable to PacifiCare, regarding the disclosure and use of such Protected Health Information. Such addendum will, at a minimum, comply with the requirements set forth at 45 CFR § 164.504(f). 8.02 PacifiCare Names, Logos and Service Marks. PacifiCare reserves the right to control all use of its name, product names, symbols, logos, trademarks, and service marks currently existing or later established. Group shall not use PacifiCare's name, product names, symbols, logos, trademarks, or service marks without obtaining the prior written approval of PacifiCare. 8.03 Assignment. This Agreement and the rights, interests and benefits hereunder shall not be assigned, transferred, pledged, or hypothecated in any way by either party and shall not be subject to execution, attachment or similar process, nor shall the duties imposed herein be subcontracted or delegated without the approval of the other party. Notwithstanding the above, if PacifiCare assigns, sells or otherwise transfers substantially all of its assets and business to another corporation, firm or person, with or without recourse, this Agreement will continue in full force and effect as if such corporation, firm or person were a party to this Agreement, provided such corporation, firm or person continues to provide prepaid health services. Notwithstanding the foregoing, Group acknowledges and agrees that PacifiCare may delegate certain functions, including,but not limited to medical management, utilization review, credentialing and/or claims payment, to provider groups or other certified organizations which contract with PacifiCare and that PacifiCare may contract with its corporate affiliates to perform certain management and administrative services for PacifiCare. 8.04 Validity. The unenforceability or invalidity of any part of this Agreement shall not affect the enforceability and validity of the balance of this Agreement. 8.05 Confidentiality. PacifiCare agrees to maintain and preserve the confidentiality of any and all medical records of Member in accordance with all applicable State and federal laws, including HIPAA. However, Member authorizes the release of information and access to any and all of Member's medical records for purposes of utilization review, quality review, processing of any claim, financial audit, coordination of benefits, or for any other purpose reasonably related to the provision of benefits under this Agreement to PacifiCare, its agents and employees, Member's participating medical group, and appropriate governmental agencies. PacifiCare shall not release any information to Group which would directly or indirectly indicate to the Group that a Member is receiving or has received Covered Services, unless authorized to do so by the Member. 8.06 Amendments. This Agreement may be modified by PacifiCare as set forth in Section 3.07, above, or it may be amended upon the mutual written consent of the parties. PCO1531 13 8.07 Group Use of Administrative Manual. Group agrees to comply with and conform to policies and procedures in the Administrative Manual provided by PacifiCare. PacifiCare agrees to provide 30 days notice to Group of any changes in the Administrative Manual. In the event of conflict between this Agreement and the Administrative Manual, the terms of this Agreement shall prevail. 8.08 Attachments. The Cover Sheet and Attachments to this Agreement, the Combined Evidence of Coverage and Disclosure Form, and all terms and conditions set forth therein, as they are from time-to-time amended by parties, are incorporated by reference herein and made an integral part of this Agreement. 8.09 Use of Gender. The use of masculine gender in this Agreement includes the feminine gender and the singular includes the plural. 8.10 Waiver of Default. The waiver by PacifiCare of any one or more defaults by Group or Member shall not be construed as a waiver of any other or future defaults under the same or different terms, conditions or covenants contained in this Agreement. 8.11 Notices. Any notice required or permitted under this Agreement shall be in writing and either delivered personally or by regular, registered, or certified mail, U.S. Postal Service Express Mail, or overnight courier, postage prepaid, or at the addresses set forth below: If to PacifiCare: PacifiCare of Colorado P.O. Box 6770 Englewood, CO 80155 If to Group or Member: Group's or Member's last address known to PacifiCare. Any notice sent by registered or certified mail, return receipt requested, shall be deemed given on the date of delivery shown on the receipt card, or if no delivery date is shown, the postmark date. If sent by regular mail, the notice shall be deemed given 48 hours after the notice is addressed and mailed with postage prepaid. Notices delivered by U.S. Postal Service Express mail or overnight courier that guarantees next day delivery shall be deemed given 24 hours after delivery of the notice to the United State Postal Service or courier. If any notice is transmitted by facsimile transmission or similar means, the notice shall be deemed served or delivered upon telephone confirmation of receipt of the transmission, provided a copy is also delivered via delivery or mail. 8.12 Acceptance of Agreement. Group accepts the terms and conditions of this Agreement by making its initial payment to PacifiCare of Health Plan Premiums on or before the due date specified on the Cover Sheet or by executing this Agreement. If acceptance is made by payment of the first premium, Group must still execute a copy of the Agreement to keep coverage in force. Failure to execute this Agreement may result in termination of coverage. All Members accepts the terms, conditions and provisions of this Agreement upon completion and execution of the Enrollment form. Acceptance by any of these methods shall render all terms and provisions of this Agreement binding on PacifiCare, Group and Members. PCO1531 14 8.13 Entire Agreement. This Agreement, including all exhibits, attachments, and amendments, contains the entire understanding of Group and PacifiCare with respect to the subject matter hereof and it incorporates all of the covenants, conditions, promises, and agreements exchanged by the parties hereto with respect to such matter. This Agreement supersedes any and all prior or contemporaneous negotiations, agreements, representations, or communications, whether written or oral, between Group and PacifiCare with respect to the subject matter of this Agreement. This Agreement may be executed in two or more counterparts, each of which shall constitute an original, but all of which shall constitute one and the same document. 8.14 Contracting Provider Termination. PacifiCare will provide written notice to Group within a reasonable time if it receives notice that any contracting provider terminates or breaches its contract with PacifiCare, or is unable to perform such contract, if the termination, breach, or inability to perform may materially and adversely affect Group. 8.15 Headings. The headings of the various sections of this Agreement are inserted merely for the purpose of convenience and do not expressly, or by implication, limit or define or extend the specific terms of the section so designated. 8.16 No Third Party Beneficiaries. Except as otherwise expressly indicated in this Agreement, this Agreement shall not create any rights in any third parties who have not entered into this Agreement, nor shall this Agreement entitle any such third party to enforce any rights or obligations that may be possessed by such third party. 9. ARBITRATION 9.01 Member Appeals and Grievances. The attached PacifiCare Combined Evidence of Coverage and Disclosure Form includes complete description of the PacifiCare appeals and grievance procedures and dispute resolution processes for Members. 9.02 Disputes Between PacifiCare and Group. All disputes between Group and PacifiCare shall be resolved by binding arbitration before the Commercial Arbitration Rules of the American Arbitration Association unless both PacifiCare and the Group agree in writing to use another form of alternative dispute resolution (e.g., mediation). The parties will seek to mutually agree on the appointment of an arbitrator; however, if an agreement cannot be reached within 30 days following the date demanding arbitration, the parties will use the arbitrator appointment procedures in the Rules. Arbitration hearings will be held at the neutral administrator's offices in Denver, Colorado, or at another location agreed upon in writing by the parties. The results of the binding arbitration shall be final, with no further recourse in a court of law or otherwise will be available to either PacifiCare or the Group. The arbitrator(s) will prepare in writing an award that includes the legal and factual reasons for the decision. Judgement upon the award rendered by the arbitrator(s) shall be entered into any court having jurisdiction. PacifiCare and the Group shall equally share the costs of arbitration; however, each party shall be individually responsible for the expenses related to its attorney, experts and evidence. The Federal Arbitration Act, 9 U.S.C. §§ 1-4, will also apply to the arbitration. 9.03 Mandatory Arbitration. Group and PacifiCare agree and understand that any and all disputes, including claims of medical malpractice, shall be determined by submission to binding arbitration. Any such dispute will not be resolved by a lawsuit or resort to court process, except as Colorado law provides for judicial review of arbitration proceedings. Each party to this agreement is giving up the constitutional right to have any such dispute decided in a court of law before a jury, and instead is accepting the use of binding arbitration. PCO1531 15 IN WITNESS�� WHEREOF, the parties hereto have executed this Agreement in G?me e tey , Colorado, on re A / , 20 el GROUP: Weld County Government PACIFICARE OF COLORADO, INC. BY: A,. tl LC,. BY: NAME: d)be42± 691 d e YJJ NAME: Brian Crary TITLE: Oil A 1 ta, 7c1 tUP d 4, avri mis 5110141STITLE: President of PacifiCare of Colorado DATE: ,-2/9A V DATE: February 9, 2004 PCO1531 16 PacifiCare of Colorado Formularya =.r:;, a a 11.,- ,;,(- e+ _..y , dca_N :, , -Ye 1ijilr d ,3 A/T/S erythromycin Dermatologic Agents Generic Accolate zafldukast Respiratory Agents Brand Accutane isotretinoin Dermatologic Agents Brand Achromycin tetracycline Anti-Infective Agents Generic Aciphex rabeprazole Gastrointestinal Agents Brand Aclovate alclometasone dipropionate Dermatologic Agents Brand Acligall ursodiol Gastrointestinal Agents Generic Acular ketorolac tromethamine ophthalmic Ophthalmic/Otic Agents Brand Adalat CC nifedipine Cardiovascular Agents Brand Adapin doxepin Central Nervous System Agents Generic Adderall amphetamine/dexamphetamine Central Nervous System Agents Generic Adderall 7 5m amphetamine/dexamphelamine 7.5mg Central Nervous System Agents Brand Adderall XR Amphetamine-Dextroamphelamine Central Nervous System Agents Brand Advair Diskus salmeterol xinafoate 8 fluticasone propionate Respiratory Agents Brand Advicor lovastatin&niacin SR Cardiovascular Agents Brand Aerochamber respiratory device Respiratory Agents Brand Aerochamber w/Mask respiratory device Respiratory Agents Brand Agenerase amprenavir Anti-Infective Agents Brand Agrylin anagrelide het Cardiovascular Agents Brand Albalon naphazoline Ophthalmic/Otic Agents Generic Aldactazide 25mg/25mg spironolactone/hydrochlorothiazide 25mg/25mg Cardiovascular Agents Generic Aldactazide 50mg/50mg spironolactone/hydrochlorothiazide Cardiovascular Agents Brand Aldactone spironolactone Cardiovascular Agents Generic Aldara imiquimod Dermatologic Agents Brand Aldomet methyldopa Cardiovascular Agents Generic Aldodl-15 methyldopa/HCTZ Cardiovascular Agents Generic Aldoril-25 methyldopa/HCTZ Cardiovascular Agents Generic Alesse levonorgestrel-ethinyl estradiol Metabolic/Endocrine Agents Brand Antineoplastics and Alkeran melphalan Immunosuppressants Brand Allegra 180 MG fexofenadine hd Respiratory Agents Brand Allegra 30mg,60mg fexofenatline 30mg,60mg Respiratory Agents Brand Alora estradiol transdermal patch Metabolic/Endocrine Agents Brand Alphagan brimonidine tartrate OphthalmiclObc Agents Brand Alupent Inhalation Solution metaproterenol inhalation solution Respiratory Agents Generic Alupent Inhaler metaproterenol inhaler Respiratory Agents Brand Amoxil(not 200mg) amoxicillin(not 200mg) Anti-Infective Agents Generic Amoxil 400mg/5m1 suspension amoxicillin 400mg/5m1 suspension Anti-Infective Agents Brand Amoxil 875mg amoxicillin 875mg Anti-Infective Agents Brand Anafranil domipramine Central Nervous System Agents Generic Analpram HC hydrocortisone acetate/pramoxine Gastrointestinal Agents Brand Anaprox naproxen sodium Musculoskeletal Agents Generic Androderm testosterone transdermal patches Metabolic/Endocrine Agents Brand Antabuse disulfiram Miscellaneous Agents Generic Anusol-HC cream,suppository hydrocortisone acetate cream,suppository Gastrointestinal Agents Generic Anzemet dolasetron mesylate Gastrointestinal Agents Brand Apresoline hydralazine Cardiovascular Agents Generic Aralen 500mg chloroquin phosphate 500mg Anti-Infective Agents Generic Antineoplastics and Arimidex anastrozole Immunosuppressants Brand Aristocort tablet triamcinolone tablet Metabolic/Endocdne Agents Brand Armour Thyroid thyroid Metabolic/Endocrine Agents Generic Antineoplastics and Aromasin exemestane Immunosuppressants Brand Artane mhexyphenidyl Central Nervous System Agents Generic Asacol mesalamine Gastrointestinal Agents Brand Astelin azelasline Respiratory Agents Brand Atarax 100mg tablet hydroxyzine 100mg tablet Respiratory Agents Brand Atarax 10mg,25mg,50mg tablet hydroxyzine 10mg,25mg,50mg tablet Respiratory Agents Generic Atarax Syrup hydroxyzine Respiratory Agents Generic Ativan lorazepam Central Nervous System Agents Generic Atropine Sulfate atropine sulfate Gastrointestinal Agents Generic Atrovent Inhalation Solution ipralropium inhalation solution Respiratory Agents Generic Atrovent Inhaler ipralropium inhaler Respiratory Agents Brand 20030111 9/03 Page 1 of 13 PCO1541 Augmentin amoxicillin&K davulanate Anti-Infective Agents Brand Augmentin XR amoxicillin&K davulanate SR Anti-Infective Agents Brand Auralgan benzocaine-antipyrine Ophthalmic/Otic Agents Generic Avelox moxifloxacin Anti-Infective Agents Brand Aventyl capsule nortriptyline capsule Central Nervous System Agents Generic Azopt brinzolamide OphthalmidOtic Agents Brand Azulfidine sulfasalazine Gastrointestinal Agents Generic B-D Insulin Syringes B-D Insulin Syringes Diabetic Testing Supplies Brand Bacitracin bacitracin Ophthalmic/Otic Agents Generic Bactrim trimethoprim/sulfamethoxazole Anti-Infective Agents Generic Bactrim DS trimethoprim/sulfamethoxazole Anti-Infective Agents Generic Bactroban mupirocin Dermatologic Agents Brand BD Ultrafine Lancets lancets Diabetic Testing Supplies Brand Beconase AO beclomethasone nasal spray Respiratory Agents Brand Benemid probenecid Metabolic/Endocrine Agents Generic Bentyl dicydomine Gastrointestinal Agents Generic Bentyl syrup dicydomine syrup Gastrointestinal Agents Brand Benzamycin erythromycin/benzoyl peroxide Dermatologic Agents Brand Betagan levobunolol Ophthalmic/Otic Agents Generic Betapace sotalol Cardiovascular Agents Generic Betapace AF sotalol Cardiovascular Agents Brand Betimol timolol hemihydrate Ophthalmic/Otic Agents Brand Betoptic betaxolol OphthalmidOtic Agents Generic Betoptic S betaxolol Ophthalmic/Otic Agents Brand Biaxin danthromycin Anti-Infective Agents Brand Biaxin XL darithromycin SR Anti-Infective Agents Brand Biltncide praziquantel Anti-Infective Agents Brand Bleph-10 sulfacetamide Ophthalmic/Otic Agents Generic Blephamide sulfacetamide/prednisolone Ophthalmic/Otic Agents Brand Brethine terbutaline Respiratory Agents Brand Brethine terbutaline Metabolic/Endocrine Agents Brand Bromodiphenhydramine/codeine bromodiphenhydramine/codeine Respiratory Agents Brand Broncho Saline sodium chloride for inhalation Respiratory Agents Brand Bumex bumetanide Cardiovascular Agents Generic Buspar buspirone Central Nervous System Agents Generic Buspar 30mg buspirone 30mg Central Nervous System Agents Generic Cafatine PB ergotamine/pentobarbital/belladonna/caffeine Central Nervous System Agents Brand Cafergot tablet ergotamine tartrate/caffeine tablet Central Nervous System Agents Brand Calan SR tablet verapamil CR,ER,SR tablet Cardiovascular Agents Generic Calan tablet verapamil tablet Cardiovascular Agents Generic Canasa suppository mesalamine suppository Gastrointestinal Agents Brand Capoten captopril Cardiovascular Agents Generic Capozide captopril/hydrochlorothiazide Cardiovascular Agents Generic Antineoplastics and Carac fluorouracil Immunosuppressants Brand Carafate suspension sucralfate suspension Gastrointestinal Agents Brand Carafate tablet sucralfate tablet Gastrointestinal Agents Generic Cardene nicardipene Cardiovascular Agents Generic Cardene SR nicardipene SR Cardiovascular Agents Brand Cardizem(not CD) dilliazem Cardiovascular Agents Generic Cardizem SR diltiazem SR Cardiovascular Agents Generic Cardura doxazosin mesylate Cardiovascular Agents Generic Cardura doxazosin mesylate Genitourinary Agents Generic Antineoplastics and Casodex bicalutamide Immunosuppressants Brand Catapres tablet donidine tablet Cardiovascular Agents Generic Antineoplastics and CeeNu lomustine Immunosuppressants Brand Cefzil cefprozil Anti-Infective Agents Brand Cephulac ladulose Gastrointestinal Agents Generic Cerespan papaverine CR Cardiovascular Agents Generic Chemstrip UG&UGK Strips Chemstrip UG&UGK Strips Diabetic Testing Supplies Brand Chloroptic chloramphenicol Ophthalmic/Otic Agents Brand Chloroquin Phosphate(250mg) chloroquin phosphate(250mg) Anti-Infective Agents Brand 20030111 9/03 Page 2 of 13 PCO1541 c .�.,�7vi,: i ' d ta:: a._ .s�_.�.; s e y-1 a j a, n.—j ,a�lA , ,,i`. .:a : 7 : . Chlorpheniramine/Pyrilamine/Ph enylephrine 8/25/25 chlorpheniramine/pyrilamine/phenylephrine Respiratory Agents Generic Chlorpromazine concentrate 30mg/ml chlorpromazine concentrate Central Nervous System Agents Brand Chromagen-OB Prenatal Vitamin Nutritional Supplements Brand Chronulac lactulose Gastrointestinal Agents Generic Cipro tablet ciprofloxacin tablet Anti-Infective Agents Brand Clannex desloratadine Respiratory Agents Brand Cleodn 75mg capsule dindamycin(75mg capsule) Anti-Infective Agents Brand Cleocin capsule dindamycin capsule Anti-Infective Agents Generic Cleocin vaginal cream,vaginal suppository dindamycin vaginal cream,vaginal suppository Anti-Infective Agents Brand Cleocin-T clindam cin Y Dermatologic Agents Generic Cleocin-T lotion dindamycin lotion Dermatologic Agents Generic Clinoril sulindac Musculoskeletal Agents Generic Clorpres donidine/chlorthalidone Cardiovascular Agents Brand Codeine sulfate codeine sulfate Musculoskeletal Agents Brand Codimal-DH phenylephrine/pyrilamine/hydrocodone Respiratory Agents Generic Cogentin benztropine mesylate Central Nervous System Agents Generic Colazal balsalazide Gastrointestinal Agents Brand Colchicine colchicine Metabolic/Endocrine Agents Generic Colestid colestipol Cardiovascular Agents Brand CoLyte polyethylene glycol/electrolyte solution Gastrointestinal Agents Generic Combipres 0.1mg/15mg, 0.2mg/15mg donidine/chlorthalidone Cardiovascular Agents Generic Combivent Inhaler albuterol/ipratropium Respiratory Agents Brand Combivir lamivudine/zidovudine Anti-Infective Agents Brand Compazine prochlorperazine Gastrointestinal Agents Generic Concerta methylphenidate hd er Central Nervous System Agents Brand Condylox gel podofilox gel Dermatologic Agents Brand Condylox solution podofilox solution Dermatologic Agents Generic Cordarone amiodarone Cardiovascular Agents Generic Coreg carvedilol Cardiovascular Agents Brand Corgard nadolol Cardiovascular Agents Generic Cortef 20mg hydrocortisone 20mg Metabolic/Endocrine Agents Generic Cortef 5mg,10mg hydrocortisone 5mg,10mg Metabolic/Endocnne Agents Brand Cortenema hydrocortisone Gastrointestinal Agents Generic Cortisponn otic neomycin/polymixin b/hydrocortisone Ophthalmic/Otic Agents Generic Cotazym pancrelipase Gastrointestinal Agents Brand Coumadin warfarin Cardiovascular Agents Generic Creon pancrelipase Gastrointestinal Agents Generic Crixivan indinavir sulfate Anti-Infective Agents Brand. Crolom cromolyn sodium Ophthalmic/Otic Agents Generic Cuprimine penicillamine Musculoskeletal Agents Brand Cutivate fluticasone propionate Dermatologic Agents Brand Cydessa desogestrel-ethinyl estradiol Metabolic/Endocrine Agents Brand Cydogyl cyclopentolate Ophthalmic/Otic Agents Generic Cystospaz hyoscyamine Gastrointestinal Agents Generic Cytomel liothyronine Metabolic/Endocrine Agents Brand Cytotec misoprostol Gastrointestinal Agents Generic Antineoplastics and Cytoxan cyclophosphamide Immunosup pressants Generic Dalmane flurazepam Central Nervous System Agents Generic Danocrine danazol Metabolic/Endocrine Agents Generic Dantrium dantrolene Musculoskeletal Agents Brand Dapsone dapsone Anti-Infective Agents Brand Darapnm pyrimethamine Anti-Infective Agents Brand Darvocet-N 100 propoxyphene napsylate/acetaminophen Musculoskeletal Agents Generic Darvocet-N 50 propoxyphene napsylate/acelaminophen Musculoskeletal Agents Brand Darvon propoxyphene Musculoskeletal Agents Generic Darvon Compound propoxyphene/aspinn/cafeine Musculoskeletal Agents Generic DDAVP nasal solution desmopressin nasal solution Metabolic/Endocrine Agents Generic DDAVP oral desmopressin tablet Metabolic/Endocrine Agents Brand Decadron ophthalmic dexamethasone Ophthalmic/Otic Agents Generic Decadron oral dexamethasone Metabolic/Endocrine Agents Generic Dedomyon demeclocycline hcl Metabohc/Endocnne Agents Brand Deltasone prednisone Metabolic/Endocrine Agents Generic 20030111 9/03 Page 3 of 13 PCO1541 #rI ,:'. »A' T.., ....:, . ka. r.. Vila ,A:z.M^" rl. -;:751)2M5'71"...-7,.- I(' ' Demerol meperidine Musculoskeletal Agents Generic Demulen ethynodiol diacetate/ethinyl estradiol MetaboliGEndocnne Agents Brand Depakene valproic acid Central Nervous System Agents Generic Depakote divalproex sodium Central Nervous System Agents Brand Depakote divalproex sodium Central Nervous System Agents Brand Depakote divalproex sodium Central Nervous System Agents Brand Depakote ER divalproex sodium SR Central Nervous System Agents Brand Desogen desogestrel/ethinyl estradiol Metabolic/Endocrine Agents Brand Desyrel trazodone Central Nervous System Agents Generic Dexednne dextroamphetamine Central Nervous System Agents Generic Dexedrine SR dextroamphetamine SR Central Nervous System Agents Brand Dexstrostat Dextroamphetamine Sulfate 5mg tablet Central Nervous System Agents Generic DHT dihydrotachysterol Nutritional Supplements Brand Debate glybunde Metabolic/Endocrine Agents Generic Diabinese chlorpropamide Metabolic/Endocrine Agents Generic Diamox acetazolamide Ophthalmic/Clic Agents Generic Diaphragms Diaphragms Miscellaneous Agents Brand Dibenzyline phenoxybenzamine Cardiovascular Agents Brand Diflucan 150mg fluconazole 150mg Anti-Infective Agents Brand Digitek Digitek Cardiovascular Agents Generic Dilacor XR diltiazem ER Cardiovascular Agents Generic Dilantin phenytoin Central Nervous System Agents Brand Dilaudid hydromorphone Musculoskeletal Agents Generic Diltiazem ER(24 HR)capsule diltiazem ER(24 HR)capsule Cardiovascular Agents Generic Diprolene augmented betamethasone Dermatologic Agents Generic Diprolene AF augmented betamethasone dipropionate Dermatologic Agents Brand Diprolene lotion augmented betamethasone lotion Dermatologic Agents Brand Diprosone betamethasone dipropionate Dermatologic Agents Generic Disalcid table( salsalate tablet Musculoskeletal Agents Generic Ditropan(not XL) oxybutynin Genitourinary Agents Generic Dolobid diflunisal Musculoskeletal Agents Generic Dolophine methadone Musculoskeletal Agents Generic Donnatal phenobarbital/belladonna alkaloids Gastrointestinal Agents Generic Donnatal Extentab phenobarbital/belladonna alkaloids CR Gastrointestinal Agents Brand Drisdol ergocalciferol(vitamin D) Nutritional Supplements Generic Dnthocreme anthralin Dermatologic Agents Brand Drithocreme HP 1% anthralin Dermatologic Agents Generic Dura-Vent/DA chlorpheniramine/phenylephrine/methscopolamine Respiratory Agents Generic Duragesic fentanyl Musculoskeletal Agents Brand Duratuss G guiafenesin 1200mg Respiratory Agents Generic Duratuss HD pseudoephedrine/hydrocodone/guiafenesin Respiratory Agents Generic Duricef 500mg capsule,1gm tablet cefadroxil 500mg capsule,1gm tablet Anti-Infective Agents Generic Duricef suspension cefadroxil suspension Anti-Infective Agents Brand Dyazide lnamterene/hydrochlorothiazide Cardiovascular Agents Generic Dymelor acelohexamide Metabolic/Endocrine Agents Generic Dynacin minocycline Anti-Infective Agents Generic DynaCirc(not CR) isradipine Cardiovascular Agents Brand Dynapen dicloxacillin Anti-Infective Agents Generic Dynapen suspension dicloxacillin suspension Anti-Infective Agents Brand E-Z Spacer respiratory device Respiratory Agents Brand Easivent respiratory device Respiratory Agents Brand EES erythromycin ethylsuccinate Anti-Infective Agents Generic Effexor venlafaxine Central Nervous System Agents Brand Effexor XR venlafaxine XR Central Nervous System Agents Brand Antineoplastics and Efudex fluorouracil Immunosuppressants Brand Elavil amitriptyline Central Nervous System Agents Generic Eldepryl tablet selegiline tablet Central Nervous System Agents Generic Elimite permelhrin Dermatologic Agents Generic Elixophyllin theophylline Respiratory Agents Generic Elmiron pentosan polysulfate sodium Genitourinary Agents Brand Elocon Cream 8 Lotion mometasone Dermatologic Agents Brand Elocon ointment mometasone Dermatologic Agents Generic Antineoplastics and Emcyt eslmmusline phosphate sodium Immunosuppressants Brand Emgel erythromycin Dermalologic Agents Generic 20030111 9/03 Page 4 of 13 PCO1541 Ym, m ,,+x.-a2, , 1)........, . -'�e`k'vMxo f I.:,.fut,ww x, -14, ...m CL L'd 'r f .2._ T . Sy> Empirin w/Codeine aspinn/codeine Musculoskeletal Agents Generic -i Epifrin epinephrine Ophthalmic/Otic Agents Brand Epivir lamivudine Anti-Infective Agents Brand Ergomar ergotamine tartrate Central Nervous System Agents Brand Ery-Tab Erythromycin base Anti-Infective Agents Generic Erythromycin Stearate erythromycin stearate Anti-Infective Agents Generic Esgic acetaminophen/caffeine/butalbital Central Nervous System Agents Generic Esgic Plus tablet acetaminophen/caffeine/butalbital tablet Central Nervous System Agents Generic Eskalith 300mg capsule lithium carbonate 300mg capsule Central Nervous System Agents Generic Estrace tablet estradiol tablet Metabolic/Endoaine Agents Generic Estrace Vaginal Cream estradiol vaginal cream MelabolicEndocnne Agents Brand Estraderm estradiol transdermal patch Metabolic/Endocrine Agents Brand Estratab esterified estrogen MetabolidEndocnne Agents Brand Estratest esterified estrogen/methyltestosterone Metabolic/Endocrine Agents Brand Estratest HS esterified estrogen/methyltestosterone Metabolic/Endocrine Agents Brand Ethmozine moricizine Cardiovascular Agents Brand Antineoplastics and Eulexin flutamide Immunosuppressants Generic Eurax crotamiton Dermatologic Agents Brand chlorpheniramine/phenylephrine/methscopolami ne Extendryl(plain) (plain) Respiratory Agents Generic Fansidar pyrimethamine/sulfadoxine Anti-Infective Agents Brand Antineoplastics and Fareston toremifine citrate Immunosuppressants Brand FastTake Test Strips test strips Diabetic Testing Supplies Brand Feldene piroxicam Musculoskeletal Agents Generic Antineoplastics and Femara letrozole Immunosuppressants Brand Fioncet acetaminophen/caffeine/butalbital Central Nervous System Agents Generic Fioncet w/codeine acetaminophen/caffeine/butalbital w/codeine Central Nervous System Agents Generic Fiorinal aspirin/caffeine/butalbital Central Nervous System Agents Generic Flagyl tablet metronidazole tablet Anti-Infective Agents Generic Flexed cyclobenzapnne Musculoskeletal Agents Generic Flonase fluticasone propionate Respiratory Agents Brand Flonnef fludrocortisone Metabolic/Endocrine Agents Generic Flovent fluticasone propionate Respiratory Agents Brand Floxin Otic ofloxacin otic Ophthalmic/Otic Agents Brand Fluorabon Basic Drops pediatric vitamin ACD w/fluoride Nutritional Supplements Brand FML Forte fluorometholone Ophthalmtc/Otic Agents Brand FML Liquifilm fluorometholone Ophthalmic/Otic Agents Generic FML S.O.P. fluorometholone Ophthalmic/Otic Agents Brand Folic Acid folic acid Nutritional Supplements Generic Fortovase saquinavir Anti-Infective Agents Brand Fulvicin P/G griseofulvin ultramicrosize Anti-Infective Agents Brand Fulvicin U/F griseofulvin microsize Anti-Infective Agents Brand Furadantin suspension nitrofurantoin suspension Anti-Infective Agents Brand Furoxone furazolidone Anti-Infective Agents Brand Gantrisin suspension sulfisoxazole suspension Anti-Infective Agents Brand Garamycin Ophthalmic ointment,solution gentamicin ophthalmic ointment,solution Ophthalmic/Otic Agents Generic Garamycin topical gentamicin sulfate Dermatologic Agents Generic Glucophage metformin Metabolic/Endocrine Agents Generic Glucotrol(not XL) glipizide MetaboliUEndocrine Agents Generic Glynase PresTab glyburide micronized Metabolic/Endocrine Agents Generic Golytely polyethylene glycol/electrolyte solution Gastrointestinal Agents Brand Granulex trypsin/balsam per✓castor oil Dermatologic Agents Generic Gnfulvin V griseofulvin microsize Anti-Infective Agents Brand Gns-Peg grseofulvin ultramicrosize Anti-Infective Agents Brand Grisactin 500mg tablet griseofulvin microsize 500mg tablet Anti-Infective Agents Brand Gynodiol 0.5mg,1mg,2mg estradiol 0.5mg,1mg,2mg Metabolic/Endocnne Agents Generic Gynodiol 1.5mg estradiol 1.5mg Metabolic/Endocrine Agents Brand Halcion tnazolam Central Nervous System Agents Generic Haldol haloperidol Central Nervous System Agents Generic Haldol 10mg haloperidol 10mg Central Nervous System Agents Brand Halolestin fluoxymesterone Metabolic/Endocrine Agents Brand Helidac bismuth/metronidazole/tetracycline Gastrointestinal Agents Brand 20030111 9/03 Page 5 of 13 PCO1541 49£1 : . W tt ,._; xH.]he c.<u° ' k".:4 P` t Y .k.�., a^ . ' ,e n.w z8 rt«.. 4.°4-44:f.....4= . * ,Antineoplastics and Hexalen altretamine Immunosuppressants Brand Histussin HC pheylephrine/chlorpheniramine/hydrocodone Respiratory Agents Generic Hivid ddC/dideoxycylidine Anti-Infective Agents Brand Humalog human insulin lispro Metabolic/Endocrine Agents Brand Humalog Mix human insulin lispro 8 lispro prolamine Metabolic/Endocrine Agents Brand Humibid LA guaifenesin CR Respiratory Agents Generic Humulin Insulin human insulin Metabolic/Endocrine Agents Brand Hycodan syrup hydrocodone/homatropine syrup Respiratory Agents Generic Antineoplastics and Hydrae hyroxyurea Immunosuppressants Generic Hydrodiuril hydrochlorothiazide Cardiovascular Agents Generic Hygroton chlorthalidone Cardiovascular Agents Generic Hytone hydrocortisone Dermatologic Agents Generic Hytrin terazosin Cardiovascular Agents Generic Hymn terazosin Genitourinary Agents Generic Ilotycin erythromycin Ophthalmic/Olin Agents Generic Imdur isosorbide mononitrate Cardiovascular Agents Generic Imitrex tablet sumatriptan succinate tablet Central Nervous System Agents Brand Antineoplastics and Imuran azathioprine Immunosuppressants Generic Inderal propranolol Cardiovascular Agents Generic Inderal propranolol Central Nervous System Agents Generic Inderal LA propranolol CR Central Nervous System Agents Brand Inderal LA propranolol CR Cardiovascular Agents Brand Inderide propranolol/hydrochlorothiazide Cardiovascular Agents Generic Indocin indomethacin Metabolic/Endocrine Agents Generic Indocin indomethacin Musculoskeletal Agents Generic Inflamase Forte prednisolone phosphate Ophthalmic/Otic Agents Generic Inflamase Mild prednisolone phosphate Ophthalmic/Otic Agents Brand Inspirease respiratory device Respiratory Agents Brand Intel Inhalation Solution cromolyn sodium Respiratory Agents Generic Intal Inhaler cromolyn sodium Respiratory Agents Brand Invirase saquinavir mesylate Anti-Infective Agents Brand lodoquinol powder iodoquinol powder Anti-Infective Agents Generic Isoniazid(INH) isoniazid Anti-Infective Agents Generic Isoplin SR tablet verapamil CR.ER.SR tablet Cardiovascular Agents Generic Isoplin tablet verapamil tablet Cardiovascular Agents Generic Isopto Atropine atropine Ophthalmic/O0c Agents Generic Isopto Carbachol carbachol OphlhalmiclOtic Agents Brand Isopto Carpine pilocarpine Ophthalmic/Olic Agents Generic Isopto Carpine 0.25%,8% pilocarpine 0.25%.8% Ophthalmic/Olic Agents Brand Isopto Homatropine homatropine Ophthalmic/Otic Agents Brand Isopto Homatropine 5% homatropine 5% Ophthalmic/Otic Agents Generic Isordil 40mg tablet isosorbide dinitrate 40mg tablet Cardiovascular Agents Brand Isordil SL tablet isosorbide dinitrate 10mg SL tablet Cardiovascular Agents Brand Isordil SL tablet isosorbide dinitrate SL tablet Cardiovascular Agents Generic Isordil SR tablet isosorbide dinitrate SR tablet Cardiovascular Agents Generic Isordil tablet isosorbide dinitrate tablet Cardiovascular Agents Generic K-Dur potassium chloride CR Nutritional Supplements Brand K-Lyte(25 meq) potassium bicarbonate(25 meq) Nutritional Supplements Generic K-Lyte/CL 25 meq potassium bicarbonate/chloride effer 25 meq Nutritional Supplements Generic Kaletra lopinavir-ritonavir Anti-Infective Agents Brand Karidium Sodium Fluoride Miscellaneous Agents Generic Kayexalate sodium polystyrene sulfonate powder Miscellaneous Agents Generic Keflex cephalexin Anti-Infective Agents Generic Kenalog triamcinolone Dermatologic Agents Generic Kerlone betaxolol Cardiovascular Agents Generic Klonopin clonazepam Central Nervous System Agents Generic Lamictal lamotrigine Central Nervous System Agents Brand Lanoxin elixir digoxin elixir Cardiovascular Agents Generic lanoxin tablet digoxin tablet Cardiovascular Agents Brand Lantus insulin glargine Metabolic/Endocnne Agents Brand Lariam mefloquine Anti-Infective Agents Brand Larodopa levodopa Central Nervous System Agents Brand Lasix furosemide Cardiovascular Agents Generic 20030111 9/03 Page 6 of 13 PCO1541 z-": .iia* M, rt --p. 1 &k . ar' 4-0>f.[, ..3. . 1. rt 'a._J . Antineoplastics and Leucovorin 10mg leucovorin 10mg Immunosuppressants Brand Antineoplastics and Leucovorin 5mg,15mg,25mg leucovorin 5mg,15mg,25mg Immunosuppressants Generic Antineoplastics and Leukeran chlorambucil Immunosuppressants Brand Levatol penbutolol Cardiovascular Agents Brand Levothyroxine levothyroxine Metabolic/Endocrine Agents Generic Levoxyl levothyroxine Metabolic/Endocrine Agents Brand Levsin hyoscamine sulfate Gastrointestinal Agents Generic Levsinex L-hyoscamine sulfate Gastrointestinal Agents Generic Lexapro escitalopram oxalate Central Nervous System Agents Brand Librium chlordiazepoxide Central Nervous System Agents Generic Lidex fluocinonide Dermatologic Agents Generic LifeScan Lancets lancets Diabetic Testing Supplies Brand Lioresal baclofen Musculoskeletal Agents Generic Liquid Pred prednisone Metabolic/Endocnne Agents Brand Lithium carbonate(not 300mg capsule) lithium carbonate(not 300mg capsule) Central Nervous System Agents Brand Livostin levocabastine Ophthalmic/Otic Agents Brand Lo/Ovral norgestrel/ethinyl estradiol Metabolic/Endocrine Agents Brand Locoid hydrocortisone butyrate Dermatologic Agents Brand Lodine etodolac Musculoskeletal Agents Generic Lomotil diphenoxylate/atropine sulfate Gastrointestinal Agents Generic Loniten minoxidil Cardiovascular Agents Generic Lopid gemfibrozil Cardiovascular Agents Generic Lopressor metoprolol Cardiovascular Agents Generic Loprox ciclopirox olamine Dermatologic Agents Brand Lorcel hydrocodone bitartrate/acetaminophen Musculoskeletal Agents Generic Lortab hydrocodone bitartrate/acetaminophen Musculoskeletal Agents Generic Lotensin benazepril Cardiovascular Agents Brand Lotensin HCT benazepril/hydrochlorothiazide Cardiovascular Agents Brand Loxitane capsule loxapine capsule Central Nervous System Agents Generic Loxitane-C concentrate loxapine concentrate Central Nervous System Agents Brand Lozol indapamide Cardiovascular Agents Generic Ludiomil maprotiline Central Nervous System Agents Generic Langan bimatoprost Ophthalmic/Olic Agents Brand Luride sodium fluoride Miscellaneous Agents Generic Antineoplastics and Lysodren mitotane Immunosuppressants Brand Macrobid nitrofurantoin monohydrate macrocryslalline- Anti-Infective Agents Brand Macrodantin nitrofurantoin macrocrystalline Anti-Infective Agents Generic Marino' dronabinol Gastrointestinal Agents Brand Antineoplastics and Matulane procarbazine Immunosuppressants Brand Maxair Autohaler pirbuterol acetate Respiratory Agents Brand Maxitrol neomycin/polymixin b/dexamethasone Ophthalmic/Olin Agents Generic Maxzide triamterene/hydrochlorothiazide Cardiovascular Agents Generic Mebaral mephobarbital Central Nervous System Agents Brand Mecomen meclofenamate Musculoskeletal Agents Generic Medrol methylprednisolone Metabolic/Endocrine Agents Generic Antineoplastics and Megace megestrol acetate Immunosuppressants Generic Antineoplastics and Megace(suspension) megestrol acetate(suspension) Immunosuppressants Generic Mellaril thioridazine Central Nervous System Agents Generic Menest esterified estrogen Metabolic/Endocrine Agents Brand Mepergan Fortis meperidine/promethazine Musculoskeletal Agents Generic Mephyton phylonadione(vitamin K) Nutritional Supplements Brand Mestinon syrup,CR tablet pyridostigmine bromide syrup,CR tablet Central Nervous System Agents Brand Metaprel metaproterenol Respiratory Agents Generic Metaprel Inhalation Solution metaproterenol inhalation solution Respiratory Agents Generic Methergine methylergonovine maleate Metabolic/Endocnne Agents Brand Methitest methyltestosterone Metabolic/Endocrine Agents Brand Antineoplastics and Methotrexate methotrexate Immunosuppressants Generic Metimyd sulfacetamide/prednisolone Ophthalmic/Otic Agents Generic Metrocream metronidazole Dermatologic Agents Brand 20030111 9/03 Page 7 of 13 PCO1541 Metrogel metronidazole Dermatologic Agents Brand MetroGel-Vaginal metronidazole Anti-Infective Agents Brand Metrolotion Metronidazole Lotion 0.75% Dermatologic Agents Brand Mevacor lovastatin Cardiovascular Agents Generic Mexilil mexiletine Cardiovascular Agents Generic Micro-K 8mEq potassium chloride 8mEq Nutritional Supplements Brand Micronase glybunde Metabolic/Endocrine Agents Generic Micronor norethindrone Metabolic/Endocrine Agents Brand Microzide hydrochlorothiazide Cardiovascular Agents Generic Midamor amiloride Cardiovascular Agents Generic Midrin acetaminophervisometheptane/dichloralphenazone Central Nervous System Agents Generic Minipress prazosin Genitourinary Agents Generic Minipress prazosin Cardiovascular Agents Generic Minocin minocycline Anti-Infective Agents Generic Mintezol thiabendazole Anti-Infective Agents Brand Mircette desogestrel/ethinyl estradiol/ethinyl estradiol Metabolic/Endocrine Agents Brand Moduretic amiloride/hydrochlorothiazide Cardiovascular Agents Generic Monoket isosorbide mononitrate Cardiovascular Agents Generic Motrin ibuprofen Musculoskeletal Agents Generic MS Conlin morphine sulfate SR Musculoskeletal Agents Generic MSIR solution,tablets morphine sulfate solution,tablets Musculoskeletal Agents Generic Mucomyst acetylcysteine inhalant solution 20% Respiratory Agents Generic Mucomyst-10 acetylcysteine inhalant solution 10% Respiratory Agents Generic Myambutol ethambutol Anti-Infective Agents Generic Mycelex Troche dotrimazole Anti-Infective Agents Brand Mycifradnn neomycin sulfate Anti-Infective Agents Generic Mycobutin rifabutin Anti-Infective Agents Brand Mycolog II nystatin/Iriamcinolone Dermatologic Agents Generic Mycostatin oral nystatin Anti-Infective Agents Generic Mycostatin topical nystatin Dermatologic Agents Generic Mydriacil tropicamide OphthalmidOtic Agents Generic Antineoplastics and Myleran busulfan Immunosuppressants Brand Antineoplastics and Mylocel hydroxyurea Immunosuppressants Brand Mysoline primidone Central Nervous System Agents Generic Nalfon fenoprofen Musculoskeletal Agents Generic Nalfon capsule fenoprofen capsule Musculoskeletal Agents Brand Naprosyn naproxen Musculoskeletal Agents Generic Nardi) phenelzine sulfate Central Nervous System Agents Brand Nasalide flunisolide Respiratory Agents Generic Nasarel flunisolide Respiratory Agents Generic Nasonex mometasone furoate Respiratory Agents Brand Natacyn natamycin Ophthalmic/Otic Agents Brand Navane thiothixene Central Nervous System Agents Generic Navane 20mg capsule thiothixene 20mg capsule Central Nervous System Agents Brand NebuPent pentamidine Anti-Infective Agents Brand Neo-Synephrine phenylephnne Ophthalmic/Otic Agents Generic NeoDecadron dexamethasone/neomycin/polysorbate OphthalmidOtic Agents Brand Antineoplastics and Neoral capsule cyclosporine modified capsule Immunosuppressants Generic Antineoplastics and Neoral solution cyclosporine solution Immunosuppressants Brand Neosporin ophthalmic ointment bacitracin/neomycin/polymyxin b ophthalmic ointment Ophthalmic/O0c Agents Generic Neosporin ophthalmic solution gramicidin/neomycin/polymixin b ophthalmic solution Ophthalmic/Otic Agents Generic Neptazane methazolamide OphthalmidOtic Agents Generic Neurontin gabapentn Central Nervous System Agents Brand Niaspan niacin extended release Cardiovascular Agents Brand Antineoplastics and Nilandron nilutamide Immunosuppressants Brand Nitro-Bid nitroglycenn Cardiovascular Agents Generic Nitro-Dur nitroglycerin transdem1al patches Cardiovascular Agents Brand Nitroglycerin Ointment Nitroglycerin Ointment Cardiovascular Agents Generic Nitrostat nitroglycerin Cardiovascular Agents Generic Nizoral 2%Cream ketoconazole 2%cream Dermatologic Agents Generic Nizoral 2%Shampoo ketoconazole 2%shampoo Dermatologic Agents Brand Nizoral oral ketoconazole Anti-Infective Agents Generic 20030111 9/03 Page 8 of 13 PCO1541 H ".s e, C- Psi.xi.a. . _ a 't...s...: . Ali-:""' . ca .'::; Noctec chloral hydrate Central Nervous System Agents Brand Antineoplastics and Nolvadex lamoxifen citrate Immunosuppressants Brand Nordette levonorgestrel/ethinyl estradiol Metabolic/Endocnne Agents Brand Norfex orphenadrine citrate Musculoskeletal Agents Generic Norgesic orphenadrine/aspirin/caffeine Musculoskeletal Agents Generic Norgesic Forte orphenadrine/aspirin/caffeine Musculoskeletal Agents Generic Normodyne labetalol Cardiovascular Agents Generic Norpace disopyramide Cardiovascular Agents Generic Norpace CR 100mg disopyramide CR 100mg Cardiovascular Agents Brand Norpace CR 150mg disopyramide CR 150mg Cardiovascular Agents Generic Norpramin desipramine Central Nervous System Agents Generic Norvir ritonavir Anti-Infective Agents Brand Nulytely polyethylene glycovelectrolyte solution Gastrointestinal Agents Brand NuvaRing elonogestrel/ethinyl estradiol Metabolic/Endocrine Agents Brand Ocufen flurbiprofen Ophthalmic/Otic Agents Generic Ocuflox ofloxacin Ophthalmic/Otic Agents Brand Ogen estropipate Metabolic/Endocrine Agents Generic Omnicef cefdinir Anti-Infective Agents Brand OneTouch Test Strips test strips Diabetic Testing Supplies Brand _Ophthetic proparacaine OphthalmidOlic Agents Generic Optichamber respiratory device Respiratory Agents Brand Optihaler respiratory device Respiratory Agents Brand OptiPranolol metipranolol hcl OphthalmidOtic Agents Generic Optivar azelastine Ophthalmic/Otic Agents Brand Oramorph SR morphine sulfate SR Musculoskeletal Agents Brand Onnase tolbutamide Metabolic/Endocrine Agents Generic Ortho Evra norelgestromin/ethinyl estradiol transdermal patch Metabolic/Endocrine Agents Brand Ortho Tri-Cyclen norgestimate/ethinyl estradiol Metabolic/Endocnne Agents Brand Ortho-Cyclen norgestimate&ethinyl estradiol Metabolic/Endocnne Agents Brand Ortho-Novum 1/35 norethindrone/ethinyl estradiol Metabolic/Endocrine Agents Brand Ortho-Novum 1/50 norethindrone/mestranol Metabolic/Endocrine Agents Brand Ortho-Novum 10/11 norethindrone/ethinyl estradiol Metabolic/Endocrine Agents Brand Ortho-Novum 7/7/7 norethindrone/ethinyl estradiol Metabolic/Endocrine Agents Brand Owdis ketoprofen Musculoskeletal Agents Generic Otobiotic polymixin b/hydrocortisone Ophthalmic/Otic Agents Brand Ovral norgestrel/elhinyl estradiol Metabolic/Endocrine Agents Brand Pacerone 400mg amiodarone Cardiovascular Agents Brand Pamelor capsule nortriptyline capsule Central Nervous System Agents Generic Pancrease pancrelipase Gastrointestinal Agents Generic Pancrease MT pancrelipase Gastrointestinal Agents Generic Panmist-LA pseudoephedrine/guiafenesin Respiratory Agents Generic Pariodel capsule bromocriptine capsule Central Nervous System Agents Brand Pamate tranylcypromine sulfate Central Nervous System Agents Brand Patanol Ophthalmic Solution dopatadine hal Ophthalmic/Otic Agents Brand Paxil paroxetine Central Nervous System Agents Brand Paxil CR paroxetine CR Central Nervous System Agents Brand Pediazole erythromycin/sulsoxazole Anti-Infective Agents Generic Pen VK penicillin VK Anti-Infective Agents Generic Percocet(not 2.5mg/325mg) oxycodone/acetaminophen(not 2.5mg/325mg) Musculoskeletal Agents Generic Percodan oxycodone/aspinn Musculoskeletal Agents Generic Periactin cyproheptadine Central Nervous System Agents Generic Periactin cyproheptadine Respiratory Agents Generic Persantine dipyridamole Cardiovascular Agents Generic Phenergan promethazine Gastrointestinal Agents Generic Phenergan 12.5mg suppository promethazine 12.5mg suppository Gastrointestinal Agents Brand Phenergan 25mg,50mg suppository promethazine 25mg,50mg suppository Gastrointestinal Agents Generic Phenergan DM promethazine-dextromethorphan Respiratory Agents Generic Phenergan w/Codeine promethazine-codeine Respiratory Agents Generic Phenobarbital phenobarbital Central Nervous System Agents Generic Phoslo calcium acetate Nutritional Supplements Brand Phospholine echothiophate iodide Ophthalmic/Otic Agents Brand Phrenilin Forte acetaminophen/butalbital Central Nervous System Agents Generic Pilocar pilocarpine Ophthalmic/Otic Agents Generic Plaquenil hydroxychloroquine Anti-Infective Agents Generic 20030111 9/03 Page 9 of 13 PCO1541 ..-R&3'?4,..2.2:', liflk=— " `,s "' r dW`C.:SL,,iji '.,s"" ''e "jean w '°�u".v ! .'A Plendil felodipine Cardiovascular Agents Brand Polaramine dexchlorpheniramine maleate CR Respiratory Agents Generic Polaramine 2mg dexchlorpheniramine maleate 2mg Respiratory Agents Brand Poly-Histine pheniramine-pyrilamine-phenylloloxamine Respiratory Agents Brand Poly-Vi-Flor pediatric multiple vitamin with fluoride Nutritional Supplements Generic Poly-Vi-Flor w/Iron pediatric multiple vitamin with fluoride and iron Nutritional Supplements Generic Poly-Vi-Flor w/Iron(0.25mg tablets) pediatric multiple vitamin with FUFE Nutritional Supplements Brand Polycitra potassium/sodium citrates/citric acid Nutritional Supplements Generic Polycilra-K potassium citrate/citric acid Nutritional Supplements Generic Polycitra-LC potassium/sodium citrates/citric acid Nutritional Supplements Generic Polysponn polymyxin b/bacitracin Ophthalmic/Olic Agents Generic Polytrim trimethoprim/polymixin b Ophthalmic/Otic Agents Generic Potassium Chloride potassium chloride Nutritional Supplements Generic Pravachol pravastatin Cardiovascular Agents Brand Pred Forte prednisolone acetate 0.1% Ophthalmic/Otic Agents Generic Pred Mild prednisolone acetate 0.12% Ophthalmic/Olic Agents Brand Prednisone concentrate prednisone concentrate Metabolic/Endocrine Agents Brand Prednisone solution Prednisone solution Metabolic/Endocrine Agents Brand Prelone prednisolone Metabolic/Endocrine Agents Generic Premarin conjugated estrogen Metabolic/Endocrine Agents Brand Premphase estrogen/medroxyprogesterone Metabolic/Endocrine Agents Brand Prempro estrogen/medroxyprogesterone Metabolic/Endocrine Agents Brand Prenatal Vitamins wth Folic Acid 1mg All generic prenatal vitamins are covered. Nutritional Supplements Generic PrevPac amoxicillin/clarithromyciMansoprazole CR Gastrointestinal Agents Brand Primaquine primaquine phosphate Anti-Infective Agents Brand Principen ampicillin Anti-Infective Agents Generic Pro-Banthine 15mg probantheline bromide 15mg Gastrointestinal Agents Generic Procainamide 500mg capsule procainamide 500mg capsule Cardiovascular Agents Brand Proctofoam HC hydrocortisone/pramoxine Gastrointestinal Agents Brand Prolixin fluphenazine Central Nervous System Agents Generic Pronestyl 250mg,375mg capsule procainamide 250mg,375mg capsule Cardiovascular Agents Generic Pronestyl SR procainamide CR Cardiovascular Agents Generic Propine dipivefrin Ophthalmic/Otic Agents Generic Propylthiouracil propylthiouracil Metabolic/Endocrine Agents Generic Prolonix pantoprazole Gastrointestinal Agents Brand Proventil Inhalation Solution albuterol inhalation solution Respiratory Agents Generic Proventil Inhaler albulerol Respiratory Agents Generic Proventil Repetabs albuterol CR Respiratory Agents Brand Proventil syrup,tablet albuterol syrup,tablet Respiratory Agents Genenc Provers medroxyprogesterone MetaboliGEndocrine Agents Generic Prozac(not Prozac Weekly) fluoxetine Central Nervous System Agents Generic Antineoplastics and Purinethol mercaptopurine,6-MP Immunosuppressants Brand Pyrazinamide pyrazinamide Anti-Infective Agents Generic Pyndium phenazopyridine Genitourinary Agents Generic Questran cholestyramine Cardiovascular Agents Generic Questran Light cholestyramine Cardiovascular Agents Generic Quibron-T 300mg tablet lheophylline 300mg tablet Respiratory Agents Brand Quinaglute quinidine gluconate Cardiovascular Agents Generic Quinidex quinidine sulfate SR Cardiovascular Agents Generic Quinidine Sulfate quinidine sulfate Cardiovascular Agents Generic Quinine Sulfate quinine sulfate Anti-Infective Agents Generic Quixin levofloxacin Ophthalmic/Otic Agents Brand QVAR beclomethasone dipropionate Respiratory Agents Brand Reglan metoclopramide Gastrointestinal Agents Generic Remeron Soltab mirlazapine Central Nervous System Agents Brand Rescnptor delavirdine mesylate Anti-Infective Agents Brand Restonl temazepam Central Nervous System Agents Generic Reston'7.5mg temazepam 7.5mg Central Nervous System Agents Brand Retin-A cream,gel tretinoin cream,gel Dermatologic Agents Generic Retin-A liquid tretinoin liquid Dermatologic Agents Brand Resin-A Micro tretinoin microsphere Dermatologic Agents Brand Retrovir AZT/zidovudine Anti-Infective Agents Brand Rheumatrex methotrexate Musculoskeletal Agents Generic 20030111 9/03 Page 10 of 13 PCO1541 Rhinocort Aqua budesonide Aqua Respiratory p' ry Agents Brand Ridaura auranofin Musculoskeletal Agents Brand Rifadin nfampin Anti-Infective Agents Generic Risperdal rispendone Central Nervous System Agents Brand Ritalin methylphenidate Central Nervous System Agents Generic Ritalin SR methylphenidate SR Central Nervous System Agents Generic RMS morphine sulfate Musculoskeletal Agents Generic Robaxin methocarbamol Musculoskeletal Agents Generic Robitussin AC guaifenesin/codeine Respiratory Agents Generic Robitussin DAC pseudoephedrine/codeine/guaifenesin Respiratory Agents Generic Rocaltrol calcilriol Nutritional Supplements Brand Rocaltrol Solution calcitriol solution Nutritional Supplements Brand Rondec brompheniramine or carbinoxamine/pseudoephedrine Respiratory Agents Generic brompheniramine or Rondec DM carbinoxamine/pseudoephedrine/dextromethorphan Respiratory Agents Generic Rowasa enema mesalamine Gastrointestinal Agents Brand Roxanol,Roxanol-T morphine sulfate Musculoskeletal Agents Generic Roxicodone tablet oxycodone tablet Musculoskeletal Agents Generic Rynatan 1-120mg azatadine/pseudoephedrine cr Respiratory Agents Brand Rynatan-S ,Chlorpheniramine/phenylephrine/pyrilamine Respiratory Agents Generic Rythmol propafenone Cardiovascular Agents Generic Salagen pilocarpine hcl Miscellaneous Agents Brand Antineoplastics and Sandimmune solution cyclosporine solution Immunosuppressants Brand Sansert methysergide Central Nervous System Agents Brand Sebizon sodium sulfacetamide Dermatologic Agents Brand Sectral acebutolol Cardiovascular Agents Generic Sedapap acetaminophen/butalbital Central Nervous System Agents Generic Selsun selenium sulfide Dermatologic Agents Generic Serax oxazepam Central Nervous System Agents Generic Serevent Diskus DPI salmeterol xinafoate Respiratory Agents Brand Serevent Inhaler salmeterol Respiratory p ry Agents Brand Serzone nefazodone Central Nervous System Agents Brand Silvadene silver sulfadiazine Dermatologic Agents Generic Sinemet carbidopaaevodopa Central Nervous System Agents Generic Sinemet CR carbidopa/levodopa CR Central Nervous System Agents Generic Sinequan doxepin Central Nervous System Agents Generic Singulair montelukast sodium Respiratory Agents Brand Slo-Bid theophylline SR Respiratory Agents Generic Slo-Bid 50mg,75mg theophylline SR 50mg,75mg Respiratory Agents Brand Slo-Phyllin theophylline Respiratory Agents Brand Slo-Phyllin Solution theophylline Respiratory Agents Generic Soft Touch Lancets lancets Diabetic Testing Supplies Brand Soflclix Lancets lancets Diabetic Testing Supplies Brand Somnote chloral hydrate Central Nervous System Agents Brand Sorbitrate chewable tablet isosorbide dinitrate chewable tablet Cardiovascular Agents Brand Soriatane acitretin Dermatologic Agents Brand Spectazole econazole nitrate 1%cream Dermatologic Agents Brand 55KI potassium iodide Respiratory Agents Brand Stelazine concentrate triiluoperazine concentrate Central Nervous System Agents Brand Stelazine tablet trifluoperazine tablet Central Nervous System Agents Generic Sular nisoldipine Cardiovascular Agents Brand Sulfacet-R sulfacetamide sodiumisutfur Dermatologic Agents Generic Sultrin vaginal cream triple sulfa Anti-Infective Agents Generic Suredose Insulin Syringes Suredose Insulin Syringes Diabetic Testing Supplies Brand SureStep Test Strips test strips Diabetic Testing Supplies Brand Sustiva efavirenz Anti-Infective Agents Brand Symmetrel amantadine Anti-Infective Agents Generic Symmetrel amantadine Central Nervous System Agents Generic Syn-Rx pesudoephedrine/guiafenesin 8 guiafenesin Respiratory Agents Generic Synalar fluoonolone Dermatologic Agents Generic Synarel nafarelin Metabolic/Endocrine Agents Brand Synthroid levothyroxine MetabolicEndocnne Agents Generic T-Stat erythromycin Dermatologic Agents Generic Tagamet cimetidine Gastrointestinal Agents Generic Tambocor flecainide Cardiovascular Agents Generic 20030111 9/03 Page 11 of 13 PCO1541 ,,F..... .... =-'.:9 ..%7-1-,,`'t : -U:f. .ri.. ; .i.,ry, '.. ..: ski 1: .:C. 70.<7:...::nj R3 Antineoplastics and Tamoxifen tamoxifen citrate Immunosuppressants Brand Tapazole methimazole Metabolic/Endocrine Agents Generic Tapazole 20mg tab methimazole Metabolic/Endocrine Agents Brand Antineoplastics and Targrelin capsule bexarotene capsule Immunosuppressants Brand Tavist Gemastine Respiratory Agents Generic Tegretol suspension carbamazepine suspension Central Nervous System Agents Brand Tegretol tablet,chewable tablet carbamazepine Central Nervous System Agents Both Tegretol XR carbamazepine Central Nervous System Agents Brand Anlineoplastics and Temodar temozolomide Immunosuppressants Brand Temovate clobetasol propionate Dermatologic Agents Generic Tenex guanfacine Cardiovascular Agents Generic Tenoretic atenolol/chlorthalidone Cardiovascular Agents Generic Tenormin atenolol Cardiovascular Agents Generic Terramycin oxytetracycline/polymixin b Ophthalmic/O1m Agents Generic Terumo Insulin Syringes Terumo Insulin Syringes Diabetic Testing Supplies Brand Antineoplastics and Teslac testolactone Immunosuppressants Brand Tessalon Perles 100mg capsule benzonatate 100mg capsule Respiratory Agents Generic Testred methyllestosterone MetaboliGEndocrine Agents Brand Theo-24 theophylline SR Respiratory Agents Brand Theo-Dur theophylline SR Respiratory Agents Generic Anlineoplastics and Thioguanine thioguanine Immunosuppressants Brand Thorazine chlorpromazine Central Nervous System Agents Generic Tigan trimelhobenzamide Gastrointestinal Agents Generic Tigan 100mg,300mg capsule trimethobenzamide 100mg,300mg capsule Gastrointestinal Agents Brand Tilade nedocromil sodium Respiratory Agents Brand Timoptic timolol maleate Ophthalmic/Olic Agents Generic Tobradex dexamethasone/lobramycin Ophthalmic/Otic Agents Brand Tobrex ophthalmic ointment lobramycin ophthalmic ointment Ophthalmic/Otic Agents Brand Tobrex ophthalmic solution tobramycin ophthalmic solution OphthalmicOtic Agents Generic Tofranil imipramine Central Nervous System Agents Generic Toleclin tolmetin Musculoskeletal Agents Generic Tolectin DS tolmetin Musculoskeletal Agents Generic Tolinase tolazamide Metabolic/Endocrine Agents Generic Tonocard tocainide Cardiovascular Agents Brand Topicort desoximetasone Dermatologic Agents Generic Toradol ketorolac Musculoskeletal Agents Generic Torecan thiethylperazine Gastrointestinal Agents Brand Trandate labetalol Cardiovascular Agents Generic Tranxene dorazepate Central Nervous System Agents Generic Trental pentoxifylline CR Cardiovascular Agents Generic Antineoplastics and Trexall methotrexate Immunosuppressants Brand Tri-Vi-Flor pediatric vitamin ACD with fluoride Nutritional Supplements Generic Tri-Vi-Flor w/lron pediatric vitamin ACD with fluoride and iron Nutritional Supplements Generic Tnavil perphenazine/amitriptyline Central Nervous System Agents Generic Tndesilon desonide Dermatologic Agents Generic Trilafon perphenazine Central Nervous System Agents Generic Trilafon concentrate perphenazine concentrate Central Nervous System Agents Generic Trilisate liquid salicylate combination liquid Musculoskeletal Agents Brand Trilisate tablet salicylate combination tablet Musculoskeletal Agents Generic Trimpex Inmethopnm Anti-Infective Agents Generic Trinalin pseudoephedrine/azatadine Respiratory Agents Brand Triphasil levonorgestrel/ethinyl estradiol Metabolic/Endocrine Agents Brand Trizivir abacavir sulfateJamivudine-zidovudine Anti-Infective Agents Brand Tylenol w/Codeine acetaminophen/codeine Musculoskeletal Agents Generic Tympagesic benzocaine/phenylephdne/antipyrine Ophthalmic/Olic Agents Generic Uniphyl theophylline Respiratory Agents Brand Uniretic moexipril/HCTZ Cardiovascular Agents Brand Univasc moexipril Cardiovascular Agents Generic Urecholine bethanechol Genitourinary Agents Brand Urocit-K potassium citrate Genitourinary Agents Brand 20030111 9/03 Page 12 of 13 PCO1541 r n•.,•Z:- n:. i —'.:Ai. C . { u.: ciSi.„--uca;i1.4,11 Valisone betamethasone valerate Dermatologic Agents Generic Valium diazepam Musculoskeletal Agents Generic Valium diazepam Central Nervous System Agents Generic Velosef cephradine Anti-Infective Agents Brand Velosulin BR human regular insulin buffered Metabolic/Endocrine Agents Brand Vent°lin Inhalation Solution albuterd inhalation solution Respiratory Agents Generic Venlolin Inhaler albuterol Respiratory Agents Generic Ventolin syrup,tablet albuterol syrup,tablet Respiratory Agents Generic Antineoplastics and VePesid etoposide Immunosuppressants Brand Vermox mebendazole Anti-Infective Agents Generic Antineoplastics and Vesanoid tretinoin Immunosuppressants Brand Vibramycin doxycydine Anti-Infective Agents Generic Vicodin hydrocodone bitartrate/acetaminophen Musculoskeletal Agents Generic Vicodin ES hydrocodone bitartrate/acetaminophen Musculoskeletal Agents Generic Videx ddl/dideoxyinosine Anti-Infective Agents Brand Videx EC ddl/dideoxyinosine delayed release Anti-Infective Agents Brand Viokase pancrelipase Gastrointestinal Agents Generic Viokase 16 pancrelipase Gastrointestinal Agents Brand Vira A vidarabine Ophthalmic/Otic Agents Brand Viracept neltnavir mesylate Anti-Infective Agents Brand Viramune nevirapine Anti-Infective Agents Brand Vireed tenofovir disoproxil fumarate Anti-Infective Agents Brand Viroptic trifluridine Ophthalmic/Otic Agents Generic Visken pindolol Cardiovascular Agents Generic Vistaril hydroxyzine pamoate Respiratory Agents Generic Vivelle estradiol transdermal patch Metabolic/Endocrine Agents Brand Vivelle-DOT estradiol transdermal patch Metabolic/Endocrine Agents Brand Volmax albuterol CR Respiratory Agents Brand Voltaren diclofenac Musculoskeletal Agents Generic Voltaren ophthalmic didofenac ophthalmic Ophthalmic/Otic Agents Brand VoSol acetic acid Ophthalmic/Otic Agents Generic VoSol HC acetic acid/hydrocortisone Ophthalmic/Otic Agents Generic Vytone iodoquinol/hydrocortisone Dermatologic Agents Generic Wellbutrin bupropion Central Nervous System Agents Generic Wellbutrin SR bupropion CR Central Nervous System Agents Brand Wytensin guanabenz acetate Cardiovascular Agents Generic Xalatan latanoprost Ophthalmic/Otic Agents Brand Xanax alprazolam Central Nervous System Agents Generic Antineoplastics and Xeloda capecitabine Immunosuppressants Brand Xylocaine 2%gel lidocaine 2%gel Dermatologic Agents Generic Xylocaine 5%ointment lidocaine 5%ointment Dermatologic Agents Generic Xylocaine Viscous lidocaine viscuous Miscellaneous Agents Generic Yasmin drospirenone/ethinyl estradiol Metabolic/Endocrine Agents Brand Yodoxin tablet iodoquinol tablet Anti-Infective Agents Brand Zantac syrup ranitidine Gastrointestinal Agents Brand Zantac tablet ranitidine Gastrointestinal Agents Generic Zarontin ethosuximide Central Nervous System Agents Brand Zaroxolyn metolazone Cardiovascular Agents Brand Zephrex LA pseudoephedrine/guaifenesin Respiratory Agents Generic Zerit stavudine Anti-Infective Agents Brand Zestoretic IisinopriMydrochlorothiazide Cardiovascular Agents Generic Zestnl lisinopril Cardiovascular Agents Generic Ziagen abacavir sulfate Anti-Infective Agents Brand Zithromax azithromycin Anti-Infective Agents Brand Zocor simvastatin Cardiovascular Agents Brand Zofran ODT ondansetron Gastrointestinal Agents Brand Zofran solution ondansetron Gastrointestinal Agents Brand Zofran tablet ondansetron tablet Gastrointestinal Agents Brand Zomig zolmitriptan Central Nervous System Agents Brand Zomig ZMT zolmitriptan Central Nervous System Agents Brand Zovirax oral acydovir Anti-Infective Agents Generic Zovirax topical acydovir Dermatologic Agents Brand Zylopnm allopunnol Metabolic/Endochne Agents Generic Zyprexa olanzapine Central Nervous System Agents Brand 20030111 9/03 Page 13 of 13 PCO1541 PacifiCare Signature Valuer A select group of physicians • Aler PacifiCare of Colorado 2004 Combined Evidence of Coverage and Disclosure Form Non-Federally Qualified Plans IE 1:i Welcome to PacifiCare Welcome to Pacificare of Colorado For more than 25 years, PacifiCare and its,predecessor companies have been providing health care coverage in the state. This publication wilt help you become more familiar with your health care benefits. It will also introduce you to our health care community. PacifiCare provides health care coverage to Members who have properly enrolled in our Plan and meet our eligibility requirements. To learn more about these requirements, see Section Seven—Member Eligibility. What is this publication? This publication is called a Combined Evidence of Coverage and Disclosure Form. It is a legal document that explains your health care plan and should answer many important questions about your benefits. Many of the words and terms are capitalized because they have special meanings. To better understand these terms, please see Section Ten- Definitions. Whether you are the Subscriber of this coverage or enrolled as a Dependent, your Combined Evidence of Coverage and Disclosure Form is a key to making the most of your membership. You'll learn about important topics like how to select a Primary Care Physician and what to do if you need hospitalization. What else should I read to understand my benefits? Along with reading this publication, be sure to review your Schedule of Benefits and any additional benefit materials. Your Schedule of Benefits provides the details of your particular Health Plan, including any Copayments that you may have to pay when using a health care service. Together, these documents explain your coverage. What if I still need help? After you become familiar with your benefits, you may still need assistance. Please don't hesitate to call our Customer Service department at 1-800-877-9777 or 1-800-360-1797 (TDD). NOTE: Your Combined Evidence of Coverage and Disclosure Form and Schedule of Benefits provides the terms and conditions of your coverage with PacifiCare and all applicants have a right to view these documents prior to enrollment. The Combined Evidence of Coverage and Disclosure Form should be read completely and carefully Individuals with special health needs should pay special attention to those sections that apply to them. You may correspond with PacifiCare at the following address: PacifiCare P.O. Box 6770 Englewood, Colorado 80155 PacifiCare's Web site is: www.pacificare.com �� Table of Contents Section One: Section Four: Getting Started: Changing Your Doctor 12 Your Primary Care Physician 3 Changing Your Primary Care Physician 12 Introduction 3 When We Change Your Primary Care Physician 12 What is a Primary Care Physician? 3 Continuing Care with a Terminated Physician 12 Access to Care Physician Network 3 _ ___- Continuity of Care for New Members 12 What is the difference between Section Five: a Subscriber and an Enrolled Dependent? 4 Your Medical Benefits 13 Choosing a Primary Care Physician 4 -__ --- ---- -- ----------------------- What is Continuity of Care? 4 Your Medical Benefits 13 Your Provider Directory- Inpatient Benefits 13 Choice of Physicians and Hospitals (Facilities) 5 Outpatient Benefits 16 Choosing a Primary Care Physician Exclusions and Limitations for Each Enrolled Dependent 5 of Benefits 26 If You Are Pregnant 5 General Exclusions 26 Section Two: Other Exclusions and Limitations 27 Seeing the Doctor 6 Seeing the Doctor: Scheduling Appointments 6 Section Six: PacifiCare Express Referrals° 6 Payment Responsibility 38 Referrals to Specialists 6 What are Premiums (Prepayment Fees)? 38 OB/GYN: Getting Care Without a Referral 7 _______ What are Copayments (Other Charges)? 38 Second Medical Opinions 7 Ann-- f--__— ____ --- ---- . _- ___ Annual0ut-of-Pocket Maximum 38 What is PacifiCare's Case _____________ - ------- ------If You Get a Bill (Reimbursement Provisions) 38 Management Program? 8 What is a Schedule of Benefits? 39 Prearranging Hospital Stays 8 Bills From Non-Participating Providers 39 Section Three: How to Avoid Unnecessary Bills 39 Emergency and Urgently Needed Services 9 Your Billing Protection 39 What are Emergency Medical Services? 9 Coordination of Benefits s ts 40 What is an Emergency Medical Condition? 9 Important Rules for Medicare- and What To Do When You Require Medicare-Eligible Members 44 -------------- Emergency Services 9 Assignment 44 Post-stabilization and Follow-up Care 9 Out-of-Area Services 10 Always Remember 10 ---------- -------------- What To Do When You Require Urgently Needed Services 10 Out-of-Area Urgently Needed Services 11 International Emergency and Urgently Needed Services 11 ' I ii li li ll !,f 1 C Table of Contents . . kh Section Seven: Section Eight: Member Eligibility 45 Overseeing Your Health Care Decisions 56 Who is a PacifiCare Member? 45 How PacifiCare Makes Important Eligibility 46 Health Care Decisions 56 What is an HMO Service Area? 46 Authorization, Modification and enia l - of Health Care Services 56 Open Enrollment 47 Medical Management Guidelines 57 Adding Dependents to Your Coverage 47 Utilization Criteria 57 Qualified Medical Child Support Order 47 What To Do If You Have a Problem 57 Continuing Coverage for Student and Disabled Dependents 48 Appealing a Health Care Decision or Requesting a Quality Review 58 Late Enrollment 48 -__- Quality Review 58 Notifying You of Changes in Your Plan 49 The Appeals Process 58 About Your PacifiCare Identification Card HID) 49 Binding Arbitration 61 Updating Your Enrollment Information 50 Complaints Against Participating Providers, Renewal and Reinstatement Physicians and Hospitals 61 (Renewal Provisions) of 50 Ending Coverage (Termination of Benefits) 50 Section Nine: General Information 62 Coverage Options Following Termination (Individual Continuation of Benefits) 52 What should I do if I lose or misplace my Federal COBRA Continuation Coverage 52 membership card? 62 Extending Your Coverage: Converting to an Does PacifiCare offer a translation service? 62 Individual Conversion Plan 54 Does PacifiCare offer hearing and speech Certificate of Creditable Coverage 55 impaired telephone line? 62 Uniformed Services Employment and How is my coverage provided under Reemployment Rights Act 55 extraordinary circumstances? 62 How does PacifiCare compensate its Participating Providers? 62 How To Get Help 62 Advanced Directives 63 Section Ten: Definitions 64 Section Eleven: Your Rights and Responsibilities 71 Section One - Getting Started Getting Started: Your What is a Primary Care Physician? Primary Care Physician When you become a Member of PacifiCare, one of the first things you do is choose a doctor to be your Primary Introduction Care Physician. This is a doctor who is contracted with PacifiCare and who is primarily responsible for the • What is a Primary Care Physician? coordination of your health care services. A Primary Access to Care: Physician Network Care Physician is trained in internal medicine, general practice, family practice or pediatrics. ▪ What is the difference between a Subscriber and an Enrolled Dependent? Access to Care: Physician Network ▪ Choosing Your Primary Care Physician Many of PacifiCare's participating Physicians are ▪ Your Provider Directory— Choice of Physicians organized into groups of Primary Care Physicians and and Hospitals (Facilities) specialists who have joined together to provide services to • Choosing a Primary Care Physician for Each PacifiCare Members. This unique arrangement has Enrolled Dependent benefits for patients and doctors alike. For those Physicians affiliated in this manner, Primary Care ▪ If You Are Pregnant Physicians belong to just one group, but some specialists What is Continuity of Care? may have more than one affiliation.When you need specialty care, your Primary Care Physician may refer you One of the first things you do when joining PacifiCare to a specialist with whom he or she is affiliated. Primary is to select a Primary Care Physician. This is the doctor Care Physicians typically have established relationships in charge of overseeing your care through PacifiCare. I with other doctors to whom they will most likely refer This section explains the role of the Primary Care patients when specialized care is needed. Primary Care Physician, as well as how to make your choice. You'll Physicians work closely with the specialty Physicians they also learn about your Participating Provider and how I know and trust- to ensure that each Member receives the to use your Provider Directory care he or she needs. This system of referring creates a framework for effective PLEASE READ THE FOLLOWING INFORMATION SO YOU I coordinated care and communications regarding patient WILL KNOW FROM WHOM OR WHAT GROUP OF health, supported by trusting Physician relationships-all I PROVIDERS HEALTH CARE MAY BE OBTAINED. important elements of a quality health care system. Referring to a specialist with whom your Primary Care Physician is familiar makes it easy for your Primary Care Introduction Physician to communicate with both you and your Now that you're a PacifiCare Member, it's important to specialist and coordinate your care. PacifiCare's policy is become familiar with the details of your coverage. to encourage Primary Care Physicians to consider Reading this publication will help you go a long way patients' input in care decisions. This arrangement toward understanding your coverage and health care benefits patients and doctors alike. benefits. It's written for all our Members receiving AN ACCESS PLAN DETAILING THE MANAGED CARE this plan, whether you're the Subscriber or an NETWORK IS AVAILABLE UPON REQUEST. PLEASE enrolled Dependent CONTACT OUR CUSTOMER SERVICE DEPARTMENT Please read this Combined Evidence of Coverage and AT 1-800-877-9777. Disclosure Form along with any supplements you may ------------------------_ have with this coverage. You should also read and become familiar with your Schedule of Benefits, which lists the benefits and costs unique to your plan. Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. g�w Section One - Getting Started it, we What is the difference between a Subscriber Choosing a Primary Care Physician and an enrolled Dependent? ` When choosing a Primary Care Physician, you should always make certain your doctor is selected from the list of While both are Members of PacifiCare, there's a difference Primary Care Physicians in PacifiCare's Provider Directory. between a Subscriber and an enrolled Dependent.A Subscriber is the Member who enrolls through his or her You'll find a list of our participating Primary Care employer after meeting the eligibility requirements of the Physicians in the Provider Directory. It's also a source Employer Group and PacifiCare. A Subscriber may also for other valuable information. contribute toward a portion of the Premiums paid to PacifiCare for his or her health care coverage for him or herself and any enrolled Dependents. An enrolled What is Continuity of Care? Dependent is someone such as a Spouse or child whose Under certain circumstances, new Members of Dependent status with the Subscriber allows him or her PacifiCare may be able to temporarily continue receiving to be a Member of PacifiCare. Why point out the services from a Non-Participating Provider. This short- difference? Because Subscribers often have special term transition assistance is intended for new Members responsibilities, including sharing benefit updates with who are experiencing an acute episode of care white any enrolled Dependents. Subscribers also have special making the transition to PacifiCare. Typically, this responsibilities that are noted throughout this publication. condition requires prompt medical attention and is of If you're a Subscriber, please pay attention to any limited duration. (Examples include, but are not limited instructions given specifically for you. to: pregnancy in the third trimester; being in an acute FOR A MORE DETAILED EXPLANATION OF ANY TERMS, hospital or scheduled to be in the hospital immediately SEE THE "DEFINITIONS"SECTION OF THIS PUBLICATION. after your PacifiCare coverage becomes effective; undergoing a course of chemotherapy, radiation therapy or psychiatric counseling; being on a transplant list.) Unless you need emergency or urgently needed care, your Primary Care Physician is your first stop for using If you're a new Member and believe you qualify for these medical benefits. Your Primary Care Physician will Continuity of Care, please call our Customer Service also seek authorization for any referrals, as well as department and request the form "Continuity of Care for initiate and coordinate any necessary Hospital Services. New Enrollees Request." Complete and return this form All Members of PacifiCare are required to have a to PacifiCare as soon as possible. Upon receiving the Primary Care Physician. If you don't select one when completed form,a medical review will be completed in three business days. If you qualify,you will be notified by you enroll, PacifiCare will choose one for you. Except in telephone of the decision and provided with the plan for an urgent or emergency situation, if you see another your care. If you don't qualify, attempts will be made to health care Provider without the approval of either your notify you by telephone of the decision.You will be Primary Care Physician or PacifiCare, the costs for these notified in writing within three business days of the services may not be covered. completed review, and alternatives will be offered. Please note: It's not enough to simply prefer receiving treatment from a former Physician or other Non- Participating Provider, even for a Chronic Condition. You should not continue care with a Non-Participating Provider without our formal approval. If you do not receive preauthorization by PacifiCare,payment for services performed by a Non-Participating Provider will be your responsibility. A STATEMENT DESCRIBING PACIFICARE'S POLICIES AND PROCEDURES FOR PRESERVING THE CONFIDENTIALITY OF MEDICAL RECORDS IS AVAILABLE AND WILL BE FURNISHED TO YOU UPON REQUEST. Section One - Getting Started ) Your Provider Directory- Choice of Physicians If You Are Pregnant and Hospitals (Facilities) Every Member of PacifiCare needs a Primary Care Along with listing our participating Physicians, your Physician, including your newborn. If you are pregnant, Provider Directory has detailed information about our we encourage you to plan ahead and pick a Primary other Providers. Every Subscriber should receive a Care Physician for your baby Provider Directory. If you need a copy or would like Newborns remain enrolled with the mother's Primary assistance picking your Primary Care Physician, Care Physician from birth until discharge from the please call our Customer Service department. You can hospital. You may enroll your newborn with a different also find an online version of the Directory at Primary Care Physician following the newborn's www.pacificare.com. discharge by calling PacifiCare's Customer Service department. If a Primary Care Physician isn't chosen for Choosing a Primary Care Physician for Each Enrolled Dependent your child, the newborn will remain with the mother's Primary Care Physician. Every PacifiCare Member must have a Primary Care Physician; however, the Subscriber and any enrolled You can learn more about changing Primary Care Dependents don't need to choose the same doctor. Physicians in Section Four- Changing Your Doctor. Each PacifiCare Member can choose his or her own (For more about adding a newborn to your coverage, Primary Care Physician, so long as the doctor is selected see Section Seven-Member Eligibility.) from PacifiCare's list of Primary Care Physicians. If a Dependent doesn't make a selection during enrollment, PacifiCare will choose the Member's Primary Care Physician. (NOTE: If an enrolled Dependent is pregnant, please read below to learn how to choose a Primary Care Physician for the newborn.) Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. Section Two - Seeing the Doctor Seeing the Doctor PacifiCare Express Referrals® A select network of Participating Physicians offers a • Seeing the Doctor: Scheduling Appointments program called PacifiCare's Express Referra[s® • Referrals to Specialists Express Referrals® means if your Primary Care Physician decides you need a specialist, no further • PacifiCare Express Referrals"` authorization is required. Without this program, any • Standing Referrals to Specialists referral made by your Primary Care Physician will be • OB/GYN: Getting Care Without a Referral reviewed and can be denied by PacifiCare. Second Medical Opinions To locate the Participating Providers offering Express • Referrals®, see your Provider Directory. You can also • What is PacifiCare's Case contact our Customer Service department or find a Management Program? list at www.pacificare.com. Prearranging Hospital Stays• Referrals to Specialists Now that you've chosen a Primary Care Physician, you have a doctor for your routine health care. Your Your Primary Care Physician is responsible for Primary Care Physician will determine when you need determining when it's Medically Necessary for you to a specialist, arrange any necessary hospital care and see a specialist. (There is an exception for visits to oversee your health care needs. obstetrical and gynecological (OB/GYN) Physicians. This is explained below in "OB/GYN: Getting Care Without a This section will help you begin taking advantage of Referral.") If your Primary Care Physician does not your health care coverage. It will also answer common participate in Express Referrals® and determines you questions about seeing a specialist and receiving need a referral, he or she will submit a request to medical services that are not Emergency Services or PacifiCare. If approved, the referral is authorized; if the Urgently Needed Services. (For information on request is not approved, the referral is denied. In the Emergency Services or Urgently Needed Services, please event of a denial, you can request an appeal of the r Section Three) :turn to k see Section Eight:decision. For more about appeals, g Overseeing He alth alth Care Decisions. • Seeing the Doctor: Scheduling Appointments Your H To visit your Primary Care Physician, simply make an Standing Referrals to Specialists appointment by calling your doctor's office. Your A standing referral is a referral by your Primary Care Primary Care Physician is your first stop for accessing Physician that authorizes more than one visit to a care except when you need Emergency Services, or participating specialist or specialized treatment center when you require Urgently Needed Services and you are for ongoing treatment. A standing referral may be outside of the HMO Service Area. Without an authorized provided if your Primary Care Physician, in consultation referral from your Primary Care Physician or PacifiCare, with you, the specialist and a PacifiCare Medical no Physician or other health care services will he Director, determines that as part of a treatment plan you covered except for Emergency Services and Urgently need continuing care from a specialist. You may request Needed Services. (There is an exception if you wish to a standing referral from your Primary Care Physician or visit an obstetrical and gynecological Physician. See PacifiCare. Please note: A standing referral and below, "OB/GYN: Getting Care Without a Referral.") treatment plan is only allowed if approved by PacifiCare. When you see your Primary Care Physician or use one of Your Primary Care Physician will specify how many your health care benefits, you may be required to pay a specialist visits are authorized. The treatment plan may charge for the visit. This charge is called a Copayment. Limit your number of visits to the specialist and the The amount of a Copayment depends upon the health period for which visits are authorized. It may also require care service. Your Copayments are outlined in your the specialist to provide your Primary Care Physician with Schedule of Benefits. More detailed information can also regular reports on your treatment and condition. be found in Section Six— Payment Responsibility. a Section Two - Seeing the Doctor 1 OB/GYN: Getting Care Without a Referral Either you or your treating Participating Provider may Women may receive obstetrical and submit a request for a second medical opinion. 'lb gynecological find out how you should submit your request, talk to (OB/GYN) Physician services directly from a Participating OB/GYN or Primary Care Physician. This means you may your Primary Care Physician or call our Customer receive these services without preauthorization or a Service department. referral from your Primary Care Physician. In all cases, Second medical opinions will be provided or authorized however, the doctor must be participating with PacifiCare. in the following circumstances: Please remember: if you visit an OB/GYN or Physician • When you question the reasonableness or necessity of not participating with PacifiCare, without recommended surgical procedures; preauthorization or a referral, you will be financially • When you question a diagnosis or treatment plan for responsible for these services. All OB/GYN inpatient or a condition that threatens loss of life, loss of limb, loss Hospital Services, except Emergency or Urgently of bodily functions or substantial impairment Needed Services, need to be authorized in advance by (including, but not limited to, a Chronic Condition); your Primary Care Physician or PacifiCare. The only exception to the OB/GYN direct access process • When the clinical indications are not clear, or are complex and confusing; is OB/GYN specialists whose practices primarily consist of subspecialty care such as Infertility or genetics. Such • When a diagnosis is in doubt due to conflicting test specialists can be accessed only by referral from the results; Member's Primary Care Physician. • When the treating Provider is unable to diagnose the If you would like to receive OB/GYN Physician services, condition; simply do the following: • When the treatment plan in progress is not improving • Call our Customer Service department telephone your medical condition within an appropriate period number on your ID Card and request the names and of time given the diagnosis, and you request a second telephone numbers of the OB/GYNs participating with opinion regarding the diagnosis or continuance of the PacifiCare; treatment; • Telephone and schedule an appointment with your • When you have attempted to follow the treatment plan selected Participating OB/GYN. or consulted with the initial Provider and still have serious concerns about the diagnosis or treatment. After your appointment, your OB/GYN will contact your Primary Care Physician about your condition, treatment A PacifiCare Medical Director will approve or deny a and any needed follow-up care. request for a second medical opinion. The request will PacifiCare also covers important wellness services for our be approved or denied in a timely fashion appropriate to the nature of your condition. For circumstances other Members. For more information, see "Health Education than an imminent or serious threat to your health, a Services" in Section Five—Your Medical Benefits. second medical opinion request will be approved or Second Medical Opinions denied within the time frames required by state and federal law. A second medical opinion is a reevaluation of your condition or health care treatment by an appropriately When there is an imminent and serious threat to your qualified Provider. This Provider must be either a health, a decision about your second opinion will be Primary Care Physician or a specialist acting within his made within 72 hours after receipt of the request by or her scope of practice, and must possess the clinical PacifiCare. An imminent and serious threat includes the background necessary for examining the illness or potential loss of life, limb or other major bodily condition associated with the request for a second function, or where a lack of timeliness would be medical opinion. Upon completing the examination, the detrimental to your ability to regain maximum function. Provider's opinion is included in a consultation report. Questions aboutyour benefits? Call _ _ the Customer Service Department at 1 800 877 9777. Section Two - Seeing the Doctor If you are requesting a second medical opinion about care given by your Primary Care Physician, the second What is PacifiCare's Case medical opinion will be provided by a Primary Care Management Program? Physician or specialist listed in our Provider Directory. PacifiCare has licensed registered nurses who, in If you request a second medical opinion about care collaboration with the Member, Member's family and received from a specialist, the second medical opinion the Member's Participating Primary Care Physician will be provided by any health care professional of your or specialists help arrange care for PacifiCare choice from the PacifiCare Participating Provider Members experiencing a major illness or recurring network of the same or equivalent specialty. hospitalizations. Case Management is a collaborative process that assesses, plans, implements, The second medical opinion will be documented in a coordinates, monitors and evaluates options to meet consultation report, which will be made available to you an individual's health care needs based on the health and your treating Participating Provider. It will include care benefits and available resources. any recommended procedures or tests that the Provider giving the second opinion believes are appropriate. If To receive a copy of the Second Medical Opinion this second medical opinion includes a timeline, you may call or write PacifiCare's Customer recommendation for a particular treatment, diagnostic Service department at: test or service covered by PacifiCare—and the recommendation is determined to be Medically PacifiCare Customer Service Department Necessary by PacifiCare —the treatment, diagnostic test PO. Box 6770 or service will be provided or arranged by PacifiCare. Englewood, CO 80155 1-800-877-9777 Please note: The fact that an appropriately qualified Provider gives a second medical opinion and Prearranging Hospital Stays recommends a particular treatment, diagnostic test or Your Primary Care Physician or the Provider you were service does not necessarily mean that the referred to will prearrange any Medically Necessary recommended action is Medically Necessary or a hospital or facility care, including inpatient Transitiona Covered Service. You will also remain responsible for Care or care provided in a Subacute/Skilled Nursing paying any outpatient office Copayments to the Provider Facility. If you've been referred to a specialist and the who gives your second medical opinion. specialist determines you need hospitalization, your If your request for a second medical opinion is denied, Primary Care Physician and specialist will work togetht PacifiCare will notify you in writing and provide the to prearrange your hospital stay reasons for the denial. You may appeal the denial by Your hospital costs, including semi-private room, tests following the procedures outlined in Section Eight — and office visits, will be covered, minus any required Overseeing Your Health Care Decisions. If you obtain Copayments, as well as any deductibles. Under normal a second medical opinion without preauthorization circumstances, your Primary Care Physician will from PacifiCare, you will be financially responsible for coordinate your admission to a local PacifiCare the cost of the opinion. Participating Hospital or facility; however, if your As part of the precertification process, PacifiCare may situation requires it,you could be transported to a request a second opinion. regional medical center. If Medically Necessary, your Primary Care Physician or the Provider you were referred to may discharge you from the hospital to a Subacute/Skilled Nursing Facilitl He or she can also arrange for skilled home health car a r . Section Three - Emergency—) and Urgently Needed Services ) Emergency and Urgently X4LIMPORTANT! Needed Services If you believe you are experiencing an Emergency Medical Condition, call 911, or its local equivalent, or ▪ What are Emergency Medical Services? go directly to the nearest hospital emergency room What is an Emergency Medical Condition? or other facility for treatment. • What To Do When You Require Emergency What To Do When You Require Emergency Services Services ▪ Post-stabilization and Follow-up Care If you believe you are experiencing an Emergency Out-of-Area• Services Medical Condition, call 911, or its local equivalent, or go directly to the nearest hospital emergency • What To Do When You Require Urgently Needed room or other facility for treatment. You do not Services need to obtain preauthorization to seek treatment for • Out-of-Area Urgently Needed Services an Emergency Medical Condition that could cause you harm. Ambulance transport services provided through • International Emergency and Urgently Needed the "911" emergency response system, or its local Services equivalent, are covered if you reasonably believe that Worldwide, wherever you are, PacifiCare provides your medical condition requires emergency ambulance coverage for Emergency Services and Urgently Needed transport services. PacifiCare covers all Medically Services. Ibis section will explain how to obtain Necessary Emergency Services provided to Members in Emergency Services and Urgently Needed Services. It order to stabilize an Emergency Medical Condition. will also explain what you should do following receipt You, or someone else on your behalf, must notify of these services. PacifiCare or your Primary Care Physician within 24 hours, or as soon as reasonably possible, following What are Emergency Medical Services? your receipt of Emergency Services so that your Emergency Services are Medically Necessary ambulance Primary Care Physician can coordinate your care and or ambulance transport services provided through the schedule any necessary follow-up treatment. When 911 emergency response system or its local equivalent. you call, please be prepared to give the name and It is also the medical screening, examination and location of the facility and a description of the evaluation by a Physician, or other personnel-to the Emergency Services that you received. extent provided by law-to determine if an Emergency Medical Condition or psychiatric Emergency Medical Post-stabilization and Follow-up Care Condition exists. If this condition exists, Emergency Following the stabilization of an Emergency Medical Services include the care, treatment and/or surgery by a Condition, the treating health care Provider may Physician necessary to stabilize or eliminate the believe that you require additional Medically Necessary Emergency Medical Condition or psychiatric medical Hospital (health care) Services prior to your being safely condition within the capabilities of the facility. discharged. In such a situation, the medical facility (Hospital) will contact PacifiCare, in order to obtain What is an Emergency Medical Condition? the timely authorization for these post-stabilization An Emergency Medical Condition is any event which a services. PacifiCare reserves the right, in certain Prudent Layperson reasonably believes threatens his or circumstances, to transfer you to a Participating her life or limb in such a manner that a need for Hospital in lieu of authorizing post-stabilization immediate medical care is created to prevent death or services at the treating facility. serious impairment of health. Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. fl 1 ii • am F cry Section Three - Emergency and Urgently Needed Services Following your discharge from the Hospital, any Medically Necessary follow-up medical or Hospital Always Remember Services must be provided or authorized by your Emergency Services: Following receipt of Emergency Primary Care Physician in order to be covered by Services, you, or someone else on your behalf, must PacifiCare. Regardless of where you are in the notify PacifiCare or your Primary Care Physician world, if you require additional follow-up medical within 24 hours, or as soon as reasonably possible, or Hospital Services, please call your Primary Care after initially receiving these services. Physician or PacifiCare's out-of-area unit to request Urgently Needed Services:When you require authorization. PacifiCare's out-of-area unit can be Urgently Needed Services, you should, if possible, calf reached during regular business hours (8 a.m. -5 p.m., MST) at 1.800-762-8456 (or have someone else call on your behalf] your Primary Care Physician or PacifiCare. If you are Out-of-Area Services unable to contact your Primary Care Physician, and you receive medical or Hospital Services, you must PacifiCare arranges for the provision of Covered Services notify PacifiCare or your Primary Care Physician through its Participating Providers. With the exception within 24 hours, or as soon as reasonably possible of of Emergency Services, Urgently Needed Services, initially receiving these services. authorized post-stabilization care or other specific services authorized by PacifiCare, when you are away Copayments: from the HMO Service Area, you are not covered for any There are two Copayment levels for Emergency other medical or Hospital Services. These services are Services. The higher Copayment applies when covered when needed in order to prevent serious services are obtained in a hospital emergency room; deterioration of your health that would result from an the lower Copayment applies when the Emergency unforeseen illness or injury if you are temporarily Services are obtained in a Physician's office outside absent from the HMO Service Area and receipt of your normal business hours or an urgent care facility. health care cannot be delayed until your return to the Thus, it is to your advantage to visit your Primary Care HMO Service Area. If you do not know the HMO Service Physician's office when you have a choice. Please Area, please see the HMO Service Area map in Section refer to your Schedule of Benefits for the applicable Seven— Member Eligibility, or please call our Copayments for these services. Customer Service department to inquire. If a Member is admitted as an inpatient to a hospital The out-of-area services that are not covered include, from urgent care or the emergency room, the urgent but are not limited to: or emergency Copayment is waived. • Routine follow-up care to Emergency or Urgently `-- Needed Services, such as treatments, procedures, PacifiCare provides 24-hour access to request X-rays, lab work and doctor visits, Rehabilitation authorization for out-of-area care. You can also Services, Skilled Nursing Care or home health care. request authorization by calling the PacifiCare out- of-area unit during regular business hours • Maintenance therapy and Durable Medical (8 a.m. - 5 p.m., MST) at 1-800-762-8456. Equipment, including, but not limited to, routine dialysis, routine oxygen, routine laboratory testing or What To Do When You Require Urgently a wheelchair to assist you while traveling outside the Needed Services HMO Service Area. If you need Urgently Needed Services when you are in • Medical care for a known or Chronic Condition the HMO Service Area, you should contact your Primary without acute symptoms as defined under Emergency Care Physician or PacifiCare. The telephone numbers for Services or Urgently Needed Services. your Primary Care Physician are on your PacifiCare ID • Ambulance services are limited to transportation to card. Assistance is available 24 hours a day, seven days a the nearest facility with the expertise for treating your week. Identify yourself as a PacifiCare Member and ask condition. to speak to a Physician. If you are calling during nonbusiness hours, and a Physician is not immediately available, ask to have the Physician-on-call paged. A 10 Section Three - Emergency and Urgently Needed Services Physician should call you back shortly Explain your You, or someone else on your behalf, must notify situation and follow any provided instructions. If PacifiCare within 24 hours, or as soon as reasonably your Primary Care Physician is temporarily unavailable possible, after the initial receipt of Urgently Needed or inaccessible, you should seek Urgently Needed Services. When you call, please be prepared to give Services from a licensed medical professional wherever a description of the Urgently Needed Services that you are located. you received. You, or someone else on your behalf, must notify International Emergency and Urgently PacifiCare within 24 hours, or as soon as reasonably Needed Services possible, after the initial receipt of Urgently Needed Services. When you call, please be prepared to give If you are out of the country and require Urgently a description of the Urgently Needed Services that Needed Services, you should still, if possible, call your you received. Primary Care Physician or PacifiCare.Just follow the same instructions outlined above. If you are out of the Out-of-Area Urgently Needed Services country and experience an Emergency Medical Urgently Needed Services are covered Medically Condition, either use the available emergency response Necessary health care services required to prevent the system or go directly to the nearest hospital emergency serious deterioration of room. Following receipt of Emergency Services, please a M ember's health resultin g from an unforeseen illness or injury for which treatment notify your Primary Care Physician or PacifiCare within cannot be delayed until the Member returns to the 24 hours, or as soon as reasonably possible, after HMO Service Area. initially receiving these services. Urgently Needed Services are required in situations Notes: where a Member is temporarily outside the HMO In addition to our standard coverage for Emergency Service Area and the Member experiences a medical Services and Urgently Needed Services, follow-up care condition that, while less serious than an Emergency to Emergency Services received outside the HMO Medical Condition, could result in the serious Service Area are covered to the maximum Limits as deterioration of the Member's health if not treated described in your Schedule of Benefits. Ask the out-of- before the Member returns to the HMO Service Area or area Provider to send the bill directly to PacifiCare contacts his or her Primary Care Physician. Customer Service Department at P.O. Box 6770, When you are temporarily outside the HMO Service Englewood, CO 80155. If the Provider demands Area and you believe that you require Urgently Needed payment at the time of service, PacifiCare of will Services, you should, if possible, call (or have someone reimburse you, less Copayments. else call on your behalf) your Primary Care Physician as Under certain circumstances, you may need to initially described above in "What To Do When You Require pay for your Emergency or Urgently Needed Services. If Urgently Needed Services." The telephone numbers for this is necessary, please pay for such services and then your Primary Care Physician are on your PacifiCare ID contact PacifiCare at the earliest opportunity. Be sure to card. Assistance is available 24 hours a day, seven days a keep all receipts and copies of relevant medical week. Identify yourself as a PacifiCare Member and ask documentation. You will need these to be properly to speak to a Physician. If you are calling during reimbursed. For more information on submitting claims nonbusiness hours, and a Physician is not immediately to PacifiCare, please refer to Section Six— Payment available, ask to have the Physician-on-call paged. A Responsibility in this Combined Evidence of Coverage Physician should call you back shortly Explain your and Disclosure Form. situation and follow any provided instructions. If you are unable to contact your Primary Care Physician, you should seek Urgently Needed Services from a licensed medical professional wherever you are located. Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. ID r — Section Four - Changing Your Doctor Changing Your Doctor Please note: Except for Emergency and Urgently Needed Services, once an effective date with your new Primary • Changing Your Primary Care Physician Care Physician has been established, a Member must use his or her new Primary Care Physician to authorize all • When We Change Your Primary Care Physician services and treatments.Receiving services elsewhere • Continuing Care with a Terminated Physician will result in PacifiCare's denial of benefit coverage. • Continuity of Care for New Members Continuing Care with a Terminated Physician There may come a time when you want or need to You may be eligible to continue receiving care from a change your Primary Care Physician. This section terminated Physician. The care must be Medically explains how to make this change, as well as how we Necessary. The cause of termination by PacifiCare also continue your care. has to be for a reason other than a medical disciplinary cause, fraud or any criminal activity. Changing Your Primary Care Physician Continued care from the terminated Physician may be When you want to change doctors, you should contact provided for an acute or serious Chronic Condition for our Customer Service department. PacifiCare will up to 60 days, or a longer period until you can be safely approve your request if the Primary Care Physician transferred to another Provider. Continued care from a you've selected is participating with PacifiCare and terminated Physician may be provided if you have a high- accepting new patients. risk pregnancy or a pregnancy in the third trimester. The change will take effect on the first day of the Care may be extended through completed treatment of following month. To transfer your records, contact your pregnancy-related and postpartum conditions, or until former Primary Care Physician and follow his/her your care can be safely provided by another Physician. If procedures. Remember that any specialist Physician you are receiving treatment for any of these conditions, referral must be reissued by your new Primary Care contact our Customer Service department. You can Physician. You must contact him/her before you receive request permission to continue being treated by this further specialist care. Physician beyond the termination date. When We Change Your Primary Care Physician PacifiCare must preauthorize or coordinate services for continued care. If you have any questions, want to jUnder special circumstances, PacifiCare may require that appeal a denial, or would like a copy of PacifiCare's a Member change his or her Primary Care Physician. Continuity of Care Policy, call our Customer Service Generally, this happens at the request of the Primary department. (To learn more about appealing a Care Physician after a material detrimental change in his denial, see Section Eight - Overseeing Your Health or her relationship with a Member. If this occurs, we Care Decisions.) will transfer the Member to another Primary Care Physician, provided he or she is medically stable. Continuity of Care for New Members PacifiCare will also notify the Member in the event that Under certain circumstances, new Members of the agreement terminates between PacifiCare and the PacifiCare may be able to temporarily continue Member's Primary Care Physician. If this occurs, receiving services from a Non-Participating Provider. PacifiCare will make a good faith effort to provide This short-term coverage is intended for new 45 days notice of the termination. PacifiCare will also Members who are experiencing an acute episode of assign the Member a new Primary Care Physician. If the care white making the transition to PacifiCare. For Member would like to select a different Primary Care more detail, see Section One - Getting Started:Your Physician, he or she may do so by contacting our Primary Care Physician. Customer Service department. Upon the effective date of transfer, the Member can begin receiving services from his or her new Primary Care Physician. Section Five - Your Medical Benefits Your Medical Benefits to acute care, Subacute Care, Transitional Inpatient Care and Skilled Nursing Care Facilities • Inpatient Benefits that are authorized by PacifiCare. • Outpatient Benefits PLEASE REFER TO YOUR SCHEDULE OF BENEFITS FOR FURTHER INFORMATION, INCLUDING, BUT NOT • Exclusions and Limitations LIMITED TO,ANY APPLICABLE COPAYMENTS AND • Other Terms of Your Medical Coverage LIMITATIONS FOR ALL PROVISIONS LISTED IN SECTION FIVE. • Terms and Definitions 1. Alcohol, Drug or Other Substance Abuse This section explains your medical benefits, including Detoxification- Detoxification is the medical what is and isn't covered by PacifiCare. You can find treatment of withdrawal from alcohol, drug or other some helpful definitions in the back of this publication. substance addiction. Treatment in an acute care You must also reference part III of this section, setting is covered for the acute stage of alcohol, drug "Exclusions and Limitations of Benefits"to determine if or other substance abuse withdrawal when medical restrictions apply to the benefits referenced in this complications occur or are highly probable. section. For any Copayments that may be associated Detoxification is initially covered up to 48 hours and with a benefit,you should refer to your Schedule of extended when Medically Necessary. Methadone Benefits. Your Schedule of Benefits is explained in treatment for detoxification is not covered. Section Six-Payment Responsibility. Rehabilitation for substance abuse or addiction is PacifiCare may determine Medical Necessity by using covered at a facility designated and authorized by precertification programs and criteria as deemed PacifiCare. Inpatient services are those services appropriate by PacifiCare. Such programs and criteria provided to Members who reside for the course of are reviewed and updated from time to time. See their treatment at the program site. Section Ten - Definitions, "PacifiCare Criteria" for 2. Blood and Blood Products - Blood and blood further information. Through the precertification products are covered. Autologous (self-donated), process, PacifiCare may encourage that certain services donor-directed and donor-designated blood be directed to, and performed at, the most cost-effective processing costs are limited to blood collected for a setting. Covered benefits under your PacifiCare Health scheduled procedure. Plan are determined and interpreted in accordance with (i) the Schedule of Benefits, (ii) the terms and 3. Bloodless Surgery- Surgical procedures conditions set forth in this Group Agreement, and (iii) performed without blood transfusions or blood the actual language of the Colorado insurance laws products, including Rho(D) Immune Globulin, for regarding specific mandated benefits. Members who object to such transfusion on religious grounds are covered only when available Your Medical Benefits from a Participating Provider. I. INPATIENT BENEFITS 4. Bone Marrow and Stem Cell Transplants- Non-Experimental/Non-Investigational autologous These benefits are provided when admitted or and allogeneic bone marrow and stem cell authorized by the Member's Primary Care transplants are covered. The testing of immediate Physician or PacifiCare. All services must be blood relatives to determine the compatibility of Medically Necessary as defined in this Combined bone marrow and stem cells is limited to immediate Evidence of Coverage and Disclosure Form. blood relatives who are sisters, brothers, parents and With the exception of Emergency or Urgently natural children. The testing for compatible Needed Services, a Member will only be admitted unrelated donors and costs for computerized The benefits described in Section Five will not be Covered Services unless they are determined to be Medically Necessary by PacifiCare and are provided by Member's Primary Cam Physician or authorized by PacifiCare.Unless described as a Covered Service in the attached supplement,all services and benefits described below are excluded from coverage or limited under this Health Plan.Any supplement must be an attachment to this Combined Evidence of Coverage and Disclosure Fine.(Note: Additional exclusions and limitations may be included with your explanation of your benefits.PLEASE REFER TO YOUR SCHEDULE OF BENEFITS FOR FURI'HER INFORMATION,INCLUDING,BUT NOT LIMITED TO,ANY APPLICABLE COPAYMEMIS AND LIMITATIONS FOR ALL PROVISIONS LLSTED IN SECI'ON FIVE. Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. ED • • !; ction Five - Your Medical Benefits national and international searches for unrelated necessary to relieve the family members or other allogeneic bone marrow or stem cell donors_ persons caring for the Member ("respite care"). conducted through a registry are covered when the Respite care is limited to an occasional basis and to Member is the intended recipient. A PacifiCare no more than five consecutive days at a time. National Preferred Transplant Network facility 6. Inpatient Alcohol-Drug Rehabilitation Care- approved by PacifiCare must conduct the Alcohol-drug inpatient Rehabilitation Services are computerized searches. There is no dollar limitation covered at the participating facility designated by for Medically Necessary donor related clinical PacifiCare when Medically Necessary. Inpatient transplant services once a donor is identified. services are those services provided to Members who 5. Hospice Services - Hospice services are covered reside for a course of their treatment program at the for Members with a terminal illness, defined as a program site. A Medically Necessary course of medical condition resulting in a prognosis of life treatment may be either inpatient or outpatient or a expectancy of six months or less, if the disease combination of both if authorized by the PacifiCare follows its natural course. Hospice services are participating program site. provided as determined by the plan of care 7. Inpatient Hospital Benefits/Acute Care— developed by the Member's interdisciplinary team, Medically Necessary inpatient Hospital Services which includes, but is not limited to, the Member, authorized by PacifiCare are covered, including, but the Member's Primary Care Physician, a registered not limited to: semi-private room, nursing and other nurse, a social worker and a spiritual caregiver. licensed health professionals, intensive care, Hospice services are provided in an appropriately operating room, recovery room, laboratory and licensed Hospice facility when the Member's professional charges by the hospital pathologist or interdisciplinary team has determined that the p p g radiologist and other miscellaneous hospital charges Member's care cannot be managed at home because for Medically Necessary care and treatment. of acute complications or the temporary absence of a capable primary' caregiver. 8. Inpatient Physician and Specialist Care—Services from Physicians, including specialists and other Hospice services include skilled nursing services, licensed health professionals within, or upon referral certified home health aide services and homemaker from, PacifiCare or a Participating Provider, are services under the supervision of a qualified covered while the Member is hospitalized as an registered nurse; bereavement services; social inpatient. A specialist is a licensed health care services/counseling services; medical direction; professional with advanced training in an area of volunteer services; drugs and biologicals; prosthesis medicine or surgery. and orthopedic appliances; oxygen and respiratory supplies; diagnostic testing; rental or purchase of 9. Inpatient Rehabilitation Care-Rehabilitation durable equipment; transportation; Physician Services that must be provided in an inpatient services; nutritional counseling by a nutritionist or rehabilitation facility are covered. Inpatient dietitian; medical equipment and supplies that are rehabilitation consists of the combined and reasonable and necessary for the palliation and coordinated use of medical, social, educational and management of the terminal illness and related vocational measures for training or retraining conditions; and physical and occupational therapy individuals disabled by disease or injury. The goal of and speech-language pathology services for these services is for the disabled Member to obtain purposes of symptom control, or to enable the his or her highest level of functional ability. Member to maintain activities of daily living and Rehabilitation Services include, but are not limited basic functional skills. to physical, occupational and speech therapy. Inpatient Hospice services are provided in an This benefit does not include drug, alcohol or other appropriately licensed Hospice facility when the substance abuse rehabilitation. Member's interdisciplinary team has determined 10. Mastectomy, Breast Reconstruction After that the Member's care cannot be managed at home Mastectomy and Complications From because of acute complications or when it is Mastectomy- Medically Necessary mastectomy and 1 v Section Five - Your Medical Benefits J lymph node dissection are covered, including an inpatient or partial hospitalization in a hospital prosthetic devices and/or reconstructive surgery to or psychiatric hospital licensed by the Department restore and achieve symmetry for the Member of Public Health and Environment, the period of incident to the mastectomy. The length of a hospital confinement for which benefits are payable shall be stay is determined by the attending Physician and at least 45 days for inpatient care or 90 days for surgeon in consultation with the Member, consistent partial hospitalization in any one 12-month benefit with sound clinical principles and processes. period. "Partial hospitalization" under this benefit is Coverage includes any initial and subsequent defined as treatment for at least three hours, but not reconstructive surgeries or prosthetic devices for the more than 12 hours, in a 24-hour period. For diseased breast on which the mastectomy was purposes of computing a period for which benefits performed. Coverage is provided for surgery and are payable, each two days of partial hospitalization reconstruction of the other breast if, in the opinion shall reduce by one day the 45 days available for of the attending surgeon, this surgery is necessary to inpatient care, and each day of inpatient care shall achieve symmetrical appearance. Medical treatment reduce by two days the 90 days available for partial for any complications from a mastectomy, including hospitalization care. lymphedema, is covered. 13. Newborn Care - Postnatal Hospital Services are 11. Maternity Care- Prenatal and maternity care covered, including circumcision (if desired and services are covered, including labor, delivery and performed in the Hospital) and special care nursery. recovery room charges, delivery by cesarean section, 14. Organ Transplant and Transplant Services— Non- treatment of miscarriage and complications of experimental and non-investigational organ pregnancy or childbirth. Certified nurse midwife transplants and transplant services are covered when services are covered only when provided through a the recipient is a Member and the transplant is Participating OB/GYN. performed at a National Preferred Transplant A minimum 48-hour inpatient stay for normal Network facility. Listing of the Member at a second vaginal delivery and a minimum 96-hour inpatient National Preferred'l'ransplant Network Center is stay following delivery by cesarean section are excluded, unless the Regional Organ Procurement covered. Coverage for inpatient hospital care may be Agencies are different for the two facilities and the for a time period less than the minimum hours if Member is accepted for listing by both facilities. In the decision for an earlier discharge of the mother these cases, organ transplant listing is limited to two and newborn is made by the treating Physician in National Preferred Transplant Network facilities. If the consultation with the mother. In addition, if the Member is dual listed, his or her coverage is limited mother and newborn are discharged prior to the 48- to the actual transplant at the second facility. The or 96-hour minimum time periods, a post-discharge Member will be responsible for any duplicated follow-up visit for the mother and newborn will be diagnostic costs incurred at the second facility. provided within 48 hours of discharge, when Covered Services for living donors are limited to prescribed by the treating Physician. Medically Necessary clinical services once a donor is identified. Transportation and other nonclinical Educational courses on lactation, childcare and/or prepared childbirth classes are not covered. expenses of the living donor are excluded and are the responsibility of the Member who is the recipient of Home deliveries are not covered. the transplant. (See"National Preferred Transplant 12. Mental Health Services—Medically Necessary Network" in Section Ten— Definitions.) inpatient mental health services are covered, as 15. Reconstructive Surgery—Reconstructive surgery is described under this subsection. In the case of basic covered to correct or repair abnormal structures of coverage benefits based upon either confinement as the body caused by congenital defects, The benefits described in Section Five will not be Covered Services unless they am determined to he Medically Necessary by PacifiCarc and are pi ided by Member's Nimwy Cam Physician or authorized by PacifiCare.Unless described as a Covered Service in the attached supplement,all services and benefits described below are excluded from coverage or limited under this Health Plan.Any supplement must be an attachment to this Combined Evidence of Coverage and Disclosure Form.(Note: Additional occlusions and limitations maybe included with your explanation of your benefits.PLEASE REFER TO YOUR SCHEDULE OF BENFITIS FOR FURTHER INFORMATION.INCLUDING,Bur NOT I.IMITEDTO,ANY APPHCAn1.E COPAYMEN'IS AND ILMrrAnoNS FOR ALL PROVISIONS LISITD IN SECTION FIVE. Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. ED Section Five - Your Medical Benefits developmental abnormalities, trauma, infection, 17. Voluntary Termination of Pregnancy- tumors or disease. The purpose of reconstructive Costs related to an elective abortion are covered. surgery is to correct abnormal structures of the body to improve function and create a normal appearance II. OUTPATIENT BENEFITS to the extent possible. Reconstructive procedures The following benefits are available on an require preauthorization by the Member's Primary outpatient basis and must be authorized or Care Physician or PacifiCare, in accordance with arranged by the Member's Primary Care Physician standards of care as practiced by Physicians or authorized by PacifiCare. All services must be specializing in reconstructive surgery. Medically Necessary as defined in this Combined The expenses of plastic, reconstructive or cosmetic Evidence of Coverage and Disclosure Form. surgery will be covered if the surgery is performed as PLEASE REFER TO YOUR SCHEDULE OF BENEFITS soon as medically feasible and is Medically Necessary FOR FURTHER INFORMATION, INCLUDING, BUT NOT for either of the following reasons: LIMITED TO,ANY APPLICABLE COPAYMENTS AND • The repair is initiated within one year following LIMITATIONS FOR ALL PROVISIONS LISTED IN the injury; SECTION FIVE. • The correction of a congenital defect that 1. Alcohol, Drug or Other Substance Abuse substantially impairs major organ function or Detoxification-Services for detoxification are leads to a progressive deterioration of the health limited to removal of the toxic substance or of a covered child. substances from the system, including diagnosis, evaluation, and care of emergency or acute medical 16. Skilled Nursing Facility Care/Subactue and conditions. Alcohol-drug outpatient Rehabilitation Transitional Care— Medically Necessary Skilled Services are covered at a participating facility Nursing Care and Skilled Rehabilitation Care are designated by PacifiCare. Outpatient services are covered. The Member's Primary Care Physician or those services provided to Members who are living PacifiCare will determine where the Skilled Nursing at home and receiving services at the program site Care and Skilled Rehabilitation Care will be on an ambulatory basis. provided. Refer to the Schedule of Benefits for the number of days covered under your Health Plan. 2. Allergy Testing— Services and supplies are covered for the determination of the appropriate course of Skilled Nursing Facility services will be provided allergy treatment. when authorized by the Member's Primary Care Physician, referred to the Provider and authorized 3. Allergy Treatment— Services for the treatment of by PacifiCare, in place of a Hospital stay, when allergies, including serum, are covered according to Medically Necessary. Days spent out of a Skilled an established treatment plan. Nursing Facility when transferred to an acute 4. Ambulance—The use of an ambulance (land or air) hospital setting are not counted toward the Limits, is covered without preauthorization, when the as described in your Schedule of Benefits, when the Member, as a Prudent Layperson, reasonably Member is transferred back to a Skilled Nursing believes that the medical or psychiatric condition Facility. Such days spent in an acute hospital setting requires Emergency Services, and an ambulance do not count toward renewing the Limits as transport is necessary to receive these services. Such described in your Schedule of Benefits. In order to coverage includes, but is not limited to, ambulance renew the room and board charge in a Skilled or ambulance transport services provided through Nursing Facility, the Member must either be out of the "911" emergency response system, or its local all Skilled Nursing Facilities for 60 consecutive days, equivalent. Ambulance transportation is limited to or if the Member remains in a Skilled Nursing the nearest available emergency facility having the Facility, then the Member must not have received expertise to stabilize the Member's Emergency Skilled Nursing Rehabilitation Care for 60 Medical Condition. Use of an ambulance for non- consecutive days. Emergency Services is covered only when specifically authorized by the Member's primary a Section Five - Your Medical Benefits Care Physician or PacifiCare. 10. Cochlear Implant Medical and Surgical Services -The implantation of a cochlear device for bilateral, 5. Attention Deficit/Hyperactivity Disorder-- The medical management of Attention Deficit/ profoundly hearing impaired or prelingual individuals who are not benefited from conventional Hyperactivity Disorder (`ADHD") is covered, amplification (hearing aids) is covered. This benefit including the diagnostic evaluation and laboratory includes services needed to support the mapping monitoring of prescribed drugs. Coverage for outpatient prescribed drugs is only available if the and functional assessment of the cochlear device at the auth r' Subscriber's Employer Group has purchased the o Ized Participating Provider. (For an explanation of speech therapy benefits, please refer supplemental Outpatient Prescription Drug Benefit. This benefit does not include non-crisis to "Outpatient Medical Rehabilitation Therapy") mental health counseling, or behavior 11. Dental Treatment Anesthesia- See "Oral Surgery modification programs. and Dental Services: Dental Treatment Anesthesia 6. Blood and Blood Products-Blood and blood for Dependent Children." products are covered.Autologous (self-donated), 12. Diabetic Management and Treatment-Coverage donor-directed and donor-designated blood includes outpatient self-management training, processing costs are limited to blood collected for a education and medical nutrition therapy services. scheduled procedure. The diabetes outpatient self-management training, education and medical nutrition therapy services 7. Bloodless Surgery- Please refer to the benefit described above under"Inpatient Benefits" for covered under this benefit will be provided by "Bloodless Surgery" Outpatient services appropriately licensed or registered health care Copayments or coinsurance apply for any services professionals. These services must be provided under the direction of and prescribed by a received on an outpatient basis. Participating Provider. 8. Clinics-Coverage to include: 13. Diabetic Self-Management Items - Equipment and Pain Clinics-Outpatient services that must be supplies for the management and treatment of Type requested in writing by the Primary Care Physician. 1, Type 2 and gestational diabetes are covered, This request must include supporting second based upon the medical needs of the Member, opinions from two participating specialists, one of including, but not necessarily limited to: blood whom is a licensed mental health Provider. Any glucose monitors; strips; lancets and lancet psychotherapy and/or physical therapy sessions as a puncture devices; ketone urine testing strips; insulin part of the program wil l be counted P g toward the pain syringes, podiatry services and devices to prevent or clinics Limits. treat diabetes-related complications. Members must have coverage under the Outpatient Prescription 9. Cochlear Implant Device-An implantable cochlear device for bilateral, profoundly hearing Drug Benefit for insulin, glucagon and other impaired individuals who are not benefited from diabetic medications to be covered. conventional amplification (hearing aids) is covered. 14. Dialysis —Acute and chronic hemodialysis services Coverage is for Members at least 18 months of age and supplies are covered. For chronic hemodialysis, who have profound bilateral sensory hearing loss or application for Medicare Part A and Pan B coverage for prelingual Members with minimal speech must be made. Chronic dialysis (peritoneal or perception under the best hearing aided condition. hemodialysis)y ) must be authorized by the Member's Please also refer to "Cochlear Implant Medical and Primary Care Physician or PacifiCare and provided Surgical Services." by a Participating Provider. The benefits described in Section Five will not he Covered Services unless they are determined to be Medically Necessary by PacifiCare and are provided by Member's Primary Care Physician or authorised by PacifiCare.Unless described as a Covered Service in the attached supplement,all services and benefits described below are excluded from coverage or limited under this Health Plan.Any supplement must be an attachment to this Combined Evidence of Coverage and Disclncure Pone.(Note Additional occlusions and limitations maybe included with your explanation of your benefits.PLEASE REFER TO YOUR SCHEDIILE OF BENEFITS FOR FURTHER INFORMATION,INCLUDLNG,BUT NOT LIMITED TO,ANY APPLI CABLE COPAYMENTS AND LIMITATIONS FOR All.PROVISIONS❑S'IEll IN SECTION FIVE. Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. la OM Section Five - Your Medical Benefits *too 15. Durable Medical Equipment (Rental, Purchase 18. Health Education Services—PacifiCare makes health or Repair) — Durable Medical Equipment is covered and wellness information available to Members. For when it is designed to assist in the treatment of an any wellness program, call the PacifiCare Customer injury or illness of the Member, and the equipment Service department at 1-800-877-9777, or they can be is primarily for use in the home when Medically accessed at www.pacificare.com. Necessary. Durable Medical Equipment is medical StopSnwking"Program: equipment that can exist for a reasonable period of time without significant deterioration. Examples of PacifiCare of Colorado supports the Colorado covered Durable Medical Equipment include Department of Health Tobacco Cessation Program. wheelchairs, hospital beds and standard oxygen This program, The Colorado Quitline, is a self- delivery systems. directed, self-paced program that includes telephonic support for the person choosing to quit Replacements, repairs and adjustments to Durable tobacco use. The program is designed to be Medical Equipment are limited to normal wear and customized to each individual's needs and readiness tear or because of a significant change in the to quit. The components of the intervention build Member's physical condition. PacifiCare has the the participant's self confidence in their ability to option to repair or replace Durable Medical quit smoking or to quit using other tobacco Equipment items. Replacement of lost or stolen products through goal-oriented lifestyle Durable Medical Equipment is not covered. The modification. PacifiCare Members who are enrolled following equipment and accessories are not in the program and have coverage under the covered: non-Medically Necessary optional Outpatient Prescription Drug benefit will be eligible attachments and modifications to Durable Medical for Nicotine replacement therapy aids (NRT). Equipment for the comfort or convenience of the Applicable Copayment(s) will apply for NRT Member, accessories for portability or travel, a coverage under this program. For more information. second piece of equipment with or without or to enroll in the Tobacco Cessation program, additional accessories that is for the same or similar please call 1-800-639-QUIT. There is no charge for medical purpose as existing equipment and home this program. and car remodeling. 19. Home Health Care—A Member is eligible to 16. Family Planning— Coverage for voluntary family receive home health care services if the Member: (1) planing to include: is confined to the home ("home" is wherever the • Family planning counseling; Member makes his or her home but does not include acute care, rehabilitation or Skilled Nursing • Information on birth control; Facilities); (2) needs intermittent skilled nursing • IUDs and implantable contraceptive devices, services or needs physical, speech or occupational including their insertion and removal; therapy; and (3) the services are provided under a • Diaphragms and cervical caps, including their plan of care established and periodically reviewed fitting; and ordered by a PacifiCare participating Physician. "Intermittent skilled nursing services" means skilled • Pre- and post-abortion counseling; nursing services provided by a registered nurse or • Surgical procedures causing permanent licensed vocational nurse that are required less than sterilization, including vasectomies and tubal eight hours each day for periods of 21 days or less. ligations. If a Member is eligible for home health care services 17. Footwear— Specialized footwear, including foot in accordance with the authorized treatment plan, orthotics, custom-made or standard orthopedic coverage may include, but is not limited to the shoes, are covered for a Member with diabetic foot following Medically Necessary home health care disease or when an orthopedic shoe is permanently services: (Please refer to the Schedule o,�'Benefits attached to a Medically Necessary orthopedic brace. for any applicable Copayments or coinsurance amounts.) a t 1 . . • Section Five - Your Medical Benefits • (i) Intermittent skilled nursing set-vices (as defined medical equipment and supplies that are reasonable above); and necessary for the palliation and management of the terminal illness and related conditions; physical and (ii) Intermittent home health aide services that provide supportive services in the home which occupational therapy and speech-language pathology services for purposes of symptom control, or to enable are reasonable and necessary to the Member's illness or injury, (as defined above); the Member to maintain activities of daily living and basic functional skills. (iii) Physical, occupational or speech therapy that is provided on a per visit basis; Covered Hospice services are available in the home on a 24-hour basis when Medically Necessary, during (iv) Medical supplies, Durable Medical Equipment; and periods of crisis, when a Member requires continuous (v) Infusion therapy medications and supplies and care to achieve palliation or management of acute laboratory services as prescribed by a participating medical symptoms. Inpatient Hospice services are Physician to the extent such services would be provided in an appropriately licensed Hospice facility covered by PacifiCare had the Member remained when the Member's interdisciplinary team has in the hospital, rehabilitation or Skilled Nursing determined that the Member's care cannot be Facility managed at home because of acute complications or when it is necessary to relieve the family members or If the Member's Primary Care Physician determines that other persons caring for the Member ("respite care"). Skilled Nursing Care needs are more extensive than Respite care is limited to an occasional basis and to no part-time or intermittent services, the Member will be more than five consecutive days at a time. • transferred to a Skilled Nursing Facility to obtain coverage for this benefit. PacifiCare, in consultation with 21. Immunizations—Immunizations for children • the Member's Primary Care Physician, will determine the (through age 18 years) are covered consistent with the appropriate setting for delivery of the Member's Skilled most current version of the Recommended Childhood Nursing Care services. Immunization Schedule/United States'. An exception is made if, within 45 days of the published date of the 20. Hospice Services- Hospice services are covered schedule, the State Department of Health Services for Members with a terminal illness, defined as a determines that the schedule is not consistent with medical condition resulting in a prognosis of life state law Immunizations for adults are covered expectancy of six months or less, if the disease consistent with the most current recommendations of • follows its natural course. Hospice services are the Center for Disease Control (CDC) for routine • provided pursuant to the plan of care developed by adult immunizations as advised by the Advisory • the Member's interdisciplinary team, which Committee on Immunization Practices. For children includes, but is not limited to, the Member, the under two years of age, refer to"Periodic Health • Member's Primary Care Physician, a registered Evaluation-Well-Baby Care." • nurse, a social worker and a spiritual caregiver. Routine boosters and immunizations must be Hospice services include skilled nursing services, obtained through the Member's Primary Care certified home health aide services and homemaker Physician. • services under the supervision of a qualified • registered nurse; bereavement services; social Work immunizations are not covered. services/counseling services; medical direction; Immunizations recommended for travel by the volunteer services; drugs and biologicals; prosthesis Centers for Disease Control immunization guidelines and orthopedic appliances; oxygen and respiratory are covered. • supplies; diagnostic testing; rental or purchase of 'This is jointly adopted by the American Academy of Pediatrics, durable equipment; transportation; Physician services; the Advisory Committee on Immunization Practices(ACIP),and nutritional counseling by a nutritionist or dietitian; the American Academy of Family Physicians. The benefits described in Section Five will not be Coated Senices unless they are determined to be Medically Necessuy by PacifiCare and are provided by Member's Primary Care Physician or authorized by PacifiCare.Unless described as a Covered Service in the attached supplement all services and benefits described below are excluded from coverage or limited under this Health Plan-Any supplement must be an attachment to this Combined Evidence of Coverage and Disclosure linnx.(Note: Additional exclusions and limitations may he included with your explanation of your benefits.PLEASE.REFER TO YOUR SCI IEDUIE OF BENEFITS FOR FURTHER INFORMMR)N,INCLLDING,BIT NOT LIMITED TO,ANYAPPLIGABIE COPAYMENTS AND LIMITATIONS FOR ALL PROVISIONS LISTED IN SECTION FIVE. Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. 0 1 Section Five - Your Medical Benefits gitfr 22. Infertility Services-Please refer to the Schedule of benefit. The Outpatient Prescription Drug Benefit is Benefits for coverage, if any. Coverage for Infertility covered only if it has been selected by your services is only available if purchased by the employer as part of the subscribing group's plan. Subscriber's Employer Group as a supplemental 25. Laboratory Services - Medically Necessary benefit. If the Member's Health Plan includes an diagnostic and therapeutic laboratory services are Infertility services supplemental benefit, a supplement covered. to the Combined Evidence of Coverage and Disclosure Form will be provided to the Member. 26. Maternity Care, Tests and Procedures- Physician visits, laboratory services and radiology services are 23. Infusion Therapy- Infusion therapy means the covered for prenatal and postpartum maternity care. therapeutic use of drugs or other substances, Certified nurse midwife services are covered when prepared or compounded, and administered by a available from and authorized by the Member's Participating Provider and given to a Member through Participating OB/GYN. a needle or catheter. Services must be provided in the Member's home or an institution that is not a hospital Genetic testing and counseling are covered when or is not primarily engaged in providing skilled authorized by PacifiCare as part of an amniocentesis nursing or Rehabilitation Services. (For example, or chorionic villus sampling procedure. board and care, custodial care facility and assisted 27. Medical Supplies and Materials —Medical supplies living facility.) Infusion therapy is only covered as part and materials necessary to treat an illness or injury of a treatment plan authorized by PacifiCare. are covered when used or furnished while the 24. Injectable Drugs (Outpatient Injectable Member is treated in the Participating Provider's Medications and Self-Injectable Medications) - office, during the course of an illness or injury, or Outpatient injectables approved by the Food and stabilization of an injury or illness, under the direct Drug Administration (FDA) for the given diagnosis supervision of the Participating Provider. Examples or protocol, when oral administration of prescribed of items commonly furnished in the Participating medication is not medically appropriate. Outpatient Provider's office to treat the Member's illness or injectable medications administered in the injury are gauzes, ointments, bandages, slings and Physician's office (except insulin) are covered when casts. a pan of the medical office visit. Self-injectable 28. Mental Health Services- Services for Medically medications (except insulin) are covered and Necessary outpatient mental health care for adults subject to the applicable Copayment when the and children are covered. The coverage under this Member is trained in the administration of the benefit, and any coverage of services necessary to medication, and the medication has been prescribed fulfill the designated treatment program in addition by a participating provider, and obtained at a to those services listed here, are based on Medical designated PacifiCare participating pharmacy as Necessity as determined by the Participating authorized by PacifiCare. Certain self-injectables may Provider and are subject applicable Limits as be limited to coverage through PacifiCare's Mail outlined in the Schedule of Benefits. Service Pharmacy. A Copayment will be collected for up to a 30-day supply of medication, course of Care for schizophrenia, schizoaffective disorder therapy or treatment of an acute episode, whichever bipolar affective disorder, major depressive disorder, is shorter. No more than a 30-day supply will be specific obsessive-compulsive disorder and panic dispensed at one time. A Copayment will also be disorder shall be covered as any other physical collected when a self-administered injectable is illness and will not be subject to the limitations of administered in the Physician's office. Mental Health Services, as described above. Outpatient injectable medications, including self- 29. OB/GYN Physician Care—See "Physician OB/GYN injectables, must be obtained through a Participating Care." Provider and may require preauthorization. Insulin 30. Oral Surgery and Dental Services— Emergency is covered as a pharmacy benefit if you are covered Services for stabilizing an acute injury to sound by an Outpatient Prescription Drug supplemental natural teeth, the jawbone or the surrounding 20 r Section Five - Your Medical ts �Bene f•a _._9 structures are covered. Coverage is limited to Charges for the dental procedure(s) beyond treatment provided within 48 hours of injury. Other emergency treatment to stabilize an acute injury, • covered oral surgery and dental services include: including, but not limited to, professional fees of • Biopsy and excision of cysts or tumors of the jaw, the dentist or oral surgeon, X-ray and laboratory treatment of malignant neoplastic disease; fees or related dental supplies provided in connection with the care, treatment, filling, removal • Treatment of temporomandibular joint syndrome or replacement of teeth or structures directly (TMJ) when Medically Necessary and supporting the teeth, are not covered except for preauthorization has been obtained; services covered by PacifiCare under this outpatient • Tooth extraction prior to a major organ transplant benefit, "Oral Surgery and Dental Services." or radiation therapy to the head or neck; 31. Oral Surgery and Dental Services: Dental • Preventive fluoride treatment prior to an Treatment Anesthesia for Dependent Children— Anesthesia and associated facility charges for dental aggressive chemotherapeutic or radiation• therapy protocol; procedures provided in a hospital, outpatient surgery center or other licensed facility pursuant to • Cleft lip, cleft palate or any condition or illness Colorado law are covered when: that is related to or developed as a result of the cleft lip or cleft palate will be considered to be • The child is defined as a Dependent as defined in compensable for coverage under the provisions of Colorado law; Colorado law for newborn children born with • The child has a physical, mental or medically cleft lip or cleft palate or both, compromising condition or; The following care and treatment is covered to the • The child has dental needs for which local extent Medically Necessary and when ordered by a anesthesia is ineffective because of acute Participating Physician: infection, anatomic variations or allergy or; • • Oral and facial surgery, surgical management • The child is an extremely uncooperative, and follow-up care by plastic surgeons and oral unmanageable, anxious or uncommunicative child surgeons; or adolescent with dental needs deemed • Prosthetic treatment such as obturators, speech sufficiently important that dental care cannot be appliances and feeding appliances; deterred; or • Medically Necessary orthodontic treatment; • The child has sustained extensive orofacial and dental trauma. • Medically Necessary prosthodontics treatment; The Member's dentist must obtain preauthorization • • Habilitative speech therapy; from PacifiCare before the dental procedure is provided. • Otolaryngology treatment; Dental anesthesia in a dental office or dental clinic is • Audiological assessments and treatment. not covered. Charges for the dental procedure(s) itself, including, but not limited to, professional fees If a dental insurance policy is in effect at the time of of the dentist or oral surgeon, X-ray and laboratory the birth, or is purchased after the birth of a child fees or related dental supplies provided in with cleft lip or cleft palate or both, no benefit connection with the care, treatment, filling, removal under this Group Agreement will be provided for or replacement of teeth or structures directly any orthodontics or dental care needed as a result supporting the teeth arc not covered except for of the cleft lip or cleft palate or both. services covered by PacifiCare under the outpatient benefit, "Oral Surgery and Dental Services." The benefits described in Section Five will not be Covered Services unless they are determined to be Medically Necessary by PacifiCare and are provided by Member's Primary Care Physician or authorized by i acifiCare.Unless described as a Covered Service in the attached supplement,all services and benefits described below are excluded from coverage or limited under this Health Plan.Any supplement must be an attachment to this Combined Evidence of&merage and Disclosure limn.(Note: Additional exclusions and limitations maybe included with your explartation of your benefits.PLEASE REFER TO YOUR SCHEDULE OF BENEITIS FOR FURFHER INFORMATION,INCIL DEYG,BUF NOT DMITF,D 1O.ANY APPU('ABLF.COPAYMENIS AND LIMITATIONS FOR ALL PROVISIONS LISTED IN SECFION FIVE. • Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. 21 r _ _. _ _ _ i Section Five - Your Medical Benefits 32. Outpatient Medical Rehabilitation Therapy- 33. Outpatient Surgery- Short-stay, same-day or other Services provided by a registered physical, speech participating similar outpatient surgery facilities are or occupational therapist for the treatment of an covered when provided as a substitute for inpatient illness, disease or injury are covered. care. 34. Periodic Health Evaluation- Periodic Health Cardiac Evaluations are covered as recommended by Short-term cardiac rehabilitation is covered based PacifiCare's Preventive Health Guidelines. on criteria established by PacifiCare at an approved This includes: facility for the short-term follow-up of acute care episode. This benefit is an extension of the • Breast Cancer Screening and Diagnosis— Services are covered for routine and certain diagnostic treatment for an thin two months achsecare e. and screening by low-dose mammography for the must begin within on of adb ishede. Cardiac presence of breast cancer. Screening and rehabilitation based approved facili es for the s orby die nosis will be covered consistent with f flow- p of ac tcarfstable ity for the short-term generally accepted medical practice and scientific follow-up of acute care for angina pectoris. evidence. Mammography for screening or Occupational Physical diagnostic purposes is covered at a Participating Short-term, outpatient occupational and physical Provider. therapy by licensed therapists who are Participating Coverage shall be the lesser of$79 per Providers or approved by PacifiCare. This short- mammography screening, or the actual charge for term, outpatient physical therapy is for the such screening. Coverage is provided according to treatment of acute conditions that are subject to the following guidelines: ! significant improvement within two months of when - Provision of a single baseline mammogram for treatment begins. women 35 years of age and under 40 years The Member's status may be reevaluated and, if it is of age; determined that the condition is no longer acute, it - Screening not less than once every two years for may not be covered. women 40 years of age, but at least once each Physical and occupational therapy for the care and such year, as specified in the policy or contract, treatment of congenital defect and birth for a woman with risk factors to breast cancer as abnormalities for children up to age five are determined by her Physician. covered, without regard to whether the condition is a n Anul - screening as specified in the policy or acute or chronic and without regard to whether the Annual for women who are 50 to 65 years purpose of the therapy is to maintain or to improve co functional capacity. of age. . Hearing Screening- Routine hearing screening by Speech a participating health professional is covered Services of licensed speech therapists who are to determine the need for hearing correction. Participating Providers or approved by PacifiCare are Hearing aids are not covered, nor is their testing covered. This therapy is a benefit only for the short- or adjustment. term rehabilitation required immediately following Prostate Screening-Coverage annual an acute episode. The goal of this therapy is a • rostae for the early detection for annual within two imonths. nt of a Member's condition cancer in men over the age of 50 years and in within months. men over the age of 40 years who are in high-risk Speech therapy for the care and treatment of categories. Coverage shall be the lesser of$65 per congenital defects and birth abnormalities for screening or the actual charge for such screening. children up to age five, without regard to whether Such benefits shall in no way diminish or limit the condition is acute or chronic and without regard diagnostic benefits otherwise allowable under the to whether the purpose of the therapy is to maintain policy or contract. The screening shall consist, at or to improve functional capacity. Section Five - Your Medical Benefits • a minimum, of the following tests: Coverage for Inherited Enzymatic Disorders caused — A prostate-specific antigen ("PSA') blood test; by Single Gene Defects shall include, but not be limited to the following diagnosed conditions: • — Digital rectal examination; Phenylketonuria, Maternal Phenylketonuria, Maple — At least one screening per year shall be covered Syrup Urine Disease, Tyrosinemia, Homocystinuria, for any man 50 years of age or older; Histidinemia, Urea Cycle Disorders, Hyperlysinemia, Glutaric Acidemias, Methylmalonic Acidemia and — At least one screening per year shall be covered Propionic Acidemia. Covered care and treatment of for any man from 40 to 50 years of age who is at such conditions shall include, to the extent increased risk of developing prostate cancer. Medically Necessary, medical foods for home use for • . Vision Screening-Annual routine eye health which a Participating Physician has issued a written, assessment and screening by a Participating oral or electronic prescription. Provider are covered to determine the health of The maximum age to receive this benefit for the Member's eyes and the possible need for Phenylketonuria is 21 years of age; except that the vision correction. An annual retinal examination is maximum age to receive this benefit for covered for Members with diabetes. Phenylketonuria for women who are child-bearing Well-Baby Care- Up to the age of two, preventive age is 35 years of age. health services are covered (including 36. Physician Care (Primary Care Physician and immunizations) when provided by the child's Specialist) - Diagnostic, consultation and treatment Primary Care Physician. An office Copayment services provided by the Member's Primary Care applies when infants are ill at the time services Physician are covered. Services of a specialist are are provided. covered upon referral by Member's Primary Care . Well-Woman Care- Medically Necessary services, Physician. A specialist is a licensed health care • professional with advanced training in an area of including a Pap smear, are covered. The Member may receive obstetrical and gynecological medicine or surgery. Physician services directly from a Participating 37. Physician OB/GYN Care -The Member may obtain OB/GYN or Participating Primary Care Physician. obstetrical and gynecological Physician services 35. Phenylketonuria (PKU) and Inherited Enzymatic directly from a Participating OB/GYN or Primary Disorders Testing and Treatment—Testing for Care Physician. Phenylketonuria (PKU) is covered to prevent the development of serious physical or mental disabilities or to promote normal development or function as a consequence of PKU enzyme deficiency. Medical foods, for the purpose of this benefit, refer exclusively to prescription metabolic formulas and their modular counterparts, obtained through a pharmacy. Medical foods are specifically designated and manufactured for the treatment of Inherited Enzymatic Disorders caused by Single Gene Defects. The benefits described in Section Five will not be Covered Services unless they are determined to he Medically Necessary by PaifiCare and are presided by Member's • Primary Care Physician or authorized by PacifiCare.Unless described as a Covered Service in the attached supplement,all services and benefits described below are excluded Flom coverage or limited under this Health Plan.Any supplement must be an attachment to this Combined Evidence of Co erage and Disclosure finnn.(Note: Additional exclusions and limitations may be included with your explanation of your benefits.PLEASE REFER TO YOUR SCHEDULE OF BENEFITS FOR FURTHER INFORMAHON,INCLINING,BUT NOT LLMITED TO,ANY APPLICABLE COPAYMEN'tS AND❑Mf1Al1ONS FOR ALL PROVISIONS LISTED IN SECTION FIVE. Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. ID • ail li Section Five - Your Medical Benefitsav 38. Preventive Services: Covered Preventive Services All Persons • 1 smoking cessation education program benefit under Physician supervision or as authorized by plan per lifetime, not to exceed $150 payment by insurer. • Chicken pox vaccination for all persons who have not had chicken pox. All Children • Immunizations. • Immunization deficient children are not bound by "recommended ages." Age 0-12 months • 1 newborn home visit during first week of life if newborn released from hospital less than 4E hours after delivery. •5 Well-Child Visits.' ■ 1 PKU. Age 13-35 months • 2 Well-Child Visits. Age 3-6 •3 Well-Child Visits. Age 7-12 •3 Well-Child Visits. Age 13-18 • 1 age-appropriate health maintenance visit' every year. ■ 1 Td. • Females: screening Pap smears not to exceed 1 per year. ■ 1 hepatitis B vaccination if not given previously. Age 19-39 • 1 Td every ten years. • 1 age-appropriate health maintenance visit every three years. • 1 fasting lipid panel • Females ages 35-39: 1 baseline screening mammogram and clinical breast exam. • Females: screening Pap smears not to exceed 1 per year. Age 40-64 • 1 Td every ten years. • 1 fasting lipid panel every five years. • Either annual fecal occult blood testing or 2 colorectal visualizations between ages 50 and 75. • 1 age appropriate health maintenance visit every 24 months. • Females ages 40-49: 1 screening mammogram and clinical breast exam every 2 years (annually, if high risk). • Females ages 50-64: 1 screening mammogram and clinical breast exam every 12 months. • Females: screening Pap smears not to exceed 1 per year. • Mates: Prostate screening as specified in state law. Age 65 and older • 1 influenza immunization every year. • 1 pneumococcal vaccine at or after age 65. • Females: screening Pap smears not to exceed 1 per year. • 1 Td every ten years. • 1 age-appropriate health maintenance visit every year. • Females age 65 to 74: 1 screening mammogram and clinical breast exam every 12 months. • Either annual fecal occult blood testing or 2 colorectal visualizations between ages 50 and 75. a Section Five - Your Medical Benefits 1. "Well-Child Visit" means a visit to a primary care other tissues. Myoelectric prosthetics are provider that includes the following elements: prosthetics which have electric motors to age-appropriate physical exam (but not a enhance motion. complete physical exam unless this is age • Replacements, repairs and adjustments to appropriate), history, anticipatory guidance and education (e.g., examine family functioning and corrective appliances and prosthetics coverage are limited to normal wear and tear or because of a dynamics, injury prevention counseling, discuss significant change in the Member's physical dietary issues, review age appropriate behaviors, condition. Repair or replacement must be etc.), and growth and development assessment. authorized by PacifiCare. For older children, this also includes safety and health education counseling. • Preauthorized external extremity prosthetics are covered up to the Durable Medical Equipment 2. "Age-appropriate health maintenance visit" maximum, described in your Schedule of Benefits, means an exam which includes the following only if the prosthesis will restore function of the components: age-appropriate physical exam (but extremity. not a complete physical exam unless this is age appropriate), history, anticipatory guidance and • Coverage for prosthetic arms and legs is based on education (e.g., examine family functioning and criteria and is not subject to the Durable Medical dynamics, discuss dietary issues, review health Equipment maximum, described in your Schedule promotion activities of the patient, etc.), and of Benefits. exercise and nutrition counseling (including folate • Refer to "Footwear." counseling for women of child-bearing age). 40. Radiation Therapy (Standard and Complex): 39. Prosthetics and Corrective Appliances — Prosthetics (except for bionic or myoelectric as • Standard photon beam radiation therapy is explained below) are covered when Medically covered. Necessary as determined by PacifiCare. Prosthetics • Complex radiation therapy is covered. This therapy are durable, custom-made devices designed to requires specialized equipment, as well as specially replace all or part of a permanently inoperative or trained or certified personnel to perform the malfunctioning body pan or organ. Examples of therapy Examples include, but are not limited to: covered prosthetics include initial contact lens in an brachytherapy (radioactive implants) and conformal eye following a surgical cataract extraction and photon beam radiation. Gamma knife procedures removable, non-dental prosthetic devices such as a and stereotactic procedures are covered as limb that does not require surgical connection to outpatient surgeries for the purpose of determining nerves, muscles or other tissue. Copayments. (Please refer to your Schedule of Custom-made or custom-fitted corrective appliances Benefits for applicable Copayment, if any) are covered when Medically Necessary, as 41. Radiology Services—Coverage includes, but is not determined by PacifiCare. Corrective appliances are limited to, standard X-ray films (with or without oral, devices that are designed to support a weakened rectal, injected or infused contrast medium) for the body part. These appliances are manufactured or diagnosis of an illness or injury are covered. Standard custom-fitted to an individual Member. X-ray services are X-ray(s) of an extremity, abdomen, Notes: head, chest, back, mammograms, nuclear studies and barium studies. Also see "Maternity Care" and • Bionic and myoelectric prosthetics are not "Periodic Health Evaluation." • covered. Bionic prosthetics are prosthetics that require surgical connection to nerves, muscles or Specialized scanning and imaging procedures, such The benefits described in Section Five will not be Covered Services unless they are determined to be Medically Necessary by PacifiCare and are provided by Member's Primary Cant Physician or authorized by PacifiCare.Unless described as a Covered Service in the:unshed supplement,all services and benefits described below are excluded from coverage or limited under this Health Plan-Any supplement must be an attachment to this Combined Evidence ofCoarrage and Disclosure Tom.(Note: Additional exclusions and limitations may be included with your explanation of your benefits.PLEASE REFER TO YOUR SCHEDULE OF BENEFITS FOR FURTHER INFORMATION,INCLUDING,BCT NOT LI virrEn to.ANY APPLICABLE COPAYMEN'IS AND uMTIAI1ONS FOR MJ.PROVISIONS HSITEH IN SECTION FIVE. Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. ill • • • Section Five - Your Medical Benefits as CT, SPECT, PET, and MRI (with or without the additional materials.) contrast media), are covered. PLEASE REFER TO YOUR SCHEDULE OF BENEFITS 42. Reconstructive Surgery- Reconstructive surgery FOR FURTHER INFORMATION, INCLUDING, BUT NOT is covered to correct or repair abnormal structures LIMITED TO,ANY APPLICABLE COPAYMENTS AND of the body caused by congenital defects, LIMITATIONS FOR ALL PROVISIONS LISTED IN developmental abnormalities, trauma, infection, SECTION FIVE. tumors or disease. The purpose of reconstructive GENERAL EXCLUSIONS surgery is to improve function and create a normal appearance to the extent possible. Reconstructive Services that are not Medically Necessary, as defined in procedures require preauthorization by the the "Definitions" section of this Combined Evidence of Member's Primary Care Physician or PacifiCare in Coverage and Disclosure Form, are not covered. accordance with standards of care as practiced by Services not specifically included in this Combined Physicians specializing in reconstructive surgery. Evidence of Coverage and Disclosure Form, or any The expenses of plastic, reconstructive or cosmetic supplement purchased by the Subscriber's Employer surgery will be covered if the surgery is performed Group, are not covered. as soon as medically feasible and 1. Services that are rendered without authorization is Medically Necessary for either of the from the Member's Primary Care Physician or following reasons: PacifiCare (except for Emergency Services or • The repair is initiated within one year following Urgently Needed Services described in this the injury. Combined Evidence of Coverage and Disclosure Form, and for obstetrical and gynecological • The correction of a congenital defect that physician services obtained directly from a substantially impairs major organ function, or OB/GYN or Primary Care Physician), leads to a progressive deterioration of the health participating y ) are not covered. of a covered child. 2. Services obtained from Non-Participating Providers, 43. Refractions— Routine testing every 12 months is when such services were offered or authorized by covered to determine the need for corrective lenses PacifiCare and the Member refused to obtain the (refractive error), including a written prescription services as offered by the Primary Care Physician, are for eyeglass lenses. (Coverage for frames and lenses not covered. may be available if the Member's Health Plan includes a supplemental vision benefit.) 3. Services rendered prior to the Member's effective date of enrollment or after the effective date of Coverage under this benefit also includes eyeglasses disenrollment are not covered. when prescribed following cataract surgery with an intra ocular lens implant. Eyeglasses must be 4. Any service provided by a Non-Participating Provider obtained through Participating Providers. unless authorized in advance by PacifiCare or as set forth in Section Three —Emergency and Urgently 44. Voluntary Termination of Pregnancy—Costs Needed Services are not covered. related to an elective abortion are covered. 5. PacifiCare does not cover the cost of services III. EXCLUSIONS AND LIMITATIONS provided in preparation for a non-Covered Service OF BENEFITS where such services would not otherwise be Unless described as a Covered Service in an Medically Necessary. Additionally, PacifiCare does attached supplement, all services and benefits not cover the cost of routine follow-up care for non- described below are excluded from coverage or Covered Services (as recognized by the organized limited under this Health Plan. Any supplement medical community in the state of Colorado). must be an attachment to this Combined Evidence PacifiCare will cover Medically Necessary services of Coverage and Disclosure Form. (NOTE: directly related to non-Covered Services when Additional exclusions and limitations may be complications exceed routine follow-up care such as included with the explanation of your benefits in life-threatening complications of cosmetic surgery. a Section Five - Your Medical Benefits OTHER EXCLUSIONS AND LIMITATIONS include, but are not limited to, art therapy, music 1. Acupuncture and Acupressure -Acupuncture and therapy and play therapy acupressure are not covered. (Coverage for 6. Biofeedback- Biofeedback services are not covered acupuncture and acupressure may be available if except as covered under pain clinics or for bladder purchased by the Subscriber's employer as a rehabilitation as part of an authorized supplemental benefit. If the Member's Health Plan treatment plan. includes an acupuncture and acupressure supplemental benefit, a brochure describing it will Blood and Blood Products—Special blood handling fees and the storage of cord blood be enclosed with these materials.) are not covered. 2. Air Conditioners, Air Purifiers and Other 8. Bloodless Surgery Services- Bloodless surgery Environmental Equipment-Air conditioners, air services are only covered to the extent available purifiers and other environmental equipment are not covered. from a Participating Provider. 9. Bone Marrow and Stem Cell Transplants - 3. Alcoholism, Drug Addiction and Other Autologous or allogeneic bone marrow or stem cell Substance Abuse Rehabilitation- One course of treatment per contract year. Two courses of transplants are not covered when they are inpatient or outpatient treatment for each Member Experimental or Investigational. Unrelated donor during his/her lifetime. For inpatient rehabilitation, searches must be performed at a PacifiCare approved transplant center. (See "National Preferred services are covered at the designated facility and will be subject to the Limits as described in your Transplant Network" in Section Ten - Definitions.) Schedule of Benefits or until the Participating 10. Chiropractic Care— Care and treatment provided Provider has determined satisfactory completion of by a chiropractor are not covered. (Coverage for the inpatient program, whichever is less. For chiropractic care may be available if purchased by outpatient rehabilitation, refer to your Schedule of the Subscriber's employer as a supplemental Benefits for applicable limitations under this benefit. benefit. If your Health Plan includes a chiropractic Not Covered: care supplemental benefit, a brochure describing it will be enclosed with these materials.) • Rapid anesthesia opiate detoxification; 11. Certified Nurse Midwife Services— Certified nurse • Services which are not Medically Necessary for the midwife services are covered only when provided treatment of substance abuse disorders; through a Participating OB/GYN. • Services that are required by a court order as a 12. Clinics—Multidisciplinary service clinics, centers or part of parole or probation, or instead of programs on an inpatient or outpatient basis, except incarceration, which are not Medically Necessary; as otherwise listed are not covered. Pain Clinics— • Methadone maintenance or treatment. Outpatient services that must be requested in writing by the Primary Care Physician. This request 4. Ambulance —Ambulance service provided due to must include supporting second opinions from two the absence of another medically appropriate form participating specialists, one of whom is a licensed of transportation or for the Member's convenience mental health Provider. Any psychotherapy P Y py and/or is not covered. physical therapy sessions as a part of the program 5. Behavior Modification and Non-Crisis Mental will be counted toward the pain clinics Limits. Health Counseling and Treatment— Behavior 13. Communication Devices —Computers, personal modification and non-crisis mental health digital assistants and any speech-generating devices counseling and treatment are not covered. Examples are not covered. The benefits described in Section Five will not be Covered Services unless they arc determined to be Medically Necessary by PacifiCare and are provided by Member's Primary Care Physician or authorized by PacifiCare,Unless described as a Covered Service in the attached supplement,all services and benefits described below are excluded from coverage or limited under this Health Plan.Any supplement must be an attachment to this Combined Gtidence c fCourage and Disclosure Farm.(Note: Additional exclusions and limitations maybe included with your explanation of your benefits.PLEASE REFER TO YOUR SO'EMU OF BENEFtIS FOR FIIRI'HER INFORMATION,INCLUDING,BUT NOT LLMITED TO,ANY APPLICABLE COPAYMENTS AND HMITAI'IONS FOR ALL PROVISIONS LISTED IN SECTION FIVE. Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. Section Five - Your Medical Benefits L 14. Complementary and Alternative Medicine- 18. Dental Care, Dental Appliances and Complementary and Alternative Medicine are not Orthodontics- Except as otherwise provided covered unless purchased by the Subscriber's under "Outpatient Benefits" "Oral Surgery and Employer Group as a supplemental benefit. (See the Dental Services," dental care, dental appliances and definition for "Complementary and Alternative orthodontics, and care provided under newborn Medicine" in Section Ten— Defmitions.) care concerning coverage of cleft palate and cleft lip arc not covered. Maxillary and mandibular 15. Cosmetic Services and Surgery— Plastic, reconstructive or cosmetic surgery are not covered, osteotomies are only covered when actual including, but not limited to, skin lesions that are significant deterioration in the Member's physical removed for cosmetic purposes. Exceptions for condition is demonstrated due to inadequate reconstructive surgery must be approved in writing respiration or nutrition. Dental care means all by PacifiCare and will be considered only when services required for prevention and treatment of preformed primarily to improve the physical health diseases and disorders of the teeth, including, but not limited to: oral exams, X-rays, routine fluoride and function of the patient. Any non-Covered Services received prior to written approval will not treatment; plaque removal, tooth decay, routine tooth extraction, dental embryonal tissue disorders, be reimbursed by PacifiCare and will be the financial responsibility of the Member. periodontal disease, crowns, fillings, dental implants, caps, dentures, braces and orthodontic However, the expenses of plastic, reconstructive procedures. (Coverage for dental care may be or cosmetic surgery will be covered if the surgery available if purchased by the Subscriber's employer is performed as soon as medically feasible and is as a supplemental benefit.) Medically Necessary for either of the following reasons: 19. Dental Treatment Anesthesia—Dental treatment anesthesia provided or administered in a dentist's • The repair is initiated within one year office is not covered, except as provided for children following the injury. as defined above in "Outpatient Benefits," "Oral • The correction of a congenital defect that Surgery and Dental Services: Dental Treatment substantially impairs major organ function, or Anesthesia for Dependent Children." Charges for leads to a progressive deterioration of the health the dental procedure(s) itself, including, but not of a covered child. limited to, professional fees of the dentist or oral surgeon, X-ray and laboratory fees or related dental 16. Cumulative Benefits—Any service provided to a supplies provided in connection with the care, Subscriber or Dependent during a contract year is treatment, filling, removal or replacement of teeth limited cumulatively to the benefits covered in this or structures directly supporting the teeth are not Group Agreement. The following changes in a covered except for services covered by PacifiCare Member's status may not increase any restriction or under "Outpatient Benefits," "Oral Surgery and limitation on the number of services or benefits a Dental Services." Member can receive in a contract year: 20. Diabetic and Dietary Management and • From Subscriber to Dependent; Treatment—has the following exclusions and • From Dependent to Subscriber; limitations: • From group coverage to Continuation Coverage, Limit: individual plan coverage or conversion coverage. These services must be provided under the direction 17. Custodial Care—Custodial Care is not covered of and prescribed by a Participating Provider. except for those services provided by an appropriately Coverage includes outpatient diabetic educational licensed Hospice agency or appropriately licensed and outpatient diabetic self-management training Hospice facility incident to a Member's terminal illness when determined to be Medically Necessary, and as described in the explanation of"Hospice Services" specific criteria are met. in the "Medical Benefits"section of this Combined Not Covered: Evidence of Coverage and Disclosure Form. Dietary counseling for obesity, including weight a Section Five - Your Medical Benefits reduction programs. child's current academic level of function and the level 21. Dialysis—Chronic dialysis (peritoneal or that would be expected for a child of that age. Educational services include, but are not limited to, hemodialysis) is not covered outside of the language and speech training, reading and PacifiCare HMO Service Area. 22. Disabilities Connected to Military Services- psychological and visual integration training as Treatment in a government facility for a disability Sdefined by the American Academy of Pediatrics Policy connected to military service that the Member is Vision A Suent-SLubject Reviewng Disabilities, Dyslexia and legally entitled to receive through a federal Vision:ASubject 26. Elective Enhancements-Procedures, services and governmental agency and to which Member has supplies for elective, non-Medically Necessary reasonable access, is not covered. 23. Drugs and Prescription Medication (Outpatient) enhancements to normal body parts (items, devices or - Outpatient drugs services to improve appearance or perfonnance) are prescription medications are not covered. This includes, but is not limited to, not covered; however, coverage for prescription medications may be available as a supplemental elective ante, c cosmetic c related toand hair growth, athletic benefit. If your Health Plan includes a supplemental performance,n changes anti-aging. Please benefit, a brochure will be enclosed with these refer to "Reconstructive Surgery" for a description of reconstructive surgery services covered by your Health materials. Infusion drugs and infusion therapy not considered outpatient drugs for the purposes of Plan. • this exclusion. Refer to "Outpatient Benefits," 27. Exercise Equipment and Services- Exercise "Injectable Drugs (Outpatient Injectable Medications equipment or any charges for activities, instructions or and Self-injectable Medications)" and "Infusion facilities normally intended or used for developing or Therapy" for benefit coverage. Pen devices for the maintaining physical fitness are not covered. This includes, but is not limited to, charges for physical delivery of medication are not covered. fitness instructors, health clubs or gyms or home 24. Durable Medical Equipment-Replacements, exercise by a equipment or swimming pools, even if repairs and adjustments to Durable Medical Equipment are limited to normal wear and tear or ordered by a health care professional. 28. Experimental and/or Investigational Procedures, because of a significant change in the Member's physical condition. Replacement of lost or stolen Items and Treatments - Experimental and/or Investigational procedures, items and treatments are Durable Medical Equipment is not covered. The not covered. Unless otherwise required by federal or following equipment and accessories are not state law; decisions as to whether a particular covered: non-Medically Necessary optional attachments and modifications to Durable Medical treatment is Experimental or Investigational and therefore not a covered benefit are determined by a Equipment for the comfort or convenience of the PacifiCare Medical Director, or his or her designee. Member, accessories for portability or travel, a For the purposes of this Combined Evidence of second piece of equipment with or without additional accessories that is for the same or similar Coverage and Disclosure Form, procedures, studies, medical purpose as existing equipment and home tests, drugs or equipment will be considered and car remodeling. Experimental and/or Investigational if any of the 25. Educational Services for Developmental Delays following criteria/guidelines is met: and Learning Disabilities- Educational services to • It cannot lawfully be marketed without the approval of the Food and Drug Administration treat developmental delays or learning disabilities are not covered. A learning disability is a condition (FDA) and such approval has not been granted at where there is a meaningful difference between a the time of its use or proposed use. The benefits described in Section Five will not be Coscroi Servicd.s unless they are determined to be Medically Ncrcscty by I$rYfiCart:and am provided by Member's Primary Care Physician or authorized by PacifiCare.Unless described as a Covered Service in the attached supplement,all services mid benefits described below are excluded from coverage or lint i under this I lealth Plan.Any supplement must be an anachment to this Combined Evidence o(Cncrrage and Disclosure limn.(Note. Additional exclusions and lintiunons maybe included with your explanation of your benefits.PLEASE REFER TO YOUR SCI IEDULE OF BENEFITS FOR FURTHER INFORMATION,INCLUDING,BUT NUE maim i't),ANY APPLICABLE COPAYMENTS AND LIMnATIONS FOR ALL PROVISIONS LISTED IN SRCnON FIVE. Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. 29 r � Section Five - Your Medical Benefits • It is a subject of a current investigation of new will be asked to execute, in order to receive the drug or new device (IND) application on file with drug, device, treatment or procedure; the FDA - The published authoritative medical and • It is the subject of an ongoing clinical trial (Phase scientific literature regarding the drug, device, I, II or the research arm of Phase III) as defined in treatment or procedure; regulations and other official publications issued — Expert medical opinion; by the FDA and Department of Health and Human Services (DHHS). — Opinions of other agencies or review organizations, e.g., ECRI Health Technology • It is being provided pursuant to a written Assessment Information Services, HAYES New protocol that describes among its objectives the Technology Summaries or MCMC determination of safety, efficacy, toxicity, Medical Ombudsman; maximum tolerated dose or effectiveness in comparison to conventional treatments. — Regulations and other official actions and publications issued by agencies such as the FDA, • It is being delivered or should be delivered DHHS and Agency for Health Care Policy and subject to approval and supervision of an Research (`AHCPR"). institutional review board (IRS) as required and defined by federal regulations or other official Appeal rights are available to you. Should you wish actions (especially those of the FDA or DHHS). to appeal any health care decision, please refer to • Section Eight-Overseeing Your Health Care Other facilities studying substantially the same Decisions, for instructions on how to submit drug, device, medical treatment or procedures an appeal. refer to it as Experimental or as a research project, a study, an invention, a test, a trial or 29. Eyewear and Corrective Refractive Procedures- other words of similar effect. Corrective lenses and frames, contact lenses and contact lens fitting and measurements are not • The predominant opinion among experts as expressed in published, authoritative medical covered (except for initial post-cataract extraction or corneal bandages and for the treatment of literature is that usage should be confined to keratoconus and aphakia). Surgical and laser research settings. procedures to correct or improve refractive error are • It is not Experimental or Investigational itself not covered. (Coverage for frames and lenses may pursuant to the above criteria, but would not be be available if the Subscriber's employer purchased Medically Necessary except for its use in a vision supplemental benefit. If your Health Plan conjunction with a drug, device or treatment that includes a vision supplemental benefit, a brochure is Experimental or Investigational (e.g., lab tests describing it will be enclosed with these materials.) or imaging ordered to evaluate the effectiveness Routine screenings for glaucoma are limited to of an Experimental therapy). Members who meet the medical criteria. • The sources of information to be relied upon by 30. Family Planning- Family planning benefits, other PacifiCare in determining whether a particular than those specifically listed in "Voluntary treatment is Experimental or Investigational, and Termination of Pregnancy" under "Inpatient therefore not a covered benefit under this plan, Benefits," and "Family Planning" under"Outpatient include, but are not limited to the following: Benefits," are not covered. Pregnancy test kits and — The Member's medical records; ovulation kits are not covered. — The protocol(s) pursuant to which the drug, device, treatment or procedure is to 31. Follow-up Care: Emergency Services or Urgently be delivered; Needed Services —Services following discharge after receipt of Emergency Services or Urgently — Any informed consent document the Member, Needed Services, including, but not limited to, or his or her representative, has executed or treatments, procedures, X-rays, lab work, Physician 30 IL Section Five - Your Medical Benefits ) 1 visits, Rehabilitation and Skilled Nursing Care are 1 not covered without PacifiCare's authorization:'the except when coverage under this Health Plan is fact that the Member is outside the HMO Service expressly required by federal or state law. Area and that it is inconvenient for the Member to 36. Health Care Expenses Incurred Due to Liable Third Party- Except as set forth in this Combined obtain the required services from a Participating Evidence of Coverage and Disclosure Form in Provider will not entitle the Member to coverage. 32. Foot Care- Except as Medically Necessary, routine Section Six- Payment Responsibility, foot care, including, but not limited to, removal or charge agaisnst t right to the repayment from h parties a debt as a reduction of corns and calluses and clipping of charge age ember' recoveries ltha x third," coverage agelf toenails, is not covered. PP g for a Member's health care expenses," coverage for 33. Foot Orthotics/Footwear-Specialized footwear, any health care expenses incurred as the result of a liable third party are not covered. including foot orthotics and custom-made or standard orthopedic shoes, is not covered, except 37. Hearing Aids and Hearing Devices—Hearing caovered. P and nonimplantable services hearing devices are not r hearing for Members with diabetic foot disease or when an orthopedic shoe is permanently attached to a Audiology services (other than Hearing caeening for hearing Medically Necessary orthopedic brace. Coverage covertty) are pinoa tableeh.hearing aid supplies nent are not g covered. Implantable devices are not shall he to the Limits as described in your Schedule of Benefits. Each $1 paid for podiatric shoe inserts coveredly except a for cochlear impaired inii for bilaterally, rally, shall reduce by$1 the amount available forprel profoundly hearing individuals or for orthopedic braces. Orthotic devices for podiatric use conventional Members who have not benefited from and arch support are not a covered benefit. conventional amplification (hearing aids). Genetic Counseling c38. Hospice Services —Hospice services are not of non-Members Testing and not Genetic resod testing covered for (1) Members who do not meet the aisg definition n of reasonable anll; orn ne2)cessary saryHospice services ofsolely o - embers is the gender covered. Genetic fetus e not covered. Genetic testing and counseling are not management at are not reasonable and necessary cache covered when done for nonmedical reasons or of a terminal Hospice sp pr(e.g., care when a Member has no medical indication or family provided in noncertified programs). General testing and 39. Irma counseling are not covered to screen newborns, immigration, camp, volunteer work, licensure, umzations—Immunizations that are required history of a genetic abnormality children or adolescents to determine their carrier for work, insurance, school, marriage, adoption, status for inheritable disorders when there would be certification, registration, sports or recreational no immediate medical benefit or when the test activities are not covered. results would not be used to initiate medical 40. Infertility Reversal— Reversals of sterilization interventions during childhood. Genetic testing and procedures are not covered. counseling are not covered except when determined by PacifiCare's Medical Director or designee to be 41. Infertility Services—Infertility services are not Medically Necessary to treat the Member for an covered unless purchased by the Subscriber's inheritable disease. Refer to "Maternity Care, Tests Employer Group. Please refer to your Schedule of and Procedures" in the "Outpatient Benefits" section Benefits. The following services are excluded under for coverage of amniocentesis and chorionic villus the PacifiCare Health Plan: ovum transplants, ovum sampling. or ovum bank charges, sperm or sperm bank charges 35. Government Services and Treatment—An and the medical or Hospital Services incurred by y surrogate mothers who are not PacifiCare Members services that the Member receives from a local, state en are not covered. Medical and Hospital Infertility or federal governmental a g cy are not covered, services for a Member whose fertility is impaired due The benefits described in Section Five will not be Cosered Services unless they am determined to be Medically Necessary Ptimad Care Physician or authorized by PadtiCani.Unless described as a Orvemd excluded Jinni coverage or limited under this 1 iealth PLm.Any supplement must lx an attachment to this Cont/a/'nee/Ei en��C aCare d are providedlos re MembeNs Bence in the attached supplement,all mitts and benefits described below am ge and Additional exclusions and limitations may be included with your expLtnation of your benefits PLEASE REFER TO YOUR SCHEDULE OF BENEFITS FOR FU Harm RTHER INFORMATION.INCH DING,BUT NOT I.LMiTED TO,ANY APFLICSBLE COPAYMENTS AND'IMITATIONS FOR ALI.PROVISIONS LISTED ECHON FIVE, (Note: Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. ID Terra Otis n. r � Section Five - Your Medical Benefits • to an elective sterilization, including surgery, Medicare covered services is not covered by medications and supplies, are not covered. PacifiCare for Medicare Eligible Members, whether 42. Implants-The following implants are not covered: or not a Medicare Eligible Member has enrolled in Medicare Part A and/or Medicare Part B. • Removal and/or replacement of breast implants for nonmedical reasons 47. Mental Health Services - The following mental health services are not covered: • Replacement of breast prosthesis and the prosthesis itself following cosmetic breast • Confinement, treatment, service or supply that is not authorized, except in the event of augmentation mammoplasty an emergency. 43. Inpatient Alcohol-Drug Rehabilitation Care —The following limitations apply: • Confinement, treatment, service or supply that is not ordinarily provided for the specific treatment • One inpatient or outpatient course of treatment which was authorized. per contact year. • Confinement, treatment, service or supply • Two courses of inpatient or outpatient treatment obtained through or required by a governmental for each Member during his/her lifetime. agency or program. • For inpatient rehabilitation, services are covered at • Weight control programs and treatment for the designated facility and will be subject to the addictions to tobacco, nicotine or food. Limits as described in your Schedule of Benefits or until the Participating Provider has determined • Treatment or psychological testing for any reading satisfactory completion of the inpatient program, or learning disorder, mental retardation or other developmental disorders as defined by the whichever is less. Diagnostic and Statistical Manual of Mental 44. Institutional Services and Supplies - Except for Disorders-IV(DSM-lV). skilled nursing services provided in a Skilled Nursing Facility, any services or supplies furnished • Counseling for adoption, custody, family by a facility that is primarily a place of rest, a place planning or pregnancy in the absence of a DSM-IV diagnosis. for the aged, a nursing home or any similar institution, regardless of affiliation or denomination, • Counseling associated with or in preparation for a are not covered. (Skilled nursing services are sex change operation. covered as described in this Combined Evidence of • Sexual therapy programs, including therapy for Coverage and Disclosure Form in the sections sexual addiction, the use of sexual surrogates and entitled, "Inpatient Benefits" and "Outpatient sexual treatment. Benefits.") Members residing in these facilities are eligible for Covered Services that are determined to • Vocational, pastoral or spiritual counseling. be Medically Necessary by PacifiCare and are •provided by Member's Primary Care Physician. Dance, poetry, music or art therapy, except as pan of a treatment program in an inpatient setting. 45. Maternity Care, Tests and Procedures - Home • Non-organic therapies, including, but not limited deliveries are not covered. Coverage for maternity to, bioenergetics therapy, confrontation therapy, services received outside the HMO Service Area is crystal healing therapy, educational remediation, subject to prior written approval from PacifiCare. Eye Movement Desensitation Reprocessing, Such approval will only be given in cases of guided imagery, marathon therapy ritual therapy primal Emergency Medical Conditions or Urgently Needed Golfing sensitivity training, training Services as defined in Section Ten - Definitions. psychoanalysis, transcendental meditation and Z Educational courses on lactation, childcare and/or therapy prepared childbirth classes are not covered. • Organic therapies, including, but not limited to, 46. Medicare Benefits for Medicare Eligible aversion therapy, carbon dioxide therapy, Members-The amount payable by Medicare for a r Section Five - Your Medical Benefits -\\\ yi environmental ecological treatment or remedies, employer as a supplemental benefit. If your Health herbal therapies, homodialysis for schizophrenia, Plan includes a supplemental acupuncturist and/or vitamin or orthomolecular therapy, narcotherapy with chiropractic benefits, a brochure describing it will be LSD and sedative action electrostimulation therapy enclosed with these materials. • Surgery or acupuncture as a mental health benefit. 50. Nursing, Private Duty- Private-duty nursing is • Laboratory fees as a mental health benefit for not covered. outpatient treatment plans. 51. Nutritional Supplements or Formulas - Formulas, • Services which are not Medically Necessary for the food, vitamins, herbs, enteral feeding substance and treatment of mental health disorders. dietary supplements are not covered (except as described under"Outpatient Benefits" • Services that are required by a court order as a "Phenylketonuria (PICU) and Inherited Enzymatic part of parole or probation, or instead of Disorders Testing and Treatment"). incarceration, which are not Medically Necessary, 52. Off-Label Drug Use-Off-label drug use, which • Long-term, insight-oriented psychotherapies that means the use of a drug for a purpose that is regress the Member emotionally or behaviorally, different from the use for which the drug has been • Personal enhancement, self-actualization therapy approved for by the FDA, including off-label self- or other similar treatment plans. injectable drugs, is not covered except as follows: If the self-injectable drug is prescribed for off-label • Services provided by a nonlicensed Provider. use, the drug and its administration is covered only • Neurological services and tests, including, but not when all of the following criteria are met: limited to, EEGs, PET scans, beam scans, MRIs, • The drug is approved by the FDA; skull X-rays and lumbar punctures. These services • The drug is prescribed by a Participating Provider must be preauthorized by the Member's Primary Care Physician. for the treatment of a life-threatening condition or for a chronic and seriously debilitating condition; • Treatments which do not meet the national standards for mental health professional practice. • The drug is Medically Necessary to treat the condition; • Medical treatment for eating disorders, • The drug has been recognized for treatment of • Treatment sessions by telephone or computer Internet the life-threatening or chronic and seriously services (except as provided by Colorado law). debilitating condition by one of the following: • Evaluation or treatment for education, The American Medical Association Drug professional training, employment investigations, Evaluations, The American Hospital Formulary fitness for duty evaluations or career counseling. Service Drug Information, The United States Pharmacopeia Dispensing Information, Volume I 48. Morbid Obesity- Surgical treatment for morbid or in two articles from major peer-reviewed obesity and services related to this surgery are not medical journals thatpresent data supporting covered. Please also see "Weight Alteration Programs 1 nr the proposed off-label drug use or uses as generally (Inpatient or Outpatient)." safe and effective; 49. Non-Physician Health Care Practitioners—This • The drug is covered under the injectable drug Plan may not cover services of all non-Physician benefit described in the "Outpatient Benefits" health care practitioners. Treatment by non-Physician section of this Combined Evidence of Coverage health care practitioners such as acupuncturists and and Disclosure Form, chiropractors may be available if purchased by your The benefits described in Section Five will not be Coverd Senses unless they are determined to be Medically Necessary by PacifiCae and am provided by Member's Primary Care Physician or authorized by I adfiCare.Unless described as a Covered Service in the attached supplement,all services and benefits desaibed below are occluded from coverage or limited under this Health Plan.Any supplement must be an attachment to this Comrbined Evidence of Coverage and Disclosure Form.(Note: Additional occlusions and limitations may be included with your explanation of your benefits.PLEASE REFER 1'0 YOUR SCHEDULE OF BENEFIT'S FOR FURTHER INFORM/MON.INCLUDING,BUT NOT HMrEED TO,ANY APPLICABLE COPAYMENTS AND[IMITATIONS FOR AIL PROVISIONS LIS'T'ED IN SECTION FIVE. • Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. ID F „ x7 1 Section Five - Your Medical Benefits Nothing in this section shall prohibit PacifiCare from the Member and escort, if any (excludes liquor use of a Formulary, Copayment, technology and tobacco). Food and housing expenses are not assessment panel or similar mechanism as a means covered for any day a Member is not receiving for appropriately managing the utilization of a drug Medically Necessary transplant services. that is prescribed for a use that is different from the • Listing of the Member at a second National use for which that drug has been approved for Preferred Transplant Network center is excluded, marketing by the FDA. unless the Regional Organ Procurement Agencies 53. Oral Surgery and Dental Services - Dental are different for the two facilities and the Member services, including, but not limited to, crowns, is accepted for listing by both facilities. In these fillings, dental implants, caps, dentures, braces and cases, organ transplant listing is limited to two orthodontic procedures, are not covered. National Preferred Transplant Network facilities. If the Member is dual listed, his or her coverage is 54. Oral Surgery and Dental Services: Dental limited to the actual transplant at the second Treatment Anesthesia- Dental anesthesia in a facility. The Member is responsible for any dental office or dental clinic is not covered, except as duplicated diagnostic costs incurred at the second provided in "Outpatient Benefits" "Oral Surgery and facility. (See the definition for"Regional Organ Dental Services: Dental Treatment Anesthesia Procurement Agency.") for Dependent Children." Professional fees of the dentist are not covered. (Please see "Dental Care, 57. Orthopedic Braces- Refer to your Schedule of Dental Appliances and Orthodontics" and "Dental Benefits for applicable limitations under this benefit. Treatment Anesthesia.") Each $1 paid for orthopedic braces shall reduce by $1 the amount available for podiatric shoe inserts as 55. Organ Donor Services -Medical and Hospital listed in "Foot Orthotics/Footwear." Services, as well as other costs of a donor or prospective donor, are only covered when the 58. Phenylketonuria (PKU) and Inherited Enzymatic recipient is a Member. The testing of blood relatives Disorders Testing and Treatment- Food products to determine compatibility for donating organs is naturally low in protein are not covered, except as limited to sisters, brothers, parents and natural provided under"Outpatient Benefits" children. Donor searches are only covered when "Phenylketonuria (PKU) and Inherited Enzymatic performed by a Provider included in the "National Disorders Testing and Treatment." Medical foods Preferred Transplant Network facility." will be subject to a 50% Copayment. 56. Organ Transplants—All organ transplants must 59. Physical or Psychological Examinations — be preauthorized by PacifiCare and performed in Examination for employment, licensing, insurance, a PacifiCare National Preferred Transplant adoption purposes, travel, premarital, examination Network facility. or treatment ordered by a court or other nonpreventive health reasons are not covered. • Transportation is limited to the transportation of Expenses for medical reports, including preparation the Member and one escort to a National and presentation are not covered. Expenses for Preferred Transplant Network facility greater than examinations and treatment conducted for the 60 miles from the Member's Primary Residence as preauthorized by PacifiCare. Transportation and purpose of medical research are not covered. other nonclinical expenses of the living donor are 60. Private Rooms and Comfort Items - Personal or excluded and are the responsibility of the Member comfort items, and non-Medically Necessary who is the recipient of the transplant. (See the private rooms during inpatient hospitalization, are definition for "National Preferred Transplant not covered. Network.") 61. Prosthetics and Corrective Appliances - • Food and housing is not covered unless the Replacement of lost prosthetics or corrective National Preferred Transplant Network center is appliances is not covered. Bionic and myoelectric located more than 60 miles from the Member's prosthetics are not covered. Bionic prosthetics are Primary Residence, in which case food and prosthetics that require surgical connection to housing is limited to $125.00 a day to cover both nerves, muscles or other tissues. Myoelectric a t , l I: i I i Section Five - Your Medical Benefits prosthetics are prosthetics which have electric Not Covered: motors to enhance motion. Replacements, repairs and adjustments to corrective appliances and Fitting contact lenses; prosthetics coverage are limited to normal wear and • Vision therapy; tear or because of a significant change in the • Radial keratotomy, keratomileusis and excimer Member's physical condition. Repair or replacement laser surgery; must be authorized by PacifiCare. g �'' Coverage under this benefit also includes eyeglasses , Reconstructive Surgery— Reconstructive surgery is when prescribed following cataract surgery with an covered to correct or repair abnormal structures of intra-ocular lens implant. Eyeglasses must be the body caused by congenital defects, obtained through Participating Providers: developmental abnormalities, trauma, infection, tumors or disease. The purpose of reconstructive Limits: surgery is to correct abnormal structures of the body • $125 per pair of eyeglasses; to improve function and create a normal appearance to the extent possible. Reconstructive procedures • One pair of eyeglasses per surgery; require preauthorization by the Member's Primary • Two pairs of eyeglasses per lifetime. Care Physician or PacifiCare in accordance with standards of care as practiced by Physicians Not Covered: specializing in reconstructive surgery. • Eyeglasses or contact lenses other than The expenses of plastic, reconstructive or cosmetic following cataract surgery as described above, I surgery will be covered if the surgery is performed except as covered as a supplemental benefit as soon as medically feasible and is Medically purchased by the subscribing group Necessary for either of the following reasons: • Special treatment for eyeglasses, including, but • The repair is initiated within one year following not limited to, tinting and scratch-resistant the injury, coatings • The correction of a congenital defect that 65. Rehabilitation Services and Therapy- substantially impairs major organ function, or Rehabilitation Services and therapy are either leads to a progressive deterioration of the health limited or not covered, as follows: of a covered child. Cardiac Recreational, Lifestyle, Educational or Hypnotic Limits: I Therapy-Recreational, lifestyle, educational or hypnotic therapy and any related diagnostic testing, • A maximum of$1,000 within a 90-day period I is not covered. Occupational/Physical I Refractions- Refractions have the following Limits: exclusions and limitations: • Refer to your Schedule of Benefits for applicable I Limits: visit limitations under this benefit; One routine exam per Member per contract year • Requires prior written authorization of an approved treatment plan by PacifiCare. Physical and occupational therapy for the care and treatment of congenital defect and birth abnormalities for children up to age five are Ii benefits described in Section Five will not be Covered Services unless they are determined to be Medically Necessary by PacifiCare and are provided by Member's (ary Care Physician or authorized by PacifiCare.Unless described as a Covered Service in the attached supplement,all services and benefits described below are 'pied km coverage or limited under this Health Plan.Any supplement must be an attachment to this Combined Evidence rye Coverage and Disclosure mi m.(Note: Ifional exclusions and limitations may be included with your explanation of your benefits.PLEASE REFER TO YOUR SCHEDI:I.I:OF BENEFITS FOR FI:RI'I IER I)RMATlON.INCLUDING,BUT NOT uM[IE)TO,ANY APPLICABLE COPAYMENTS AM)LIMITATIONS FOR ALL PROVISIONS LISTED IN SECI1ON FIVE. pestions about your benefits? Call the Customer Service Department at 1-800-877-9777. 35 Section Five - Your Medical Benefits covered, without regard to whether the condition is • Biofeedback (except as covered under pain acute or chronic and without regard to whether the clinics and as related to acute pelvic muscle purpose of the therapy is to maintain or to improve rehabilitation). functional capacity. • Cognitive therapy; Limits: • Developmental and neuroeducational testing or • Not to exceed the Limits listed in your Schedule treatment; of Benefits for physical and occupational • Hypnotherapy; therapy per acute condition. • Psychological testing; Speech • Vision therapy/orthoptics; Limits: • Vocational Rehabilitation. • Refer to your Schedule of Benefits for applicable visit limitations under this benefit 66. Respite Care— Respite care is not covered, unless part of an authorized Hospice plan and is necessary • Requires prior written authorization of an to relieve the primary caregiver in a Member's approved treatment plan by PacifiCare residence. Respite care is covered only on an • The Member's status may be reevaluated and, if occasional basis, not to exceed five consecutive days it is determined that the condition is no longer at a time. acute, it may not be covered. 67. Services in the Home— Services in the home • Not Covered: provided by relatives or other household members are not covered. • Speech therapy related to a developmental or communication delay is not covered. 68. Services While Confined—Services required for injuries or illnesses experienced while under arrest, Speech therapy for the care and treatment of detained, imprisoned, incarcerated or confined congenital defects and birth abnormalities for pursuant to federal, state or local law are not children up to age five, without regard to whether covered. However, PacifiCare will reimburse Members the condition is acute or chronic and without regard their out-of-pocket expenses for services received to whether the purpose of the therapy is to maintain while confined in a city or county jail, or, if a or to improve functional capacity juvenile, while detained in any facility, if the services Limits: were provided or authorized by your Primary Care Physician in accordance with the terms of this Health • Not to exceed the Limits listed in your Schedule Plan or were Emergency Services or Urgently Needed of Benefits per year. Services. This exclusion does not restrict PacifiCare's Rehabilitation Services and Therapies liability with respect to expenses for Covered Services Not Covered: solely because the expenses were incurred in a state hospital: however, PacifiCare's liability with respect to • Learning disability; expenses for Covered Services provided in a state • Mental retardation and related conditions; hospital is limited to the rate PacifiCare would pay • Pulmonary rehabilitation. for those Covered Services if provided by a Participating Hospital. Special evaluation and therapies including: a 1a is r Section Five - Your Medical Benefits 69. Sex Transformations- Procedures, services, 74. Transportation-Transportation is not a covered medications and supplies related to sex benefit except for Ambulance transportation as transformations are not covered. defined in Emergency and Urgently Needed Services 70. Sexual Dysfunction or Inadequacy Medications- in this Combined Evidence of Coverage and Sexual dysfunction or inadequacy medications, Disclosure Form. procedures, services, and supplies, including penile 75. Veterans' Administration Services-Except for implants/prosthesis except testosterone injections for Emergency g by oa Urgently Needed Services,' services documented low testosterone levels, are not covered. received by a Member in a Veterans'Administration facility are not covered. 71. Skilled Nursing Services or Home Health Aide Services - Skilled nursing services or home health 76. Refractive Vract Care— See "Eye weed and"Exclusions e aide services provided in the home on a full-time Procedures"u listed in and basis are not covered. "Full-time basis" shall mean Limitations of Benefits." 77. Vision Training—Vision therapy rehabilitation and care that is needed or provided in the home on a daily basis or more than eight hours each day for 22 ocular training programs (orthoptics) are not days or more. covered. 72. Surrogacy— Infertility and maternity services for 78. Weight Alteration Programs (Inpatient or Outpatient) -Weight loss or weight gain programs non-Members are not covered. PacifiCare may seek recovery of actual costs incurred by PacifiCare from are not covered. These programs include, but are a Member who is receiving reimbursement for not limited to, dietary evaluations, counseling, medical expenses for maternity services while acting exercise, behavioral modification, food and food as a surrogate. supplements, vitamins and other nutritional 73. Total Parenteral Nutrition (TPN) —1ota1 supplements. Also excluded are surgery and parenterallaboratory tests associated with monitoring weight nutrition is not covered. loss or weight gain. • • • • • • The benefits described in Section Five will not he Covered Services unless they are determined to be Medically Necessary by PacifiCue and are provided by Member's Primary Care Physician or authorized by PaifiCare.Unless desenbed as a Covered Service in the attached supplement, services and all servic and benefits described below are P excluded from coverage or limited under this Health Plan.Any supplement must be an attachment to this Combined Evidence of Coverage and Dnrlosure lvnn. ;Additional exclusions and limitations may be induded with your explanation of your benefits.PLEASE REFER TO YOUR SCHEDULE.OF BENEFITS FOR FURTHER I INFORNATTON,INCLUDING,BIT NOT LIMITED 1O,ANY APPLICABLE COPAYMEN'TS AND LIMITATIONS FOR ALT,PROVISIONS LISTED IN SECTION FIVE. Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. la • • • • • 7 Section Six - Payment Responsibility it , � - Payment Responsibility What are Copayments (other Charges)? Aside from the Premium, you may be responsible for • What are Premiums (Prepayment Fees)?-. paying a charge when you receive a Covered Service. • What are Copayments (Other Charges)? This charge is called a Copayment and is outlined in your Schedule of Benefits. If you review your Schedule • Annual Out-of-Pocket Maximum of Benefits,you'll see that the amount of the • If You Get a Bill (Reimbursement Provisions) Copayment depends on the service, as well as the Provider from whom you choose to receive your care. • What is a Schedule of Benefits? Annual Out-of-Pocket Maximum • Bills From Non-Participating Providers For certain Covered Services, a limit is placed on the • How to Avoid Unnecessary Bills total amount you pay for Copayments during a contract • Your Billing Protection year. This limit is called your Annual Out-of-Pocket Maximum and when you reach it, for the remainder of • Coordination of Benefits the contract year, you will not pay any additional • Important Rules for Medicare and Medicaid Copayments for these Covered Services. Eligible Members You can find your Annual Out-of-Pocket Maximum in • Assignment your Schedule of Benefits. If you've surpassed your Annual Out-of-Pocket Maximum, submit all your health One of the advantages of your health care coverage is care Copayment receipts and a letter of explanation to: that most out-of-pocket expenses are limited to Copayments. This section explains these and other PacifiCare health care expenses. It also explains your Customer Service Department responsibilities when you're eligible for Medicare or P.O. Box 6770 workers'compensation coverage and when PacifiCare Englewood, Colorado 80155 needs to coordinate your benefits with another plan. Remember, it's important to send us all Copayment What are Premiums? (Prepayment Fees) receipts along with your letter. They confirm that you've reached your Annual Out-of-Pocket Maximum. Premiums are fees an Employer Group pays to cover the You will be reimbursed by PacifiCare for Copayments basic costs of your health care package. An Employer you make beyond your individual or family Annual Group usually pays these Premiums on a monthly basis. Out-of-Pocket Maximum. Often the Subscriber shares the cost of these Premiums with deductions from his or her salary. By choosing the NOTE: 'fhe calculation of your Annual Out-of-Pocket coverage specified in this Group Agreement, paying the Maximum will not include supplemental benefits that Premium or accepting benefits under this Group may be offered by your Employer Group (e.g., coverage Agreement, all Members agree to the terms, conditions for outpatient prescription drugs) or those benefits and provisions of this Group Agreement, whether or subject to a separate maximum. not the Member has signed the application of the Subscriber. If You Get a Bill (Reimbursement Provisions) If you are billed for a Covered Service provided or If you are the Subscriber, you should already know if authorized by your Primary Care Physician or PacifiCare you're contributing to your Premium payment; if you aren't sure, contact your Employer Group's health or if you receive a bill for Emergency or Urgently Needed Services you should do the following: benefits representative. He or she will know if you're contributing to your Premium, as well as the amount, 1. Verify the bill is not for the applicable Copayment. method and frequency of this contribution. 2. Call the Provider, then let them know you have received a bill in error and you will be forwarding the bill to PacifiCare. 3. Give the Provider your PacifiCare Health Plan information, including your name and PacifiCare a ii IE r Section Six - Payment Responsibility Member number. Include your name, PacifiCare ID number and a brief 4. Forward the bill to: note that indicates your belief that you've been billed PacifiCare for a Covered Service. The note should also include the Customer Service Department date of service, the nature of the service and the name P.O. Box 6770 of the Provider who authorized your care. No claim Englewood, Colorado 80155 form is required. Include your name, your PacifiCare ID number and a PacifiCare will make a determination within 30 days brief note that indicates you believe the bill is for a from the date you submit a claim containing all Covered Service. The note should also include the date information reasonably necessary to decide the claim. of service, the nature of the service and the name of the PacifiCare will not pay any claim that is filed more than one year from the date the services or supplies were Provider who authorized your care. No claim form is required. If you need additional assistance, call our provided. PacifiCare also will not pay for excluded services or supplies unless authorized by your Primary Customer Service department. Care Physician, or directly by PacifiCare. Please note: Your Provider will bill you for services that are not covered by PacifiCare or haven't been properly Any payment assumes you have not exceeded your authorized. You may also receive a bill if you've benefit Limits. If you've reached or exceeded any exceeded PacifiCare's coverage Limit for a benefit. applicable benefit Limit, these bills will be your responsibility. What is a Schedule of Benefits? If you receive emergency treatment from a non- participating Your Schedule of Benefits is printed separately from this mental health Provider, you may receive a bill. Send PacifiCare Behavioral health (YBH) a copy of document and lists the Covered Services unique to your the bill or claim within 90 days of the date of service, or plan. It also includes your Copayments, as well as the Annual Out-of-Pocket Maximum and other important as soon as possible. PBH will not pay for claims submitted after 120 days of the date of service. Mail bills information. If you need assistance understanding your Schedule of Benefits, or need a new copy, please call our to: PacifiCare Behavioral Health, Claims Department, Customer Service department. 23046 Avenida de la Carlota, Suite 700, Laguna Hills, CA 92653. If your plan includes a Copayment, you are responsible to pay these directly to the Provider. Bills From Non-Participating Providers How to Avoid Unnecessary Bills If you receive a bill for a Covered Service from a Always obtain your care under the direction of Physician who is not one of our Participating Providers, PacifiCare, or your Primary Care Physician. By doing and the service was preauthorized and you haven't this, you only will be responsible for paying any related exceeded any applicable benefit Limits, PacifiCare will Copayments and for charges in excess of your benefit pay the Usual and Customary Charges for the service limitations. Except for Emergency or Urgently Needed { less the applicable Copayment. (Preauthorization isn't Services, if you receive services not authorized by required for Emergency Services and Urgently Needed PacifiCare or your Primary Care Physician, you may be Services. See Section Three— Emergency and pe responsible for pa yment.yment. This is also true if you receive Urgently Needed Services.) You may also submit a bill any services not covered by your plan. (Services not to us if a Non-Participating Provider has refused covered by your plan are included in Section Five— payment directly from PacifiCare. Your Medical Benefits.) You should file a claim within 12 months, or as soon as reasonably possible, of receiving any services and Your Billing Protection related supplies. Forward the bill to: All PacifiCare Members have rights that protect them PacifiCare from being charged for Covered Services in the event Customer Service Department PacifiCare does not pay a Provider, a Provider becomes P.O. Box 6770 insolvent or a Provider breaches its contract with Englewood, Colorado 80155 PacifiCare. In none of these instances may the { Participating Provider send you a bill, charge you or Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. ID IIIIIII , (-Section Six - Payment Responsibility have any other recourse against you for a Covered PacifiCare will follow coordination of benefits guidelines Service. However, this provision does not prohibit the promulgated by the Colorado Division of Insurance to collection of Copayment amounts as outlined in the establish the order of carrier responsibility in Schedule of Benefits. coordinating benefits with other Plans in force for Members, including Members covered by more than In the event of a Provider's insolvency, PacifiCare will one policy with PacifiCare. "Plan" is defined below continue to arrange for your benefits. If for any reason PacifiCare is unable to pay for a Covered Service on The benefits available to Members under any other Plan your behalf(for instance, in the unlikely event of will be coordinated pursuant to the provisions of this PacifiCare's insolvency or a natural disaster),you are section to avoid duplicate payment to Members for the not responsible for paying any bills as long as you same or similar benefits or services. received proper authorization from your PacifiCare In the event that the order of benefit determination Participating Provider. You may, however, be responsible rules set forth in this section differ from those permitted for any properly authorized Covered Services from a by Colorado Insurance Regulation 4-6-2, or any Non-Participating Provider or Emergency or Urgently successor regulation, then the order of benefit Needed Services from a Non-Participating Provider. determination rules set forth herein will be construed as NOTE: If you receive a bill because a Non-Participating if their terms conformed to the minimum requirements Provider refused to accept payment from PacifiCare, you of that regulation. may submit a claim for reimbursement. See above: "Bills This Coordination of Benefits ("COB") provision applies from Non-Participating Providers." to this Plan when a Subscriber or the Subscriber's Coordination of Benefits covered Dependent has health care coverage under more than one Plan. "Plan" and "This Plan" are defined below Coordination of Benefits (COB) is a process, regulated by law, which determines the financial responsibility for If this COB provision applies, the order of benefit payment when a person has group health care coverage determination rules should be looked at first. The order under more than one plan. "Plan" is defined below of benefit determination rules are stated in Order of COB is designed to provide maximum coverage for Benefit Determination Rules. Those rules determine medical and Hospital Services at the lowest cost by whether the benefits of This Plan are determined before avoiding excessive or duplicate payments. or after those of another Plan. The benefits of This Plan: The objective of COB is to ensure that all group Health • Will not be reduced when, under the order of benefit Plans that provide coverage to an individual will pay no determination rules, This Plan determines its benefits more than 100% of the allowable expense for services before another Plan; but that are received. This payment will not exceed total • May be reduced when, under the order of benefits expenses incurred or the reasonable cash value of those determination rules, another Plan determines its services and supplies when the group Health Plan benefits first. The above reduction is described in provides benefits in the form of services rather than "Effect on the Benefits of This Plan." cash payments. A. Definitions PacifiCare's COB activities will not interfere with your medical care. The following definitions only apply to coverage provided under this explanation of Coordination of The order of benefit determination rules below Benefits. determine which Health Plan will pay as the Primary Plan. The Primary Plan that pays first pays without 1. "Plan" is any of the following which provides regard to the possibility that another plan may cover benefits, indemnification or services for, or because some expenses. A Secondary Plan pays after the Primary of, medical or dental care or treatment covered by Plan and may reduce the benefits it pays so that This Plan: payment from all group plans do not exceed 100% of • Group insurance or group-type coverage the total allowable expense. "Allowable Expense" is (including other PacifiCare coverage), whether defined below. insured or uninsured. This includes prepayment, 40 Hr f t i i. I t Ph Section Six - Payment Responsibility group practice or individual practice coverage. It of generally accepted medical practice or as also includes coverage other than school accident- specifically defined in the Plan. type coverage. When a Plan provides benefits in the form of • Coverage under a governmental Plan, or coverage services, the reasonable cash value of each service required or provided by law. This does not rendered will be considered both an Allowable include a state Plan under Medicaid (Grants to Expense and a benefit paid. States for Medical Assistance Programs, Title XIX When benefits are reduced under a Primary Plan of the United States Social Security Act, as amended from time to time). because a covered individual does not comply with the Plan provisions, the amount of such reduction • Individual automobile "no-fault" or traditional will not be considered an Allowable Expense. "fault" type contracts. Examples of such provisions are those related • Hospital indemnity benefits in excess of to second surgical opinions, precertification of admissions or services and preferred Provider $100 per clay. arrangements. Each contract or other arrangement for coverage under any buffeted item above is a separate Plan. 5. "Claim Determination Period" means the period Also, if an arrangement has two pans and COB rules of time, which must not be less than twelve apply only to one of the two, each of the parts is a consecutive months, over which allowable expenses separate Plan. are compared with total benefits payable in the absence of COB, to determine: 2. "This Plan"refers to the covered benefits for health care services of the Combined Evidence of Coverage • Whether overinsurance exists; and and Disclosure Form of which this section is a part. • How much each plan will pay or provide. 3. "Primary Plan/Secondary Plan" The order of It usually is a calendar year, but a plan may use benefit determination rules state whether This Plan some other period of time that fits the coverage of is a Primary Plan or a Secondary Plan as to another the group contract. A person may be covered by a Plan covering the person. plan during a portion of a Claim Determination When This Plan is a Primary Plan, its benefits are Period if that person's coverage starts or ends determined before those of the other Plan and during the Claim Determination Period. without considering the other Plan's benefits. As each claim is submitted, each plan is to When This Plan is a Secondary Plan, its benefits are determine its liability and pay or provide benefits determined after those of the other Plan and may be based upon allowable expenses incurred to that reduced because of the other Plan's benefits. point in the Claim Determination Period. But that determination is subject to adjustment as later When there are more than two Plans covering the Allowable Expenses are incurred in the same Claim individual, This Plan may be a Primary Plan as to Determination Period. one or more other Plans, and may be a Secondary Plan as to a different Plan or Plans. However, it does not include any part of a year during which an individual has no coverage under 4. 'Allowable Expense" means a necessary, reasonable This Plan, or any part of a year before the date this and customary item of expense for health care; COB provision or a similar provision takes effect. when the item of expense is covered at least in part by one or more Plans covering the individual for B.Order of Benefit Determination Rules whom the claim is made. 1. General. When there is a basis for a claim under The difference between the cost of a private hospital This Plan and another Plan, This Plan is a Secondary room and cost of semi-private hospital room is not Plan which has its benefits determined after those of considered an Allowable Expense under the above the other Plan unless: definition unless the patient's stay in a private • The other Plan has rules coordinating its benefits hospital room is Medically Necessary either in terms with those of This Plan, and both those rules and Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. r III Section Six - Payment Responsibility 4 This Plan's rules, below require that This Plan's falls earlier in a year are determined before those of the benefits he determined before those of the other Plan of the parent whose birthday falls later in the year: Plan; or but • The other Plan is a governmental Plan or coverage • If both parents have the same birthday, the benefits of required or provided by law and This Plan is the plan which covered one parent longer are required by law or regulation to be the Primary determined before those of the Plan which covered the Plan. A basis for a claim under a governmental Plan other parent for a shorter period of time. can exist when a Member is covered or eligible for However, if the other plan does not have the rule coverage under that Plan, whether or not the described in the first bulleted item immediately above, but Member applies for or receives benefits thereunder. instead has a rule based upon the gender of the parent, The conditions shown are current examples and if, as a result, the Plans do not agree on the order of (subject to change) of some of the areas in which benefits, the rule of the other Plan will determine the this Plan is required to be the Primary Plan. order of benefits. • The Member is covered under the Civilian Health Rule c—Dependent Child/Parents Separated or Divorced. and Medical Program of the Uniformed Services If two or more plans cover an individual as a Dependent (TRIC,ARE/t.HAMP[.S). child of divorced or separated parents, benefits for the I • The Member is covered under Medicaid. child are determined in this order: 1 • The Member is actively at work and is age 65 or • First, the Plan of the parent with custody of the child; older, and is enrolled as a Subscriber or as a • Then, the Plan of the Spouse of the parent with the Dependent of a Subscriber (of any age) in the custody of the child; and group coverage of a subscribing group with 20 or more employees. • Finally, the Plan of the parent not having custody of the child. • The Member is entitled to Medicare benefits on the basis of End Stage Renal Disease, in which However, if the specific terms of a court decree state that case This Plan will he primary for the first 30 one of the parents is responsible for the health care months (or such period of time as Medicare expense of the child, and the entity obligated to pay or regulations may require) of treatment; after the provide the benefits of the Plan of that parent has actual initial period, the benefits under This Plan will he knowledge of those terms, the benefits of that Plan are reduced to the extent that they duplicate any determined first. The Plan of the other parent will he the benefits provided or available under Medicare, if Secondary Plan. This paragraph does not apply with ' the Member is covered or eligible to be covered respect to any Claim Determination Period or Plan Year under Medicare. during which any benefits are actually paid or provided before the entity has that actual knowledge. C. Rules. This Plan determines its order of benefits using the first of the following rules which Rule d—Joint Custody. If the specific terms of a court applies: decree state that the parents will share joint custody, without stating that one of the parents is responsible for Rule a—Non-Dependent/Dependent. The benefits of the the health care expenses of the child, the Plans covering Plan which covers the person as an employee, Member or the child will follow the order of benefit determination Subscriber (that is, other than as a Dependent) are rules outlined in Rule b. determined before those of the Plan which covers the individual as a Dependent. Rule e—Active/inactive Employee. The benefits of a Plan which covers a person as an employee who is neither laid Rule b—Dependent Child/Parents not Separated or off nor retired (or as that employee's Dependent) are Divorced. Except as stated in Rule c below, when This determined before those of a Plan which covers that Plan and another Plan cover the same child as a person as a laid off or retired employee (or as that Dependent of different persons, called "parents": employee's Dependent). If the other Plan does not have • The benefits of the Plan of the parent whose birthday this rule, and if, as a result, the Plans do not agree on the i II r • 5.� Section Six - Payment Responsibility order of benefits, then Rule e is ignored. This Plan must give PacifiCare any facts it needs to pay the • Rule f—Longer/Shorter Length of Coverage. If none of the claim. above rules determines the order of benefits, the benefits of the Plan which covered an employee, Member or F. Facility of Payment Subscriber longer are determined before those of the Plan A payment made under another Plan may include an amount that should have been paid under This Plan. If it which covered that individual for the shorter term. does, PacifiCare may pay that amount to the organization Rule g-Disputed Order of Benefits. If the plans can not which made that a payment. That amount will then be agree on the order of benefits within 30 calendar days treated as though it were a benefit paid under This Plan. after the plans have received all of the information needed to pay the claim, the plans shall immediately pay the claim "payment aay will not have" includes o pay pr amountn again. The term made" providing benefits in the in equal shares and determine their relative liabilities form of services, in which case "payment made"means following payment except that no plan shall be required reasonable cash value of the benefits provided in the form to pay more than it would have paid had it been primary. of services. D. Effect on the Benefits of This Plan G. Right of Recovery 1. When This Section Applies. This subsection applies If the amount of the a when, in accordance with Order of Benefit payments made by n is i more than it should have paid under the COB provision, it may Determination Rules, This Plan is a Secondary Plan as recover the excess from one or more of: to one or more other Plans. In that event, the benefits of This Plan may be reduced under this section. Such ' The individuals it has paid or for whom it has paid; other Plan or Plans are referred to as "the other Plans" • Insurance companies; or immediately below • Other organizations. 2. Reduction in This Plan's Benefits. The benefits of This The "amount of payments made" includes the reasonable Plan will be reduced when the sum of: cash value of any benefits provided in the form of services. • The benefits that would be payable for the Allowable Expense under This Plan in the absence H.Workers' Compensation of this COB provision; and 1. PacifiCare will not provide benefit services or supplies • The benefits that would be payable for the required as a result of a work-related illness or injury, except for those individuals who are not required to Allowable Expenses under the other Plans, in the absence of provisions with a purpose like that of maintain or be covered by workers' compensation this COB provision, whether or not a claim is made, insurance as defined in workers' compensation laws. exceeds those Allowable Expenses in a Claim This applies to illness or injury resulting from occupational accidents or sickness covered under any Determination Period. In that case, the benefits of This Plan will be reduced so that they and the of the following: benefits payable under the other Plans do not total • Occupational disease laws; more than those Allowable Expenses. • Employer's liability; 3. Only the amount of benefit actually paid by This Plan may be charged against any applicable limit under ▪ Eederal, state or municipal law; This Plan. • The Workers' Compensation Act. E. Right to Receive and Release Needed Information 2. To recover benefits for a work-related illness or injury, Certain facts are needed to apply these COB rules. the Member must pursue his/her rights under the PacifiCare has the right to decide which facts it needs. It Workers' Compensation Act or any of the above provisions that may apply to the illness or injury. This may get needed facts from or give them to any other organization or individual. PacifiCare need not tell, or get includes filing an appeal with the Industrial the consent of, or provide notice to, any individual Commission, if necessary to do this. Each individual claiming benefits under Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. fl r;'I Section Six - Payment Responsibility , a. When a legitimate dispute exists as to whether an agreement, even if such money becomes available injury or illness is work-related, PacifiCare will at some future time. provide benefits during the appeal process if the b) If the Member does not pursue, or fails to recover Member signs an agreement to reimburse (either because no judgment is entered or PacifiCare for 100% of the benefits provided. because no judgment can be collected from the 3. PacifiCare will not provide benefit services for a work- liable third party) a formal, informal, direct, or related illness or injury even under the following indirect claim against the liable third party, then circumstances: the Member will have no obligation to repay the Member's debt to PacifiCare, which debt shall • The Member fails to file a claim within the filing include the cost of arranging or providing period allowed by law otherwise covered health care services to the • The Member obtains care that is not authorized by Member for the care and treatment that was workers' compensation. necessary because of a liable third party. • The Member fails to comply with any other The security interest the Member grants to PacifiCare provisions of the law or its representative, agents and/or delegates applies • The Member has a choice of Providers, which ONLY to the actual proceeds, in any form, that stem includes a PacifiCare Provider, elects to use a Non- from any final judgment, compromise, settlement or Participating Provider and the claim is subsequently agreement relating to the arrangement or provision of denied by workers' compensation. the Member's health care services for injuries caused by a liable third party. 4. Benefits will not be denied to a Subscriber whose employer has not complied with the laws and Important Rules for Medicare-and Medicare- regulations governing Workers' Compensation Eligible Members Insurance, provided that such Subscriber has sought You must let PacifiCare know if you are enrolled, or and received services under the provisions of this eligible to enroll, in Medicare (Part A and/or Part B Group Agreement. coverage). PacifiCare is typically primary (that is, I. PacifiCare's right to the repayment of a debt as a PacifiCare's benefits are determined before those of charge against recoveries from third parties Medicare) to Medicare for some initial period of time. liable for a Member's health care expenses as determined by the Medicare regulations. After the initial period of time, PacifiCare will be secondary to 1. Coverage for any portion of health care expenses Medicare (that is, the benefits under this Health Plan incurred by a Member for which a third party or will be reduced to the extent they duplicate any parties or a third party's (parties') insurance company benefits provided or available under Medicare, if the (collectively, "liable third party") is liable or legally Member is enrolled or eligible to enroll in Medicare.) responsible by reason of negligence, a wrongful intentional act or the breach of any legal obligation on If you are eligible for Medicare, but fail to enroll in the part of such third party, are expressly excluded Medicare, your PacifiCare coverage will be reduced by from coverage under this Health Plan. HOWEVER, in the amount you would have received from Medicare. all cases, PacifiCare will pay for the arrangement or If you have questions about the coordination of provision of health care Medicare benefits, contact your Employer Group or services for a Member who requires such services due our Customer Service department. For questions to a liable third party in exchange for the following regarding Medicare eligibility, contact your local Social agreement: Security office. a) If a Member is injured by a liable third party, Assignment the Member agrees to give PacifiCare or its The rights and privileges of any subscribing group or representative, agents and/or delegates a security Member pursuant to this Agreement may not be interest in any money the Member actually assigned or delegated. PacifiCare shall have the right recovers from the liable third party by way of any to assign this Agreement. final judgment, compromise, settlement or Section Seven - Member Eligibility Member Eligibility Who is a PacifiCare Member? • Who is a PacifiCare Member? There are two kinds of PacifiCare Members: Subscribers and enrolled Dependents. The Subscriber is the person • Eligibility who enrolls through his or her employer-sponsored • What is an HMO Service Area? health benefit plan. The Employer Group, in turn, has signed a Group Agreement with PacifiCare. • Open Enrollment The following family members are eligible to enroll in • Adding Dependents to Your Coverage PacifiCare: • Qualified Medical Child Support Order • The Subscriber's Spouse; • Continuing Coverage for Student and Disabled • Common Law Spouses will be considered Eligible Dependents Dependents if evidence satisfactory to PacifiCare is • Late Enrollment furnished upon request; • Notifying You of Changes in Your Plan • The unmarried biological children of the Subscriber or the Subscriber's Spouse (stepchildren) through the • Updating Your Enrollment Information month in which they reach the Limiting Age of 19, or 24 d • Renewal and Reinstatement (Renewal Provisions) enrolled as a full-time student at a high school, college, university, vocational or secondary school. Verification of • About Your PacifiCare Identification (ID) Card academic enrollment must be provided to PacifiCare on • Ending Coverage (Termination of Benefits) request. Your Employer Group may establish different • Federal COBRA Continuation Coverage criteria regarding Dependents. Check with your employer or our Customer Service department for • Ending Your Coverage: Converting to an Individual information regarding the Dependent age limit(s) or Conversion Plan other Dependent eligibility information applicable to • Certificate of Credible Coverage your Employer Group; • Uniformed Services Em to • Children who are legally adopted or placed for ploy •and adoption with the Subscriber or the Subscriber's Reemployment Rights Act Spouse who meet the requirements described above. This section describes how you become a PacifiCare Legal evidence must he furnished to PacifiCare upon Member; as well as how you can add Dependents to request; your coverage. It will also answer other questions • Children for whom the Subscriber or the Subscriber's about eligibility, such as when late enrollment is permitted In addition,you will learn ways you may Spouse has assumed permanent legal guardianship. be able to extend your PacifiCare coverage when it Legal evidence of the guardianship, such as a certified would otherwise terminate. copy of a court order, must be furnished to PacifiCare upon request; • Children for whom the Subscriber or the Subscriber's Spouse is required to provide health insurance coverage pursuant to a Qualified Medical Child Support Order assignment order, or medical support order, in this section; Questions about your benefits? Call th e Cu stomer r Service Department at 1-800-877-9777. __ mu Section Seven - Member Eligibilitydir tit (1' Larimer Weld Logan r------- "`.-M.--u' — Morgan What is an Boulder HMO Service Area? rJ 1 e' Adams ' -�\ 4 Washington PacifiCare is licensed by the r =r t 2 ≥Arapahoe Colorado Division of Insurance I t f1 to arrange for medical and - Z r IJ Elbert Hospital Services in certain ! j Park geographic areas of Colorado. (__ ,1 ,Ti L El Paso Lincoln These service areas are defined I by counties. Please call our _._i i a Fremont Customer Service Department at 1-800-877-9777 for tt F I �,.- _,r 1 information about PacifiCare's ?,-;l c------ ... HMO Service Area. I 7 i t - { 1 -Broomfield 2-Clear Creek 3-Denver 4-Gilpin e Newborns of the Subscriber are covered form the date Eligibility of birth. This does not include an adopted child All Members must meet all eligibility requirements before the child is placed with the Subscriber for established by the Employer Group and PacifiCare. adoption; and PacifiCare may request evidence to validate eligibility e Regardless of age, any natural, adopted or requirements. PacifiCare's eligibility requirements are: stepchild(ren), of the Subscriber, or children) for a Have a Primary Residence within Colorado or work whom the Subscriber has assumed permanent legal guardianship, within the PacifiCare HMO Service Area; g p, as described above, are eligible if they are medically certified as disabled. Proof of such • Meet any other eligibility requirements established by incapacity and dependency must be furnished at least the Employer Group, such as exhaustion of a waiting annually as requested by PacifiCare, and as required period before an employee can enroll in PacifiCare. by the subscribing group. Such Dependents are the Employers will also establish the "Limiting Age," the only exception to the age limitation described above. age limit for providing coverage to unmarried children, provided that it is not more restrictive than Your Dependent children cannot be denied the requirements set forth by the state of Colorado. enrollment and eligibility due to the following: Eligible Dependents must enroll in PacifiCare at the — Was born to a single person or unmarried couple; same time as the Subscriber or risk not being eligible to — Is not claimed as a Dependent on a Federal Income enroll until the employer's next Open Enrollment Tax Return; Period, as explained below. Circumstances which allow for enrollment outside the Open Enrollment Period are - Does not reside with the Subscriber or within the also explained below All applicants for coverage must HMO Service Area. complete and submit to PacifiCare all applications or other forms or statements that PacifiCare may reasonably request. a IL r Section Seven - Member Eligibility )i Enrollment is the completion of a PacifiCare enrollment to enroll a Spouse or child eligible as a result of form (or a nonstandard enrollment form approved by marriage must he made within 30 days of the PacifiCare) by the Subscriber on his or her own behalf, marriage. or on the behalf of any Eligible Dependents. Enrollment . Having a baby. Newborns are covered for the first 31 is conditional upon acceptance by PacifiCare; the days of life. In order for coverage to continue beyond existence of a valid Employer Group Agreement; and the first 31 days of life, the Subscriber must submit a the timely payment of applicable Health Plan Premiums. Change Request Form to PacifiCare prior to the PacifiCare may in its discretion and subject to specific expiration of the 31 day period for coverage to protocols. accept enrollment data through an continue beyond the first 31 days of life. electronic submission. • Adoption or Placement for Adoption. To enroll a Your effective date of enrollment in PacifiCare will depend new Dependent acquired through legal adoption, the on when and how you enroll.These circumstances are Subscriber must submit written application for explained below. (PLEASE NOTE: PacifiCare enrolls Dependent coverage within 30 days of when the child applicants in the order that they become eligible and up is placed with the Subscriber for adoption. The to our capacity for accepting new Members.) Subscriber also must submit a copy of the adoption Open Enrollment papers. Coverage is effective on the date of adoption or placement for adoption. Most Members enroll in PacifiCare during the Open Enrollment Period established by the Employer Group. ' Guardianship. To enroll a Dependent child for whom This is the period of time established by the employer the Subscriber has assumed permanent legal when its Eligible Employees and their Eligible guardianship, the Subscriber must submit a Change Dependents may enroll in the employer's health benefit Request Form to PacifiCare along with a certified copy plan. An Open Enrollment Period usually occurs once a of a court order granting guardianship within year, and enrollment is effective based on a date agreed 30 days of when the Subscriber assumed legal upon by the employer and PacifiCare. Typically, this is at guardianship. Coverage will be retroactively the start of a calendar year. effective to the date the Subscriber assumed legal guardianship. Adding Dependents to Your Coverage The Subscriber's Spouse and eligible children may apply Qualified Medical Child Support Order for coverage with PacifiCare during the employer's Open A Member (or a person otherwise eligible to enroll in Enrollment Period. If you are declining enrollment for PacifiCare) may enroll a child who is eligible to enroll in yourself or your Dependents (including your Spouse) PacifiCare upon presentation of a request by a District because of other Health Plan or insurance coverage,you Attorney, State Department of Health Services or a court may in the future be able to enroll yourself or your order to provide medical support for such a Dependents in PacifiCare, provided that you request Dependent child without regard to any enrollment enrollment within 30 days after your other coverage period restrictions. ends. In addition, if you have a new Dependent as a A person having legal custody of a child or a custodial result of marriage, birth, adoption or placement for parent who is not a PacifiCare Member may ask about adoption, you may enroll yourself and your Dependents, obtaining Dependent coverage as required by a court or provided that you request enrollment within 30 days administrative order, including a Qualified Medical after the marriage, birth, adoption or placement for Child Support Order, by calling PacifiCare's Customer adoption. (Guardianship is not a Qualifying Event for Service department. A copy of the court or other Dependents to enroll). Under the following administrative order must be included with the circumstances, new Dependents may be added outside enrollment application. Information including, but not the Open Enrollment Period- limited to, the ID card, Combined Evidence of Coverage Getting married. When a new Spouse or child and Disclosure Form or other available information, becomes an Eligible Dependent as a result of including notice of termination, will be provided to the marriage, coverage begins on the first day of the custodial parent, caretaker and/or District Attorney. month following the date of marriage. An application Coverage will begin on the first of the month following Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. Eal it., Section Seven - Member Eligibility • receipt by PacifiCare of an enrollment form with the In order to continue coverage under this section for court or administrative order attached. qualifying disabled Dependents, proof of such disability and dependency must be provided to PacifiCare by the Except for Emergency and Urgently Needed Services, to Member within 31 days of the onset of the disability, receive coverage, all care must be provided or arranged attainment of the Limiting Age or at the time of the in the PacifiCare HMO Service Area by the designated Subscriber's initial enrollment in PacifiCare. Primary Care Physician, as selected by the custodial parent or person having legal custody Proof of such incapacity and dependency must be furnished annually as requested by PacifiCare and as Continuing Coverage for Student and Disabled required by the Employer Group. This proof may Dependents include supporting documentation from a state or federal agency or a written statement by a licensed Certain DependentsPlan who would it attainment t lose coverage s cholo ist, psychiatrist or other Physician to the under the Health established due the their Employer Group pf the effect that such disabled Dependent is medically Limiting Age by Group may extend their coverage under the following certified as disabled. circumstances: Late Enrollment Continuing Coverage for Student Dependents In addition to a special enrollment period due to the An unmarried Dependent who is registered on a full-time addition of a new Spouse or child, there are certain basis (at least 12 semester units or the equivalent as circumstances when employees and their Eligible determined by PacifiCare) at an accredited school or Dependents may enroll outside of the employer's Open college may continue as an Eligible Dependent through Enrollment Period. These circumstances include: the month in which they reach 24, or if greater, the 1. The Eligible Employee (on his or her own behalf, or Limiting Age established by the employer for full-time on behalf of any Eligible Dependents) declined in students, if proof of such status is provided to PacifiCare writing to enroll in PacifiCare when they were first on a periodic basis, as requested by us. If the Dependent eligible because they had other health care student resides outside of the HMO Service Area, the coverage; and student must maintain a permanent address inside the 2. PacifiCare cannot produce a written declination HMO Service Area with the Subscriber and the studentstatement fromthe produce a e nion must select a Participating Primary Care Physician within Employee stating that EtheEligible Group o Employee Eligible his the HMO Service Area. All health care coverage must he or ploher own behalf, a on behalf of any provided or arranged for in the HMO Service Area by the Dependents)b was o with and a Eligible gned designated Primary Care Physician, except for Emergency acknowledgment s provided of vplicit written notice in and Urgently Needed Services. boldface type specifying that failure to elect Continuing Coverage for Certain Disabled coverage with PacifiCare during the initial Dependents enrollment period permits the plan to impose an Unmarried enrolled Dependents, who attain the exclusion of coverage under the Health Plan for a period of 12 months from the date of election of Limiting Age establishedHealth b l the employer, yond th may ing Age coverage under the Health Plan, unless the Eligible enrollment in the en Plan beyond the the follog Age Employee or Dependents can demonstrate that he R the unmarried Dependent meets all of following: or she meets the requirements for late enrollment. 1. The unmarried Dependent resides with the Subscriber or the Subscriber's separated or divorced 3. The other health care coverage is no longer Spouse; available due to: i. The employee or Eligible Dependent has 2. is unmarried Dependent is medically certified as exhausted COBRA Continuation Coverage disabled; and under another group Health Plan; or 3. The unmarried Dependent is chiefly dependent ii. The termination of employment or reduction in upon the Subscriber for support and maintenance. work hours of a person through whom the a f r i i r , f Section Seven - Member Eligibility employee or Eligible Dependent was covered; or 6. The court has ordered health care coverage be iii. The termination of the other Health Plan provided for your Spouse or minor child. coverage; or If the employee or an Eligible Dependent meets these iv. The cessation of an employer's contribution conditions, the employee must request enrollment with toward the employee or Eligible Dependent PacifiCare no later than 30 days following the coverage; or termination of the other Health Plan coverage. PacifiCare may require proof of loss of the other v. The death, divorce or legal separation of a coverage. Enrollment will be effective the first day of the person through whom the employee or Eligible calendar month following receipt by PacifiCare of a Dependent was covered; or completed request for enrollment. vi. The Spouse of a Subscriber has coverage through his/her employment, and Dependents of the subscriber are covered under the Spouse's About Your PacifiCare Identification Card (ID) insurance. Then the Spouse involuntarily loses Your PacifiCare ID card is important for identifying you this coverage. At this time, the Spouse, if alive, as a Member of PacifiCare. Possession of this card and any Dependents of the Subscriber previously does not entitle a Member to services or benefits covered by the Spouse's insurance may enroll in under this Health Ptan. A Member should show this PacifiCare as Dependents, upon notification from card each time he or she visits a Primary Care the subscribing group of the individual's Physician or, upon referral, any other Participating eligibility; or Provider. At the time of service, a Member must identify him/herself to a hospital or Participating vii. An individual who is employed by a PacifiCare Provider as a PacifiCare Member. If he/she does not subscribing group and who previously declined do so, or if the Member misrepresents his/her enrollment is entitled to enroll if the employee membership status, claims payment may be denied. has a new Dependent by birth, marriage, adoption or placement for adoption. The IMPORTANT NOTE:Any person using this card to election to enroll must be made within 30 days receive benefits or services for which he or she is not following the birth, marriage, adoption or entitled wilt be charged for such benefits or services. placement for adoption. If any Member permits the use of his or her identification card by any other person, PacifiCare may NOTE: PacifiCare reserves the right to make it a immediately terminate that Member's membership. condition of enrollment that PacifiCare receives written proof of loss of coverage due to one of the ------------ --_-______ following circumstances: Termination of job or reduction in hours. Notifying You of Changes in Your Plan • Insurance carrier termination of coverage for Amendments, modifications or termination of the Group Agreement by either the Employer Group or the Spouse's employer. PacifiCare do not require the consent of a Member. • Death of the Spouse, leaving other Dependents PacifiCare may amend or modify the Health Plan, without coverage. including the applicable Premiums, at any time by 4. A court has ordered that coverage be provided for a providing a 30-day written notice to the Employer Dependent under a covered employee's health Group prior to the effective date of any amendment or benefit plan. modification. Your Employer Group may also change your Health Plan benefits during the contract year. In 5. A court has ordered that coverage be provided accordance with PacifiCare's Group Agreement, the under an eligible, but not enrolled, employee's Employer Group is obliged to notify employees who health benefit plan. The employee is required to are PacifiCare Members of any such amendment or enroll at the same time as the De pendent. modification. Questions about your benefits? Call the Customer Service -Department at 1 800 877-9777. • €i" 1< 7 Section Seven - Member Eligibility • ' ..___ ir Updating Your Enrollment Information Group Agreement is terminated for any reason, including the nonpayment of Health Plan Premiums. Please notify your employer of any changes to the PacifiCare is not obligated to notify you that you are no information you provided on the enrollment application longer eligible or that your coverage has been within 30 days of the change. This includes changes to terminated. Upon termination of the Group Agreement your name, address, telephone number, marital status or for nonpayment of Premium, Members in groups with the status of any enrolled Dependents. For reporting 50 or fewer employees, or as required by small group changes in marital and/or Dependent status, please see 'Adding Dependents to Your Coverage." If you wish to insurance laws, are entitled to conversion coverage. Members in groups with more than 50 employees are change your Primary Care Physician, you may contact not entitled to conversion coverage upon termination PacifiCare's Customer Service department at of the group plan. 1-800-877-9777 or 1-800-360-1797 (TDD). PacifiCare may terminate this Agreement if any one of Renewal and Reinstatement the following events occur: (i) fraud or intentional (Renewal Provisions) misrepresentation of material fact; (ii) failure to comply Your Employer Group's Group Agreement with with contribution or participation rules; (iii) movement PacifiCare renews automatically, on a yearly basis, outside of the HMO Service Area by all Members of the subject to all terms of the Group Agreement. PacifiCare subscribing group; (iv) cessation of the membership of a or your Employer Group may change your Health Plan subgroup in an association; (v) failure to comply with benefits and Premium at renewal. If the Group the requirements set forth in this Group Agreement; or Agreement is terminated by PacifiCare, reinstatement is (vi) as otherwise specified in this Group Agreement. subject to all terms and conditions of the Group In addition to terminating the Group Agreement, Agreement. In accordance with PacifiCare's Group PacifiCare may terminate a Member's coverage for any Subscriber Agreement, the Employer Group is required of the following reasons: to notify employees who are PacifiCare Members of any such amendment or modification. • The Member no longer meets the eligibility requirements established by the Group Employer Ending Coverage (Termination of Benefits) and/or PacifiCare. Usually, your enrollment in PacifiCare terminates when • The Member establishes his or her Primary Residence the Subscriber or enrolled Dependent is no longer outside the state of Colorado. eligible for coverage under the employer's health • The Members establishes his or her Primary Residence benefit plan. In most instances, your Employer Group outside the PacifiCare HMO Service Area and does not determines the date in which coverage will terminate. work inside the PacifiCare HMO Service Area (except for Coverage can be terminated, however, because of other a child subject to a qualified child medical support circumstances as well, which are described below. order, for more information refer to"Qualified Medical Continuing coverage under this Health Plan is subject to Child Support Order" in this section). the terms and conditions of the employer's Group Agreement with PacifiCare. Termination for Good Cause: When the Group Agreement between the Employer Coverage of any Member will end on the earliest one of Group and PacifiCare is terminated, all Members the following dates: covered under the Group Agreement become ineligible • The date specified in the Group Subscriber for coverage on the date of termination. If the Group Agreement; Agreement is terminated by PacifiCare for nonpayment of ' The last day of the month in which the Subscriber Premiums, coverage for all Members covered under terminates employment; the Group Agreement will be terminated effective the last day for which Premiums were received. According • The last day of the month that the required Premium to the terms of the Group Agreement, the Employer has been paid; Group is responsible for notifying you if and when the I50 A- P Section Seven - Member Eligibility • The last day of the month in which the Member termination, unless PacifiCare has specified a later requests in writing, cancellation of coverage; date in that notice. • The last day of the month in which the Subscribing • Your coverage may be terminated if you refuse to Group's coverage is involuntarily terminated; accept or comply with recommended procedures • Immediately upon termination of a Member by and/or treatment incident to a Provider/patient or hospital/patient relationship, including leaving an PacifiCare as explained below. inpatient facility against medical advice, and in the PacifiCare has the right to terminate your coverage judgement of two or more Participating Providers, no under this Health Plan in the following situations: professionally acceptable covered treatment alternative • Failure To Pay. Your coverage may be terminated if exists, then the Member will be so advised. If you still you fail to pay any required Copayments and/or refuse to accept the recommended procedure and/or coinsurance, within 10 days of being properly notified treatment, then the Participating Provider, and and you failed to comply with or are unwilling to PacifiCare will have no further liability or responsibility make appropriate payment arrangements. If coverage to provide care for the condition under treatment is terminated for any of the above reasons, you forfeit and/or the Member and/or any Dependents may be terminated after not less than 10 days' written notice all rights to enroll in the PacifiCare conversion plan from PacifiCare to the Member and the Subscribing (discussed below-) K or COBRA Plan and lose the right g to re-enroll in PacifiCare in the future. The Group. If termination results from refusal of termination is effective immediately on the date compliance, the Member and any of his/her PacifiCare mails the notice of termination, unless Dependents will not be eligible to re-enroll, in any PacifiCare has specified a later date in that notice. PacifiCare plan, in any capacity, until the first group Open Enrollment Period following termination. • Fraud or Your Misrepresentation. Y r coverage may be terminated immediately if you knowingly provide false • If you are unable to establish and maintain a satisfactory Physician-patient relationship with a information (or misrepresent a meaningful fact) P g on your enrollment form or fraudulently or deceptively Participating Provider, your coverage may be use services or facilities of PacifiCare or other health terminated with not less than 10 days' written notice care Providers (or knowingly allow another person to from PacifiCare. If termination results from failure to do the same), including altering a prescription. If establish a Primary Care Physician relationship, the coverage is terminated for any of the above reasons, Member and any of his/her Dependents will not be you forfeit all rights to enroll in the PacifiCare eligible to re-enroll, in any PacifiCare plan, in any conversion plan (discussed below) or COBRA Plan capacity, until the first group Open Enrollment Period and lose the right to re-enroll in PacifiCare in the following termination. future. The termination is effective immediately on • If you permit the use of your PacifiCare ID card by any the date PacifiCare mails the notice of termination, other person, the card will be reclaimed by PacifiCare unless PacifiCare has specified a later date in that and all rights of the Member and his/her Dependents endents P notice. under this Combined Evidence of Coverage and • Disruptive Behavior. Your coverage may be Disclosure Form will immediately be terminated. terminated after not less than a 10-day written notice Payment for services or other benefits received from PacifiCare, if you conduct yourself in a manner improperly through the use of an ID card are the that is deemed to be threatening, violent or abusive financial obligation of the individual who used the ID toward, or jeopardizes the safety of, PacifiCare card improperly If termination of a Member results employees, or its Providers, their staff or other from the misuse of the ID card, the Subscriber and patients. If coverage is terminated for any of the above any of his/her Dependents will not be eligible to re- 4 reasons, you forfeit all rights to enroll in the enroll, in any PacifiCare plan, in any capacity, at any PacifiCare conversion plan (discussed below) or time. COBRA Plan and lose the right to re-enroll in PacifiCare in the future. The termination is effective immediately on the date PacifiCare mails the notice of Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. ED La ; st ............... Section Seven - Member Eligibility ' ,_ • Your coverage may be terminated if a Subscriber's termination is effective on the last day of the month in which the change in status occurred, regardless of working hours per r reduced employee his/her whose wrmployer to ing whether the subscribing group gives PacifiCare timely than 24 hours week. An whose working hours are reduced, as described below, may be entitled notice of the changes. to Continuation Coverage as described in this section. The Subscriber shall be responsible for any services The subscribing group may contract with PacifiCare to provided to a Dependent during any period the continue coverage for the Subscriber and his/her Dependent does not meet the eligibility requirements Dependents for the same Premium and under the same stated in this section. The subscribing group agrees to terms of the Group Subscriber's Agreement and this assist PacifiCare in obtaining reimbursement for any Combined Evidence of Coverage and Disclosure Form amounts paid when a Subscriber's Dependent is if all of the following conditions are true: not eligible. - The Subscriber has been continuously employed as MI Dependent coverage terminates on the day the a full-time employee of the subscribing group and Subscriber becomes ineligible for coverage as explained has been a Subscriber covered under this Group in this section, except the provision explained above Agreement, or under any former agreement regarding reduced working hours. providing similar benefits which this Group edia replaces, fot e cti nsix orks PacifiCare will refund a maximum of one month's nta immediately before the reduction in working hours; Premium, if paid in advance for a Dependent whose coverage is terminated, if all of the following are true: — The reduction of working hours is due to economic • Notification of the change is received by PacifiCare conditions; and within 30 days of the change; - The employer intends to increase the Subscriber's PacifiCare has not paid any claims for the Dependent working hours to the full 40 hour work schedule as • days; and f p soon as economic conditions improve. within 0 • Termination of the Dependent results in a change to • Except as specifically described above, all rights to the Premium rate. covered benefits will end on the effective date of termination. If a Member is confined to a hospital or Please refer to "Coverage Options Following inpatient facility on the Member's termination date, Termination" for additional coverage which may be coverage will be extended until the Member is available to you. discharged from the hospital or inpatient facility, unless the termination was due to nonpayment of Coverage Options Following Termination Premium or fraud. Prenatal and maternity care are not (Individual Continuation of Benefits) considered confinement. Therefore, PacifiCare will If your coverage through this Combined Evidence of not continue coverage past the termination date for a Coverage and Disclosure Form ends,you and your Member receiving prenatal or postnatal care. enrolled Dependents may be eligible for additional NOTE: If a Group Agreement is terminated by Continuation Coverage. PacifiCare, reinstatement with PacifiCare is subject to all Federal COBRA Continuation Coverage terms and conditions of the Group Agreement between PacifiCare and the employer. If the Subscriber's Employer Group is subject to Colorado law, Section 10-16-10S C.R.S., and the Consolidated Ending Coverage: Special Circumstances for Omnibus Budget Reconciliation Act of 1985, as amended Enrolled Family Members: ("COBRA'), you may be entitled to temporarily extend Subscribers must terminate Dependent's coverage your coverage under the Health Plan at group rates, plus because of the Dependent's death, divorce, marriage, an administration fee, in certain instances where your induction into active military service or failure to coverage under the Health Plan would otherwise maintain the eligibility conditions in this section. The This discussion is intended to inform you, in a summary Subscriber must submit an enrollment change form to fashion, of your rights and obligations under COBRA. PacifiCare within 30 days of the change in status. The However, your Employer Group is legally responsible for 52 A 1 I i l 1 I I I r _ Section Seven - Member Eligibility informing you of your specific rights under COBRA. This event. Your Employer Group has the responsibility to section is a general notice and should not be regarded as notify its COBRA administrator of the Subscriber's a complete discussion of the applicable provisions. death, termination, reduction in hours of employment Therefore, please consult with your Employer Group or Medicare entitlement. Similar rights may apply to regarding the availability and duration of COBRA certain retirees, Spouses and Dependent children if Continuation Coverage. your employer commences a bankruptcy proceeding and these individuals lose coverage. If you are a Subscriber covered by this Health Plan, you have a right to choose COBRA Continuation Coverage if When the COBRA administrator is notified that one of you lose your group health coverage because the these events has happened, the COBRA administrator termination of your employment (for reasons other than will in turn notify you that you have the right to choose gross misconduct on your part) or the reduction of Continuation Coverage. Under the law, you have at least hours of employment to less than the number of hours 60 days from the date you would lose coverage because required for eligibility of one of the events described above to inform the COBRA administrator that you want Continuation If you are the Spouse of a Subscriber covered by this Health Coverage. For Members in groups of less than 20 Plan, you have the right to choose COBRA II Continuation Coverage for yourself if you lose group employees, notification is required within in 30 days. health coverage under this Health Plan for any of the If you do not choose Continuation Coverage on a following four reasons: timely basis, your group health insurance coverage under this Health Plan will end. 1. The death of your Spouse; If you choose Continuation Coverage, your Employer 2. Termination of your Spouse's employment (for Group is required to give you coverage which, as of the reasons other than gross misconduct) or reduction identical to the in your Spouse's hours of employment to less than time coverage is being provided, is th• e number of hours required for eligibility; coverage provided under the plan to similarly situated employees or family members. COBRA permits you to 3. Divorce or legal separation from your Spouse; or maintain Continuation Coverage for 36 months, unless you lost group health coverage because of a termination 4. Your Spouse becomes entitled to Medicare. of employment or reduction in hours. In that case, the In the case of a Dependent child of a Subscriber required Continuation Coverage period is 18 months. enrolled in this Health Plan, he or she has the right to This initial 18-month period may be extended for affected Continuation Coverage if group health coverage under individuals up to 36 months from termination of this Health Plan is lost for any of the following five employment if other events (such as a death, divorce, reasons: legal separation or Medicare entitlement) or Dependent 1. The death of the Subscriber; child ceases to be an Eligible Dependent under this Health Plan occur during that initial 18-month period. In 2. Termination of the Subscriber's employment (for addition, the initial 18-month period may be extended up reasons other than gross misconduct) or reduction to 29 months if you are determined by the Social Security in the Subscriber's hours of employment to less Administration to be disabled at any time during the first than the number of hours required for eligibility; 60 days of COBRA Continuation Coverage. Please contact 3. The Subscriber's divorce or legal separation; your Employer Group or its COBRA administrator for more information regarding the applicable length of 4. The Subscriber becomes entitled to Medicare; or COBRA Continuation Coverage available. 5. The Dependent child ceases to be a Dependent A child who is born to or placed for adoption with the eligible for coverage under this Health Plan. Subscriber during a period of COBRA Continuation Under COBRA, the Subscriber or enrolled Dependent Coverage will be eligible to enroll as a COBRA Qualified has the responsibility to inform the Employer Group Beneficiary. These COBRA Qualified Beneficiaries can be (or, if applicable, its COBRA administrator) of a divorce, added to COBRA Continuation Coverage upon proper legal separation or a child losing Dependent status notification to the Employer Group or COBRA under the Health Plan within 60 days of the date of the administrator of the birth or adoption. Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. Section Seven - Member Eligibility However, under COBRA, the Continuation Coverage Extending Your Coverage: Converting to an may be cut short for any of the following five reasons: Individual Conversion Plan 1. Your Employer Group no longer provides group Availability: Any Member who is no longer eligible for health coverage to any of its employees; coverage as part of a subscribing group may convert to 2. The Premium for Continuation Coverage is not paid individual conversion membership without regard to health status or requirement for health care services. on time; The Member cannot elect conversion coverage if he/she 3. The Qualified Beneficiary becomes covered after the is eligible for continuation or COBRA coverage (see date he or she elects COBRA Continuation Coverage "Limitations" below for additional information.) under another group Health Plan that does not The Subscriber must convert his/her membership contain any exclusion or limitation with respect to according to the policies that PacifiCare has in effect at any pre-existing condition he or she may have; the time of application for conversion. 4. The Qualified Beneficiary becomes entitled to Medicare after the date he or she elects COBRA Conversion coverage plans offered are the Basic and Standard Health Benefit plans mandated by the state of Continuation Coverage; or Colorado. 5. The Qualified Beneficiary extends coverage for up to 29 months due to disability and there has been a Notification Requirements: The Employer Group is final determination that the individual is no longer solely responsible for notifying former employees disabled. or Dependent Spouses (including former Spouses as defined above) of the availability of the coverage Under the law, you may have to pay all of the Premium at least 180 calendar days before COBRA is for your Continuation Coverage. Premiums for COBRA scheduled to end. To elect this coverage, the former Continuation Coverage is generally 102% of the employee must notify the plan in writing at least 30 applicable Health Plan Premium. However, if you are on calendar days before COBRA is scheduled to end. a disability extension, your cost will be 150% of the Limitations: Notwithstanding provisions in this section, applicable Premium. You are responsible for the timely submission of the COBRA Premium to the Employer a Subscriber and/or Dependents will have no conversion Group or COBRA administrator. Your Employer Group rights if the Subscriber is no longer eligible to continue or COBRA administrator is responsible for the timely as a Member of the subscribing group for any of the submission of Premium to PacifiCare. At the end of the following reasons: 18-month, 29-month or 36-month Continuation • Termination of entire group if the group has 51 or Coverage period, Qualified Beneficiaries will be allowed more employees, or as required by small group health to enroll in a PacifiCare individual conversion Health insurance laws; Plan. (See the explanation under "Extending Your • Termination for nonpayment of applicable Premiums Coverage: Convening to an Individual Conversion Plan.") or Copayments; • Gross abuse of PacifiCare's plan rules and regulations; If you have any questions about COBRA, please contact your Employer Group. • Falsifying membership information. Election: The Member must convert his/her membership within 31 days of the date he/she becomes ineligible for coverage under the subscribing group. The conversion is effective retroactive to the elate of ineligibility. a I . Section Seven - Member Eligibility -')/ Out-of-Area: PacifiCare may designate an insurance If you are called to active military duty and are stationed carrier to provide conversion benefits to those persons outside of the HMO Service Area, you or your Eligible who cease to be eligible for coverage because they no ' Dependents must still maintain a permanent address longer maintain residence within the HMO Service Area. inside the HMO Service Area and must select a Benefits, terms and Premiums of the conversion contract Participating Primary Care Physician. For HMO will be determined by the designated insurance carrier. coverage only: To obtain coverage, all care must be provided or arranged in the HMO Service Area by the Certificate of Creditable Coverage designated Participating Primary Care Physician, except According to the requirements of the Health Insurance for Emergency and Urgently Needed Services. Portability and Accountability Act of 1996 (HIPAA), a The Health Plan Premium for USERRA Continuation of Certificate of Creditable Coverage will be provided to benefits is the same as the Health Plan Premium for the Subscriber by either PacifiCare or the Employer other PacifiCare Members enrolled through your Group when the Subscriber or a Dependent ceases to employer plus a two percent additional surcharge or be eligible for benefits under the employer's health administrative fee, not to exceed 102% of your benefit plan. A Certificate of Creditable Coverage may employer's active group Premium. Your employer is be used to reduce or eliminate a pre-existing condition responsible for billing and collecting Health Plan exclusion period imposed by a subsequent Health Plan. Premiums from you or your Dependents and will Creditable Coverage information for Dependents will be forward your Health Plan Premiums to PacifiCare along included on the Subscriber's Certificate, unless the with your employer's Health Plan Premiums otherwise Dependent's address of record or coverage information due under this Agreement. Additionally, your employer is substantially different from the Subscriber's. Please is responsible to maintain accurate records regarding contact the PacifiCare Customer Service department if USERRA Continuation Member Health Plan Premium, you need a duplicate Certificate of Creditable Coverage. Qualifying Events, terminating events and any other If you meet HIPAA eligibility requirements, you may be information that may be necessary for PacifiCare to able to obtain individual coverage using your Certificate administer this continuation benefit. of Creditable Coverage. Uniformed Services Employment and Reemployment Rights Act Continuation of Benefits under USERRA. Continuation Coverage under this Health Plan may be available to you through your employer under the Uniform Services Employment and Reemployment Rights Act of 1994, as amended ("USERRA"). The Continuation Coverage is equal to, and subject to the same limitations as, the benefits provided to other Members regularly enrolled in this Health Plan. These benefits may be available to you if you are absent from employment by reason of service in the United States uniformed services, up to the maximum 18-month period if you meet the USERRA requirements. USERRA benefits run concurrently with any benefits that may he available through the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, as amended. Your employer will provide written notice to you for USERRA Continuation Coverage. Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. ID F � Section Eight - Overseeing ` Your Health Care Decisions _ Overseeing Your Health Care regarding receipt of approvals of requests for health care services for purposes of medical management. • How PacifiCare Makes Important Health Care p PacifiCare makes these decisions within at least the Decisions following time frames required by state law: • Authorization, Modification and Denial of Health Decisions to approve, modify or deny requests for Care Services authorization of health care services, based on Medical • PacifiCare's Utilization Management Policy Necessity, will be made in a timely fashion appropriate for the nature of the Member's condition. Prospective • Utilization Criteria Review decisions will be made within a time frame that • What to Do if You Have a Problem does not exceed two working days from PacifiCare's receipt of all information reasonably necessary to make • Appealing a Health Care Decision or Requesting a the decision. Decisions made on Concurrent Review Quality Review will he made within one working day and decisions • Quality Review made on Retrospective Review will be made within 30 working days of PacifiCare's receipt of all • The Appeals Process necessary information. • Binding Arbitration In cases involving Prospective or Retrospective Review, • Complaints Against Participating Providers, if the decision cannot he made because (i) PacifiCare is Physicians and Hospitals not in receipt of all of the information reasonably necessary and requested or (ii) PacifiCare requires This section explains how PacifiCare authorizes or consultation by an expert reviewer PacifiCare will makes changes to your health care services, how we request in writing what additional information is evaluate new health care technologies, and how we needed within two working days. reach decisions about your coverage. The notification will specify the information requested How PacifiCare Makes Important but not received. Upon receipt of all information Health Care Decisions reasonably necessary and requested by PacifiCare, PacifiCare shall approve, modify or deny the request for Authorization, Modification and Denial of authorization within the time frames specified above as Health Care Services applicable. PacifiCare uses processes to review, approve, modify or PacifiCare will notify requesting Providers of decisions deny, based on Medical Neeessiry, requests by Providers to approve, modify, or deny requests for authorization for authorization of the provision of health care services of health care services for Members within one working to Members based on Medical Necessity. day of the decision for Prospective and Concurrent PacifiCare may also use criteria or guidelines to Reviews, and five working days for Retrospective determine whether to approve, modify or deny based Reviews. Members are notified of the decision to on Medical Necessity, requests by Providers of health approve requested health care services, in writing, care services for Members. The criteria used to modify within two working days for cases involving Prospective or deny requested health care services in specific cases Review, one working day for Concurrent Review and five will be provided free of charge to the Provider, the working days for Retrospective Review. Members are Member and the public upon request. notified of decisions to deny, delay or modify requested health care services, in writing, within one working day Decisions to deny or modify requests for authorization for cases involving Prospective and Concurrent Review of health care services for a Member, based on Medical and five working days for Retrospective Review. The Necessity, are made only by licensed Physicians or other written decision will include the specific reason(s) for appropriately licensed health care professionals. the decision, the clinical reason(s) for modifications or Member agrees that their Provider will be their denials based on a lack of Medical Necessity, or "authorized representative" (pursuant to ERNSA) reference to the benefit provision on which the denial a Section Eight - Overseeing Your Health Care decision was based and information about how to file • Nationally published criteria for utilization an appeal of the decision with PacifiCare. In addition, management (specific guideline information available the internal criteria or benefit interpretation policy, if upon request). any, relied upon in making this decision will be made • HCIA-Sachs Length of Stay' Guidelines (average available upon request by the Member. PacifiCare's length of hospital stays by medical or surgical Appeals Process is outlined later in this section. diagnoses). II If you would like a copy of PacifiCare's policy and • PacifiCare Medical Management Guidelines (MMG); procedure, a description of the processes utilized for and Benefit Interpretation Policies (BIP). the authorization, modification or denial of health care services, or seek information about the utilization Those cases that meet the criteria for coverage and level management process and the authorization of care, you of service are approved as requested. Those not meeting may contact the PacifiCare Customer Service the utilization criteria are referred for review to a department at 1-800-877-9777. PacifiCare Medical Director. PacifiCare's Utilization Management Policy Denial, delay or modification of health care services based on Medical Necessity must be made by a PacifiCare distributes its policy on financial incentives to appropriately qualified licensed Physician or a qualified all its Participating Providers, Members and employees. licensed health care professional who is competent to The policy affirms that a utilization management evaluate the specific clinical issues involved in the decision is based solely on the appropriateness of a health care services requested by the Provider. given treatment and service, as well as the existence of coverage. PacifiCare does not specifically reward Denials may be made for administrative reasons that Participating Providers or other individuals conducting include, but are not limited to, the fact that the patient utilization review for issuing denials of coverage. is not a PacifiCare Member or that the service being Financial incentives for Utilization Management requested is not a benefit provided by the decision-makers do not encourage decisions that result Member's plan. in either the denial or modification of Medically Preauthorization determinations are made once the Necessary Covered Services. PacifiCare Medical Director or designee receives all reasonably necessary medical information. PacifiCare Medical Management Guidelines makes timely and appropriate initial determinations The Medical Management Guidelines Committee based on the nature of the Member's medical condition (MMGC); consisting of PacifiCare Medical Directors; in compliance with state and federal requirements. provides a forum for the development, review and adoption of medical management guidelines to support What To Do If You Have a Problem consistent, appropriate medical care determinations. PacifiCare's top priority is meeting our Members' needs, The MMGC develops guidelines using evidenced-based but sometimes you may have an unexpected problem. medical literature and publications related to medical When this happens, your first step should be to call our treatment or service. The Medical Management Customer Service department. Our Customer Service Guidelines contain practice and utilization criteria for department will assist you and attempt to find a use when making coverage and medical care decisions solution to your situation. prior to, subsequent to or concurrent with the provisions of health care services. If you have a concern about your treatment or a decision regarding your medical care, you may be eligible for a Utilization Criteria second medical opinion. You can read more about requesting, as well as the requirements for obtaining a When a Provider or Member requests preauthorization of a procedure/service requiring preauthorization, an second opinion, in Section Two- Seeing the Doctor. appropriately qualified licensed health professional If you feel that we haven't assisted you or that your reviews the request. The qualified licensed health situation requires additional action, you may also professional applies the applicable criteria, including, request a formal appeal or quality review. To learn more but not limited to: about this, read the following section; 'Appealing a Health Care Decision or Requesting a Quality Review" Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. ED Section Eight - Overseeing ' Your Health Care Decisions Appealing a Health Care Decision or The Appeals Process Requesting a Quality Review Claims Involving Utilization Review PacifiCare's Grievance system provides Members with a If you are not satisfied with a determination and wish to method for addressing Member dissatisfaction regarding pursue the issue further,you or the Member's coverage decisions, care or services. Our appeals and authorized representative may either submit a verbal or quality of care review procedures are designed to written request to initiate the appeal process.Written deliver a timely response and resolution to your requests, which may include comments, documents, Grievances. This is done through a process that includes records and any other information relating to your a thorough and appropriate investigation, as well as an appeal, regardless of whether this information was evaluation of the Complaint. You may submit a formal a submitted or considered in the initial determination, appeal within 180 calendar days of your receipt of an initial determination to our Appeals Department. 1'o should be must heed to PacifiCare Member Appeals Team. An appeal must be initiated within 180 days of the date initiate an appeal or request quality review, call our of the initial denial. Customer Service department or write the Appeals Department at: Plan Internal Review Committee (PIRC) PacifiCare This committee shall include a minimum of three Appeals Department people, and will he composed of employees of P.O. Box 6770 PacifiCare who have appropriate education, training and Englewood, Colorado 80155 professional expertise in the field of medicine. The PIRC will make a decision within 30 days from the date of the Your request initiates the appeal and/or the quality of care review processes described below If the Complaint Member's or Member's authorized representative original request. involves the Medical Necessity of a treatment, the issue will be determined by a medical reviewer with the Expedited Review education, training and relevant expertise necessary to In cases where the time frame set forth below would evaluate the specific clinical issues that are the basis of seriously jeopardize the life or health of the Member, or your concern. would to jeopardize the Member's ability regain 1 P Quality Review maximum function, subject the Member to severe pain that cannot be adequately managed with the care or MI quality of care Complaints, in l c udin quality of g treatment, P �ifi Fx i Review. PacifiCare will conduct an Expedited P service Complaints, requiring clinical review are This review shall be provided to all requests concerning 4 reviewed by PacifiCare's Health Services Department. an admission, availability of care, continued stay or Complaints affecting your current condition are health care service for a Member who has received reviewed immediately PacifiCare conducts this review by Emergency Services but has not been discharged from a investigating the Complaint and consulting with your facility. In an expedited review PacifiCare shall make a Participating treating Providers and other PacifiCare decision and notify the Member or ordering Provider as departments. We also review medical records as expeditiously as the Member's medical condition necessary, and you may need to sign an authorization to requires, but no later than 72 hours after the request is release your medical records. received. If the Expedited Review is conducted during We will notify you in writing regarding your quality of the Member's hospital stay or course of treatment, the care review within 30 calendar days of receipt of your service shall be continued without liability to the Complaint. The results of the quality of care review are Member until the Member has been notified of the confidential and protected from legal discovery in decision; for cases where a 24-hour advance notice was accordance with Colorado law. Please refer to provided, the Member or ordering Provider will be "Expedited Review" for Appeals involving an imminent notified of the decision within 24 hours. If additional and serious threat to your health, including, but not information is required in order to decide the request, limited to, severe pain or the potential loss of life, limb the Member or authorized representative will be or major bodily function. notified within 24 hours of receipt of the request of what specific information is necessary in order to make a Section Eight - Overseeing Your Health Care Decisions a decision. In all cases, PacifiCare will provide written within one working day for an expedited independent confirmation of its decision within two working days of external review) of receiving notice of the review entity providing notification of the decision, if the initial from the DOI, PacifiCare shall notify the Member or the notification was not in writing. authorized representative electronically, by facsimile or Standard Independent External Review by telephone, followed by a written confirmation. If the Member is not satisfied with the decision of the Within two working days of receipt of notice from PIRC, the Member or the Member's authorized PacifiCare, the Member or the authorized representative representative may request an independent external may provide the DOI with documentation regarding a review. The independent external review process is potential conflict of interest of the review entity, available to all PacifiCare Members who have completed electronically, by facsimile or by telephone, followed by each of the internal appeals review levels offered by a written confirmation. PacifiCare or have completed an expedited review of a If the DOI determines that the review entity presents a denial of a benefit pursuant to state regulation. conflict of interest, the DOI shall assign, within one Expedited Independent External Review working day, another review entity to conduct the external review. The DOI shall notify the Member and A Member or the Member's authorized representative PacifiCare of the name and address of the new review may make a request for an expedited independent entity to which the appeal should be sent. external review if the Member has a medical condition where the time frame for completion of a standard Within six working days (or within three working days independent external review would seriously jeopardize for an expedited independent external review) of the the life or health of the Member, would jeopardize the date the DOI notifies PacifiCare of the review entity, PacifiCare shall deliver to the assigned review entity the Member's ability to regain maximum function, subject documents and information considered in making the the Member to severe pain that cannot be managed adequately without the care or treatment, or, for determination. Within two working days (or within one Members with a disability, create an imminent and working day for an expedited independent external substantial limitation of their existing ability to live review) of receipt of the materials, the review entity independently. The Member or the authorized shall deliver to the Member or the authorized representative's request for an expedited independent representative, the index of all materials that PacifiCare external review must include a Physician's certification has submitted to the review entity. PacifiCare shall that the Member's medical condition meets the criteria. provide to the Member or authorized representative, upon request, all relevant information supplied to the Review Time Frames review entity that is not confidential or privileged under All requests for an independent external review must be state or federal law concerning the case under review made within 60 calendar days of the date the Member The review entity shall notify the Member or the receives the PIRC denial. The Member, the Member's authorized representative, the health care professional Physician or the Member's authorized representative may and PacifiCare of any additional medical information submit a written request for an independent external required to conduct the review Within five working review. PacifiCare, upon receipt of a completed request days (or within two working days for an expedited for an independent external review will deliver a copy of independent external review) of such a request, the the request to the Division of Insurance (DOI) within Member or the authorized representative or the health two working days, or within one working day for an care professional shall submit the additional expedited independent external review Within two information, or an explanation of why the additional working days (or one working day for an expedited information is not being submitted to the review entity independent external review) from the time a request and PacifiCare. If the Member or authorized for independent external review is received from representative or the health care professional fails to PacifiCare, the DOI will assign an approved independent provide the additional information, or an explanation of external review entity (the "review entity") to conduct why additional information is not being submitted the independent external review, and shall notify within the time frame specified, the assigned review PacifiCare of such entity. Within two working days (or Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. ID 1 Section Eight - Overseeing 9 Your Health Care Decisions ,v entity shall make a decision based on the information If the Member is not satisfied with the decision of the submitted by PacifiCare. standard or expedited independent external Review The reviewer's decision will be in writing and will Panel, the Member may, within 180 days of the decision include the reasons why the service or procedure is or is from the independent external review Panel, submit the not Medically Necessary, or is or is not Experimental or claim to binding arbitration, as described in below. If a Investigational, as applicable. The determinations of the written request is not submitted as stated, then the reviewer shall be binding on the health coverage plan. action or claim denial will be final. Where a determination is made in favor of the covered Arbitration individual requesting an independent external review, If a Member is not satisfied with the resolution of a legal coverage for the treatment and services required shall be claim after exhausting all levels of the appeals process provided subject to the terms and conditions applicable applicable to the claim, PacifiCare and the Member to benefits under PacifiCare's health coverage plan. agree that they shall submit the claim to binding Within 30 working days (or within seven working days arbitration in accordance with the Commercial for an expedited independent external review) after the Arbitration Rules of the American Arbitration date of receipt of the request for independent external Association, unless both PacifiCare and the Member review, the review entity shall provide written notice of agree in writing to use another form of alternative its decision to uphold or reverse PacifiCare's final dispute resolution (e.g., mediation). The results of the adverse determination to the Member or the Member's binding arbitration shall be final, with no further authorized representative, PacifiCare, the Physician or recourse in a court of law or otherwise available to other health care professional and the DOI. The either PacifiCare or the Member.Judgement upon the reviewer may request that the DOI extend the deadline award rendered by the arbitrator(s) shall be entered in for the written notice of the review entity up to 10 any court having jurisdiction. PacifiCare and the working days (or five working days for an expedited Member shall equally share the costs of arbitration; independent external review) for the consideration of however, each party shall be individually responsible for additional information. the expenses related to its attorney, experts and Upon PacifiCare's receipt of the independent external evidence. Binding arbitration is limited to appeals that review entity's notice of a decision reversing PacifiCare's are not subject to ERISA. final adverse determination, PacifiCare shall approve the Benefit Denials coverage that was the subject of the final adverse determination. For Concurrent and Prospective Reviews, This section is applicable to Complaints and appeals not and for expedited reviews, PacifiCare shall approve the related to claims involving Utilization Review as described above. coverage with one working day. For Retrospective Reviews, PacifiCare shall approve the coverage within If you are not satisfied with the resolution and wish to five working days of the receipt of the independent pursue the issue further, the Member or the Member's external review entity's decision. For all reviews, authorized representative must submit a written or PacifiCare shall provide written notice of the approval to verbal request to initiate the Member appeal process. the Member or the authorized representative within one Written requests, which may include comments, working day of PacifiCare's approval of coverage. The documents, records and any other information relating coverage shall be provided subject to the terms and to your appeal, regardless of whether this information conditions applicable to benefits under the health was submitted or considered in the initial coverage plan. determination, should he directed to the PacifiCare Member Appeals Team. Verbal requests should be directed to our Customer Service department. An appeal must be initiated within 180 days of the date of the initial denial. 60 • -t■� Section Eight - Overseeing Your Health Care Decisions Member Relations Committee Review DETERMINED BY SUBMISSION TO BINDING The Member Relations Committee will provide a formal ARBITRATION. ANY SUCH DISPUTE.WILL NOT BE review and respond to the Member or authorized RESOLVED BY A IAWSl11T OR RESORT TO COURT representative within 30 calendar days of PacifiCare's PROCESS, EXCEPT AS THE FEDERAL ARBITRATION REVIEW JUDICIAL. . ACT PROVIDES FOR receipt of the original request. In addition, the internal OF criteria or benefit interpretation policy, if any, relied ARBITRATION PROCEEDINGS. ALL PARTIES TO THIS upon in making this decision will be made available AGREEMENT ARE GIVING UP THEIR CONSTITUTIONAL upon request by the Member. RIGHT TO HAVE ANY SUCH DISPUTE DECIDED IN A COURT OF LAW BEFORE A JURY, AND INSTEAD ARE If you are not satisfied with the decision of the Member ACCEPTING THE USE OF BINDING ARBITRATION. Relations Committee, the Member may, within 180 days RIGHTS AFFORDED UNDER THE INTERNAL APPEALS of the decision from the Member Relations Committee, PROCESS AND INDEPENDENT EXTERNAL REVIEW ARE submit the claim to binding arbitration. If a written NOT AFFECTED BY THIS PROVISION. DISPUTES NOT request is not submitted as stated, then the action or FULLY RESOLVED THROUGH THE INDEPENDENT claim denial will be final. EXTERNAL REVIEW PROCESS ARE SUBJECT TO THIS Arbitration PROVISION. If a Member is not satisfied with the resolution of a legal Complaints Against Participating Providers, claim after exhausting all levels of the Member appeals Physicians and Hospitals process applicable to the claim, PacifiCare and the Claims against Participating Physicians, Providers or Member agree that they shall submit the claim to Hospitals - other than claims for benefits under your binding arbitration in accordance with the Commercial coverage—are not governed by the terms of this plan. ArbitrationR 1 Rules of the American Arbitration Association You may seek any appropriate legal action against such unless both PacifiCare and the Member agree in writing persons and entities deemed necessary. to use another form of alternative di spute e d spute resolution (e.g., mediation). The results of the binding arbitration In the event of a dispute between you and a Participating shall be final, with no further recourse in a court of law Provider for claims not involving benefits, PacifiCare or otherwise available to either PacifiCare or the agrees to make available the Member appeals process for Member.Judgment upon the award rendered by the resolution of such dispute. In such an instance, all parties arbitrator(s) shall be entered in any court having must agree to this resolution process. Any decision jurisdiction. PacifiCare and the Member shall equally reached through this resolution process will not be share the costs of arbitration; however, each party shall binding upon the parties except upon agreement be individually responsible for the expenses related to between the parties.The Grievance will not be subject to its attorney, experts and evidence. Binding arbitration is binding arbitration except upon agreement between the limited to appeals that are not subject to ERISA. parties. Should the parties fail to resolve the Grievance, you or the Participating Provider may seek any Binding Arbitration appropriate legal action deemed necessary. Member I AGREE AND UNDERSTAND THAT ANY AND ALL claims against PacifiCare will be handled as discussed DISPUTES, INCLUDING CLAIMS RELATING TO THE above under`Appealing a Health Care Decision or DELIVERY OF SERVICES UNDER THE PLAN AND Requesting a Quality Review." CLAIMS OF MEDICAL MALPRACTICE (THAT IS AS TO WHETHER ANY MEDICAL SERVICES RENDERED UNDER THE HEALTH PLAN WERE UNNECESSARY OR UNAUTHORIZED OR WERE IMPROPERLY, NEGLIGENTLY OR INCOMPETENTLY RENDERED), EXCEPT FOR DISPUTES OVER BENEFIT DENIALS SUBJECT TO ERISA, BETWEEN ITSELF, MEMBERS (INCLUDING ANY HEIRS OR ASSIGNS) AND PACIFICARE OF COLORADO, INC., OR ANY OF ITS PARENTS, SUBSIDIARIES OR AFFILIATES, SHALL BE Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. t r _ _ li Section Nine General Information How is my coverage provided under General Information extraordinary circumstances? • What should I do if I lose or misplace my There arc circumstances not reasonably within the membership card? control of PacifiCare, such as major disasters, epidemics, Does PacifiCare offer a translation service? complete or partial destruction of facilities, wars, riots • or civil insurrection, which results in the unavailability • Does PacifiCare offer hearing and speech of PacifiCare, its personnel, facilities, or the participating impaired telephone lines? medical group. In such situations, PacifiCare, the • How is my coverage provided under participating medial group and facilities shall provide or extraordinary circumstances? attempt to arrange for medical and Hospital Services insofar as practical, according to their best judgment, • How does PacifiCare compensate its Participating within the limitation of such facilities and personnel. Providers? Neither PacifiCare nor any participating medical group • How to Get Help shall have any liability or obligation for delay or failure to provide or arrange for medical and Hospital Services • Advance Directives if such delay or failure is the result of any of the What follows are answers to some common and circumstances described above. uncommon questions about your coverage. If you have How does PacifiCare compensate its any questions of your own that haven't been answered, Participating Providers?please call our Customer Service department. PaeifiCare itself is not a Provider of health care. What should I do if I lose or misplace my PacifiCare has a working relationship between its membership card? Members and a network of more than 4,300 health care If you should lose your card, simply call our Customer Physicians, including Primary Care Physicians (who are Service department. Along with sending you a internists, pediatricians and family practitioners) and I replacement card, they can make sure there is no specialists. As an IIMO, PacifiCare's obligation to its interruption in your coverage. Members is to furnish benefits in the form of medical services through its contract Providers. Therefore, it is Does PacifiCare offer a translation service? important to you that you follow PacifiCare procedures PacifiCare uses a telephone translation service for and use the Providers that have contracts with PacifiCare. almost 140 languages and dialects. That's in addition to NOTE: PacifiCare contract Providers are independent select Customer Service department representatives contractors and are not agents or employees of PacifiCare. who are fluent in Spanish. How To Get Help Does PacifiCare offer hearing and speech Customer Service Department impaired telephone lines? PacifiCare has a dedicated telephone number for the You can contact PacifiCare's Customer Service department hearing and speech impaired. This phone number is: for assistance concerning anything about PacifiCare and 1-800-360-1797. your benefits. The following are examples of the subjects you might call about: • You have changed your address. • You cannot find a specific detail about your coverage in your Combined Evidence of Coverage and F' !I I Disclosure Form. • You want to change your Primary Care Physician. • You need an updated copy of the Provider Directory. I � a i 6 i Section Nine - General Information l The Customer Service department staff can usually Advance Directives answer your question while you are on the line. If not, Your right to make medical care decision includes the they will get the answer you need and promptly return giving of"advance directives," which are written your call. instructions concerning your wishes about your medical To Call treatment. These instructions are used in the event you You become unable to make health care decisions for may call our Customer Service department at yourself through Frida y Monday t oug d y during the hours of 7 a.m. to 8 p.m. Call early to receive the most Please understand that you are not required to have any prompt service. Please have your membership number advance directives in order to receive care and be informed the Subscriber's Social Security number) from treatment. You must only c ormed about them. your ID card ready Whether or not you have advance directives, you will receive medical care and treatment appropriate for your Spanish language assistance is available by calling our condition and consistent with your consent. Customer Service department at 1-800-877-9777, Monday through Friday, during the hours of 7 a.m. to 8 You should prepare advance medical directives before p.m. Call early to receive the most prompt service. Please you get to sick to think or communicate clearly. The have your membership number (usually the Subscriber's kinds of advance directives recognized in Colorado are Social Security number) from your ID card ready. the "living will" (which applies in cases of terminal illness), the "medical durable power or attorney" (which Se offrece assistencia en Espanol, si llama al Centro de allows your named agent to make decisions for you if Servicio 1-800-877-9777 Lunes a Viernes durance las you become unable to make them) and "the CPR horas de 7 a.m- a 8 p.m. Favor de llamar temprano para directive" (which allows you to reject cardiopulmonary recibir servicio rapido. Se requiera que tenga su numero resuscitation). These documents do not take away your de identificacion de su tarjeta disponible para recibir right to decide what you want, if you are able to do so. servicio (numero igual a su numero de Seguro Social). Should a PacifiCare Member execute an advance To Write directive, your Physician or any other medical Provider, If you need to write to our Customer Service including Medicare- and Medicaid-certified hospitals, department. please note your membership number Skilled Nursing Facilities, home health agencies, (usually the Subscriber's Social Security number) from Hospice programs and ambulance personnel, should be your ID card on any correspondence. The following is informed in order to include a notation in your medical the address for our Customer Service department: record accordingly. A copy of your executed advance directive should be sent to your Primary Care Physician, PacifiCare not PacifiCare. Customer Service Department P O. Box 6770 Your decision to execute an advance directive has no Englewood, CO 80155 effect on your PacifiCare benefits or eligibility. PacifiCare will not discriminate against a Member based on Mental Health/Substance Abuse Assistance whether he or she has or has not executed an advance (PacifiCare Behavioral Health( directive. Toll Free: 1-888-777-2735 Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. I !' Section Ten - Definitions Definitions salivation, peripheral vasomotor activity and gross muscle tone into a tone or light, the loudness or brightness of PacifiCare is dedicated to making its services easily which shows the extent of activity in the function being accessible and understandable. Ti)help you understand measured. the precise meanings of many terms used to explain your Common Law Marriage-Evidence of cohabitation as benefits, we have provided the following definitions, husband and wife, and general reputation that the two These definitions apply to the capitalized terms used in individuals are living together as husband and wife and your Combined Evidence of Coverage and Disclosure claiming to be such. By general reputation it is meant the Form, as well as the Schedule of Benefits. understanding among the neighbors and acquaintances with whom the parties associate in their daily lives, that Annual Out-of-Pocket Maximum-The maximum they are living together as husband and wife, and not amount of Copayments a Member is required to pay for that they are merely living together. certain Covered Services in a contract year. (Please refer to your Schedule of Benefits.) Common Law Spouse-Party to a Common Law Marriage. Biofeedback-Biofeedback therapy provides visual, auditory or other evidence of the status of certain body Complementary and Alternative Medicine-Defined by functions so that a person can exert voluntary control the National Center for Complementary and Alternative over the functions, and thereby alleviate an abnormal Medicine as the broad range of healing philosophies bodily condition. Biofeedback therapy often uses electrical (schools of thought), approaches and therapies that devices to transform bodily signals indicative of such Conventional Medicine does not commonly use, accept, functions as heart rate, blood pressure, skin temperature, study or make available. Generally defined, these salivation, peripheral vasomotor activity and gross muscle treatments and health care practices are not taught widely tone into a tone or light, the loudness or brightness of in medical schools and not generally used in hospitals. which shows the extent of activity in the function being These types of therapies used alone are often referred to measured. as "alternative."When used in combination with other alternative therapies, or in addition to conventional Case Management-A collaborative process that assesses, therapies, these therapies are often referred to as plans, implements, coordinates, monitors and evaluates "complementary" options to meet an individual's health care needs based on the health care benefits and available resources in Concurrent Review-Utilization review conducted order to promote a quality outcome for the individual during a patient's hospital stay or course of treatment. Member. Continuation Coverage-Coverage provided to a Chronic Care-A pattern of care that focuses on long- terminated Subscriber and/or his/her Eligible Dependents term care of individuals with chronic (long-standing, as mandated or required by Section persistent) diseases or conditions. It includes care specific 10-16-108 C.R.S., Title X, Consolidated Omnibus Budget to the problem as well as other measures to encourage Reconciliation Act of 1985, as amended, or any other self-care, to promote health and to prevent loss of applicable law. function. Contracting Medical Group-An independent practice Chronic Condition-A medical condition that is association (IPA) or medical group of Physicians that has continuous or persistent over an extended period of time entered into a written agreement with PacifiCare to provide Physician services to PacifICare's Members.An IPA and requires ongoing treatment for its management. contracts with independent contractor Physicians who Claim Determination Period—Usually a calendar year, work at different office sites.A medical group employs please refer to Section Six—Payment Responsibility. Physicians who typically all work at one or several physical Cognitive Therapy—Biofeedback therapy provides visual, locations. auditory or other evidence of the status of certain body Under certain circumstances, PacifiCare will perform functions so that a person can exert voluntary control administrative services performed by the Member's over the functions, and thereby alleviate an abnormal Contracting Medical Group as described in this Combined bodily condition. Biofeedback therapy often uses electrical Evidence of Coverage and Disclosure Form. This includes, devices to transform bodily signals indicative of such but is not limited to, when the Member's Primary Care functions as heart rate, blood pressure, skin temperature, Physician contracts directly with PacifiCare and there is no a Section Ten - Definitions Contracting Medical Group. received by PacifiCare. An eligible family member is a family member who meets all the eligibility requirements Conventional Medicine-Defined by the National Center for Complementary and Alternative Medicine as medicine of the Subscriber's Employer Group and PacifiCare. as practiced by holders of M.D. (medical doctor) or D.O. Developmental and Neuroeducational Testing or (doctor of osteopathy) degrees. Other terms for Treatment-Developmental testing is a battery of conventional medicine are allopathic, Western, regular diagnostic tests for the purpose of determining a child's and mainstream medicine. developmental status and need for early intervention Copayments- I he fee that a Member is obligated to pay, services. This may include, but is not limited to, if any, at the time he or she receives a Covered Service. Psychological and behavioral developmental profiles. Copayments are a predetermined amount or a percentage Durable Medical Equipment-Items of medical to be paid to the Provider by the Member for a specific equipment owned or rented that are placed in the home service. It will not exceed the amount permitted by of the patient to facilitate treatment and/or rehabilitation. applicable regulation. Generally, these are items that can withstand repeated use, are primarily and customarily used to serve a medical Covered Services-Medically Necessary services or supplies provided under the terms of this Combined purpose, are usually not useful to an individual in the Evidence of Coverage and Disclosure Form,your absence of illness or injury. Schedule of Benefits and supplemental benefit materials. Effective Date of Coverage-The date that coverage Creditable Coverage-Benefits or coverage provided under this Group Agreement becomes effective. The under Medicare or Medicaid; an employee welfare benefit Effective Date of Coverage for the subscribing group is am shown on the Group Subscriber Agreement. The Effective plan or group health insurance or health benefit plan; individual health benefit plan; a state health benefits risk Date of Coverage fora Member is in the subscribing pool (including, but not limited to CoverColorado, group's records. (formerly Colorado Uninsurable Health Insurance Plan); Eligible Dependent-A Member of a Subscriber's family or Chapter 55 of title 10 of the United States code, a who meets all the eligibility requirements of the medical care program of the Federal Indian Health Service Subscriber's Employer Group and PacifiCare. or of a tribal organization, a Health Plan offered under Chapter 89 of title 5, United States code, a public Health Eligible Employee—is a full-time permanent employee Plan, or a health benefit plan under Section 5(e) of the of an Employer Group who has a regular work week of federal "Peace Corps Act" (22 U.S.C. Sec. 2504 (e)); if twenty-four or more hours and includes a sole proprietor and a partner of a partnership if the sole proprietor or there was no gap in coverage of more than 63 days between such individual policies, and the most recent partner is included as an employee under a health benefit r plan of a small employer, but does not include an coverage ended not more than 90 days prior to the employee who works on a temporary or substitute basis. effective date of this coverage. Custodial Care-Care and services that assist an Emergency Medical Condition-An event or medical individual in the activities of daily living. Examples condition which the Member, acting as a Prudent include: assistance in walking, getting in or out of bed, Layperson, reasonably believes threatens his or her life or limb in such a manner that a need for immediate medical bathing, dressing, feeding and using the toilet; preparation of special diets and supervision of medication care is created to prevent death or serious impairment of that usually can be self-administered. Custodial Care health. includes all homemaker services, respite care, Emergency Services- I lealth care services provided in convalescent care of extended care not requiring skilled connection with an event which the enrollee reasonably nursing. Custodial Care does not require the continuing believes threatens his or her life or limb in such a manner attention of trained medical or paramedical personnel. that a need for immediate medical care is created to prevent death or serious impairment of health. (For a Dependent-The Subscriber's Spouse and any person related to the Subscriber or Spouse by blood, marriage, detailed explanation of Emergency Services, see Section adoption or Three-Emergency and Urgently Needed Services.) p guardianship.An enrolled family member is a family member who is enrolled with PacifiCare, meets all Employer Group-A bona fide employer covering the eligibility requirements of the Subscriber's Employer employees of such employer for the benefit of persons Group and PacifiCare and for whom Premiums have been other than the employer; an association, including a labor Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. 65 1 Section Ten - Definitions1,0 union, which has a constitution and bylaws and which is be limited to the following: nursing, Physician, certified organized and maintained in good faith for purposes nurse aide, nursing services delegated to other assistants, other than that of obtaining insurance. homemaker, physical therapy, pastoral counseling, trained volunteer and social services. ERISA—The Employee Retirement Income Security Act (ERISA) of 1974 is a federal law designed to protect the Hospital Services—Services and supplies performed or rights of participants and beneficiaries of employee supplied by an institution licensed and operated pursuant welfare benefit plans. Please contact your employer's to law which is primarily engaged in providing health benefit administrator to determine whether your services on an inpatient basis for the care and treatment of employer is subject to ERISA. injured or sick individuals through medical, diagnostic and surgical facilities (including a surgical facility which Experimental or Investigational—Defined in the has a bona fide arrangement, by agreement or otherwise, "Exclusions and Limitations of Benefits" section of this with an accredited hospital to perform such surgical Combined Evidence of Coverage and Disclosure Form. procedures) by, or under the supervision of, a staff of Grievance (Complaint)—A written or oral expression of Physicians and which has 24 hour nursing services. A dissatisfaction regarding the plan and/or Provider, hospital is not primarily a place for rest or custodial care including quality of care concerns, and shall include a of the aged, and is not a nursing home, convalescent Complaint, dispute, request for reconsideration or appeal home or similar institution. made by a Member or the Member's representative. Hypnotherapy—Medical Hypnotherapy is treatment by Group Agreement—The written documents, issued by hypnotism or by inducing sleep. PacifiCare to the subscribing group, consisting of Sections One, Two, Three, Four, Five, Six, Seven, Eight, Nine, Infertility—Either: (1) the inability to conceive a pregnancy or to carry a pregnancy to a live birth after a Ten and Eleven of the Combined Evidence of Coverage and Disclosure Form, the Group Subscriber Agreement, year or more of regular sexual relations without contraception; or (2) the presence of a demonstrated the application of the subscribing group, the individual condition recognized by a licensed Physician who is a applications of the Members and any written amendments Participating Provider as a cause of Infertility. constitute the entire contract between the parties. Health Plan—A policy, contract, certificate or agreement Late Enrollee—An Eligible Employee or Dependent who entered into by, offered to, or issued by a carrier to requests enrollment in a group health benefit plan provide, deliver, arrange for, pay for or reimburse any of following the initial enrollment period for which such individual is entitled to enroll under the terms of the the costs of health care services. Your benefit plan as health benefit plan, if such initial enrollment period is a described in this Combined Evidence of Coverage and period of at least 30 days. An Eligible Employee or Disclosure Form,Schedule of Benefits, and supplemental Dependent shall be considered a Late Enrollee if: benefit materials. A. The individual: HMO Service Area—The geographic area encompassing Adams,Arapahoe, Boulder, Broomfield, Clear Creek, i. Was covered under other Creditable Coverage at Denver, Douglas, El Paso, Elbert, Fremont, Gilpin, the time of the initial enrollment period and, if Jefferson, Larimer, Lincoln, Logan, Morgan, Park, Teller, required by the carrier or issuer, the employee Washington and Weld Counties of the state of Colorado stated at the time of initial enrollment that this and such other area in which PacifiCare is licensed and was the reason for declining enrollment; and qualified to conduct the business of an HMO. ii. Lost coverage under the other Creditable Hospice—A facility or service licensed by the Department Coverage as a result of termination of of Public Health and Environment under a centrally employment or eligibility, reduction in the administered program of palliative supportive, and number of hours of employment, the involuntary interdisciplinary team services providing physical, termination of the Creditable Coverage, death of psychological, spiritual and bereavement care for a Spouse, legal separation or divorce or employer terminally ill individuals and their families within a contributions towards such coverage was continuum of inpatient and home care available 24 hours, terminated; and seven days a week. Hospice services shall be provided in iii. Requests enrollment within 30 days after the home, a licensed Hospice and/or other licensed health termination of the other Creditable Coverage; or facility. Hospice services include, but shall not necessarily 14 a Section Ten - Definitions B. A court has ordered that coverage be provided for a In applying the above definition of Medical Necessity, Dependent under a covered employee's health benefit the following terms shall have the following plan and the request for enrollment is made within 30 meanings: days after issuance of such court order; or i. Treating Physician means a Physician who has C. A person becomes a Dependent of a covered person personally evaluated the patient. through marriage, birth, adoption or placement for adoption and requests enrollment no later than 30 ii. A health intervention is an item or service delivered days after becoming such a Dependent. In such case, or undertaken primarily to treat(that is, prevent, coverage shall commence on the date the person diagnose, detect, treat or palliate) a medical becomes a Dependent if a request for enrollment is condition or to maintain or restore functional ability received in a timely fashion before such date. A medical condition is a disease, illness, injury, genetic or congenital defect, pregnancy or a Learning Disability—A learning disability is a condition biological or psychological condition that lies outside which manifests as a significant discrepancy between the range of normal, age-appropriate human estimated cognitive potential and actual level of variation.A health intervention is defined not only by educational performance and which is not a result of the intervention itself, but also by the medical generalized mental retardation, educational or condition and the patient indications for which it is psychosocial deprivation, psychiatric disorder or sensory being applied. loss. iii. Effective means that the intervention can reasonably Limits—Any provision, other than an exclusion, which be expected to produce the intended results and to restricts coverage under this Group Agreement, regardless have expected benefits that outweigh potential of Medical Necessity harmful effects. Medically Necessary(or Medical Necessity)—Refers to iv. Health outcomes are outcomes that affect health an intervention, if, as recommended by the treating status as measured by the length or quality (primarily Physician and determined by the Medical Director of as perceived by the patient) of a person's life. PacifiCare, it is all of the following: v. Scientific evidence consists primarily of controlled A. A health intervention for the purpose of treating a clinical trials that either directly or indirectly medical condition; demonstrates the effect of the intervention on health B. The most appropriate supply or level of service, outcomes. If controlled clinical trials are not to the available, observational studies that suggest a causal considering potential benefits and harms Member: relationship between the intervention and health outcomes can be used. Partially controlled C. Known to be effective in improving health outcomes. observational studies and uncontrolled clinical series For existing interventions, effectiveness is determined may be suggestive but do not by themselves first by scientific evidence, then by professional demonstrate a causal relationship unless the standards, then by expert opinion. For new magnitude of the effect observed exceeds anything interventions, effectiveness is determined by scientific that could be explained either by the natural history evidence; and of the medical condition or potential Experimental D. If more than one health intervention meets the biases. For existing interventions, the scientific requirements of(a) through (c) above, furnished in evidence should be considered first and, to the the most cost-effective manner that may be provided greatest extent possible, should be the basis for safely and effectively to the Member. "Cost-effective" determinations of Medical Necessity If no scientific evidence is available, professional standards of care does not necessarily mean lowest price. should be considered. If professional standards of A service or item will be covered under the PacifiCare care do not exist, or are outdated or contradictory, Health Plan if it is an intervention that is an otherwise decisions about existing interventions should be covered category of service or item, not specifically based on expert opinion. Giving priority to scientific excluded, and Medically Necessary. An intervention may evidence does not mean that coverage of existing be medically indicated yet not be a covered benefit or interventions should be denied in the absence of meet the definition of Medical Necessity. conclusive scientific evidence. Existing interventions can meet the definition of Medical Necessity in the Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. Section Ten - Definitions ,_ . , 4 absence of scientific evidence if there is a strong specific organ program. PacifiCare National Preferred conviction of effectiveness and benefit expressed Transplant Network facilities may be located outside the through up-to-date and consistent professiotal HMO Service Area based on a number of factors, standards of care or, in the absence of such including quality, cost and outcomes. standards, convincing expert opinion. Non-Participating Providers—A hospital or other health vi. A new intervention is one that is not yet in care entity, a Physician or other health care professional or widespread use for the medical condition and a health care vendor that has not entered into a written patient indications being considered. New agreement to provide Covered Services to PacifiCare's interventions for which clinical trials have not been Members. conducted because of epidemiological reasons (i.e., rare or new diseases or orphan populations) shall be Open Enrollment Period—The time period determined evaluated on the basis of professional standards of by PacifiCare and the Subscriber's Employer Group when care. If professional standards of care do not exist, or all Eligible Employees and their Eligible Dependents may are outdated or contradictory, decisions about such enroll in PacifiCare by submitting an enrollment new interventions should be based on convincing application to PacifiCare. expert opinion. PacifiCare-PacifiCare of Colorado, Inc., dba PacifiCare of vii. An intervention is considered cost-effective if the Colorado, is a state-licensed health maintenance organization offering non-Federally qualified products. benefits and harms relative to costs represent an economically efficient use of resources for patients PacifiCare Criteria-Written guidelines established by with this condition. In the application of this PacifiCare to determine Medical Necessity and/or coverage criterion to an individual case, the characteristics of for certain procedures and treatments. PacifiCare Criteria the individual patient shall he determinative. are based on research of scientific literature, collaboration Medicare (Original Medicare)-The Hospital Insurance with Physician specialists and compliance with federal and national regulatory agency guidelines. Criteria are Plan (Part A) and the supplementary Medical Insurance Plan (Pan B) provided under Title XVIII of the Social approved by the PacifiCare Health Care Standards and Security Act, as amended. Education Committee and are reviewed and revised on a regular basis. Criteria are available for review by the Medicare Eligible-Those Members who meet eligibility Member's participating Physician, the Member or the requirements under Title XVIII of the Social Security Act, Member's representative. as amended. Participating Hospital-Any general acute care hospital Medicare Member-Any Member entitled to benefits licensed by the state of Colorado, accredited as a hospital under both pans of Medicare (part A-hospital coverage, by the Joint Commission on Accreditation of Health Care part B-Physician coverage). Organizations and maintains contractual arrangements Member-The Subscriber or any Dependent who is with PacifiCare, and that has entered into a written eligible, enrolled and covered by PacifiCare. agreement with PacifiCare to provide I lospital Services to PacifiCare's Members. PacifiCare may contract with a Mental Retardation and Related Conditions-An hospital for a specified Member, a specified period of time individual is determined to have mental retardation based and/or a specified service. In that case, the hospital is a on the following three criteria: intellectual functioning Participating Provider only for the service(s) contracted level(IQ) is below 70-75; significant limitations exist in and/or for the designated period. two or more adaptive skill areas; and the condition is present from childhood (defined as age 18 or less). Participating Provider-Any Physician, Physician specialist, hospital, Skilled Nursing Facility, extended care National Preferred Transplant Network-A network of facility, individual, organization, agency or other Provider transplant facilities that are: who/which has entered into a contractual arrangement • Licensed in the state in which they operate; with PacifiCare to provide health services to Members. PacifiCare may contract with a Provider for a specified • Certified by Medicare as a transplant facility for a Member, a specified period of time and/or a specified specific organ transplant; and service. In that case, the Provider is Participating a art apating • Satisfies PacifiCare's quality of care standards to be Provider only for the services) contracted and/or for the designated by PacifiCare as a transplant facility for a designated period. a Section Ten - Definitions j Physician-Any licensed allopathic or osteopathic Pulmonary Rehabilitation-An individually tailored, Physician. multidisciplinary program through which accurate diagnosis, therapy, emotional support, and education Premiums-The payments made to PacifiCare by an Employer Group on behalf of a Subscriber and any stabilizes or reverses both the physio-and enrolled Dependents for providing and continuing psychopathology of pulmonary diseases and attempts to enrollment in PacifiCare, under this Group Agreement. return the patient to the highest possible functional Often the Subscriber shares the cost of these Premiums capacity allowed by the pulmonary handicap and overall with deductions from his or her salary. life situation. Prevailing Rates- As determined by PacifiCare, the Qualified Beneficiary-Any individual who, on the day usual, customary and reasonable rates for a particular before a Qualifying Event, is covered under a group health care service in the IIMO Service Area. Health Plan maintained by the employer of a covered employee. This can be: Primary Care Physician-A Participating Provider who is • The covered employee a Physician trained in internal medicine, general practice, family practice or pediatrics and who has accepted • The Spouse of the covered employee primary responsibility for coordinating a Member's health care services, initiates all referrals for specialist care and • The Dependent child of the covered employee maintains continuity of patient care. Qualifying Event-A Qualifying Event refers to an Primary Residence-The home or address where the occurrence which triggers a person's right to continuation of coverage under the Consolidated Omnibus Budget Member actually lives most of the time.A residence will Reconciliation Act of 1985 (COBRA) no longer be considered a Primary Residence if: (1) the as amended. Member moves without intent to return; (2) the Member is absent from the residence for 90 consecutive days, or Redetermination of Status—The right of and process by (3) the Member is absent from the residence for more which PacifiCare may review the level of care to identify than 100 days in any six-month period. changes in a Member's status and prognosis. This may result in a different determination of level of care and a Primary Workplace-The facility or location where the Member works most of the time and to which the different level of YacifiCare's responsibility for covered Member regularly commutes. If the Member does not benefits. Each such determination will supersede earlier regularly commute to one location, then the Member determinations and PaciRCare's obligation for coverage provided. does not have a Primary Workplace. Prospective Review-Utilization review conducted prior Regional Organ Procurement Agency-Is an organization designated by the federal government and to an admission or course of treatment. responsible for procurement of organs for transplantation Provider-Any Physician, dentist, optometrist, and the promotion of organ donation. anesthesiologist, hospital. X-ray, laboratory and ambulance Rehabilitation Services-The combined and services or other person who is licensed or otherwise coordinated use of medical, social, educational and authorized in the state of Colorado to furnish health care vocational measures for training or retraining and services. restoration to normal or near-normal functions for Prudent Layperson-A person without medical training individuals disabled by disease or injury who reasonably draws on practical experience when Retrospective Review-Utilization review conducted making a decision regarding whether Emergency Services alter services have been provided to a patient, but are needed. does not include the review of a claim that is limited Psychological Testing- Psychological testing includes to an evaluation of reimbursement levels, veracity of the administration, interpretation and scoring of tests documentation, accuracy of coding or adjudication such as WAIS-R, Rorschach, MMPI and other medically for payment. accepted tests for evaluation of intellectual strengths, Schedule of Benefits-An important part of your psychopathology, psychodynamics, mental health risks, insight, motivation, and other factors influencing Combined Evidence of Coverage and Disclosure Form treatment and prognosis. that provides benefit information specific to your Health Plan, including Copayment information. Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. 0 Section Ten - Definitions I 4 Skilled Nursing Care—Those home health care services Usual and Customary Charges (U&C)—Means charges that: for medical services or supplies for which PacifiCare is • Can only be provided by an RN or LPN legally liable and which do not exceed the average charged rate charged for the same or similar services or • Can produce the best possible and most timely supplies in the geographic region where the services or outcome for a disease process and/or treatment regimen supplies are received. Usual and Customary Charges are according to a professional assessment and plan determined by referencing the (75th or 80th) percentile of • Cannot be made available outside of the home because the most current survey published by Medical Data of the immediate home-bound nature of the Member Research (MDR) for such services or supplies. The MDR survey is a product of Ingenix, Inc., formerly known as • Can furnish reliable information to the participating Medicode. Physician and PacifiCare's medical director sufficient for proper determination of the status of the Member's Vision Therapy/Orthoptics —Low Vision Rehabilitation condition and the level of care required for that are those services designed to improve the performance condition. of activities of daily living in persons with vision impairment or loss whose sight cannot be corrected to Skilled Nursing Facility—A comprehensive free-standing normal or near normal levels by any typical restorative rehabilitation facility or a specially designed unit within a process, i.e., correction of refractive error, medically hospital licensed by the state of Colorado to provide indicated corneal transplantation or cataract surgery. Skilled Nursing Care. Vision impairment or loss ranging from low vision to total blindness may result from a primary eye diagnosis, such as Skilled Rehabilitation Care—The care provided directly macular degeneration, retinitis pigmentosa, or glaucoma, by or under the direct supervision of licensed nursing personnel or a licensed physical, occupational or speech or as a condition secondary to another primary diagnosis, thera is[. such as diabetes mellitus, acquired immune deficiency P syndrome (AIDS), infection, etc. Rehabilitation for those Spouse—The Subscriber's husband or wife who is legally with vision impairment or loss maximizes the use of recognized as a husband or wife under the laws of the residual vision and provides practical adaptations and state of Colorado. training to increase functional ability, personal safety and Subacute and Transitional Care—Subacute and independence. Transitional Care are levels of care needed by a Member Vocational Rehabilitation—The process of facilitating an who does not require hospital acute care, but who individual in the choice of or return to a suitable vocation. requires more intensive licensed Skill Nursing Care than is When necessary, assisting the patient to obtain training for provided to the majority of the patients in a Skilled such a vocation. Vocational rehabilitation can also mean Nursing Facility preparing an individual regardless of age, status (whether Subscriber—The person enrolled in the Health Plan for U.S. citizen or immigrant), or physical condition (disability whom the appropriate Premiums have been received by other than ESRD) to cope emotionally, psychologically and physically with changing circumstances in life, including PacifiCare and whose employment or other status, except for family dependency, is the basis for enrollment remaining at school or returning to school, work, or work eligibility. equivalent (homemaker). Transitional Care-See "Subacute Care." NOTE: THIS COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE FORM CONSTITUTES ONLY A Urgently Needed Services-Covered Services that are SUMMARY OF THE PACIFICARE HEALTH PLAN. THE required in order to prevent serious deterioration of a GROUP AGREEMENT BETWEEN PACIFICARE AND THE Member's health that results from an unforeseen illness or EMPLOYER GROUP MUST BE CONSULTED TO injury if: DETERMINE THE EXACT TERMS AND CONDITIONS • The Member is temporarily absent from PacifiCare's OF COVERAGE. A COPY OF THE GROUP AGREEMENT HMO Service Area; and WILL BE FURNISHED UPON REQUEST AND IS AVAILABLE AT PACIFICARE AND YOUR EMPLOYER • The receipt of the health care service cannot be delayed GROUP'S PERSONNEL OFFICE. until the Member's return to the PacifiCare HMO Service Area. 70 P Section Eleven - Your Rights and Responsibilities Your Rights and Information About PacifiCare and Contracting Providers Responsibilities • Receive information about PacifiCare and the Covered Services under your plan. As a Member you have the right to receive information about, and make recommendations regarding, your • Receive information about the Contracting Providers rights and responsibilities. involved in your medical and behavioral health I treatment, including names and qualifications. You have the right to: • Request information about our Quality Improvement Timely, Quality Care Program, its goals, processes and/or outcomes. • Discuss and actively participate in decision-making Your Responsibilities Are To: with your Contracting Provider regarding the full range of appropriate or Medically Necessary treatment • Review information regarding your benefits, Covered options for your condition, regardless of cost or Services, any exclusions, limitations, deductibles or benefit coverage. Copayments and the rules you need to follow as stated in your Combined Evidence of Coverage and • Refuse any treatment or leave a medical facility, even Disclosure Form. against the advice of a Contracting Provider. Your refusal in no way limits or otherwise precludes you • Provide PacifiCare and Contracting Providers, to the from receiving other Medically Necessary Covered degree possible, the information needed to provide Services for which you consent. care to you. • Without discrimination, submit Complaints regarding • Follow treatment plans and care instructions as PacifiCare or Contracting Providers or request appeals agreed upon with your Contracting Provider. Actively for services denied by PacifiCare or by Contracting participate, to the degree possible, in understanding Providers. and improving your own medical and behavioral• health condition and in developing mutually agreed Treatment With Dignity and Respect upon treatment goals. • Be treated with dignity and respect and have your • Accept your financial responsibility for Health Plan right to privacy recognized in accordance with state Premiums, any other charges owed and any and federal laws. Copayment or Coinsurance associated with services • Exercise these rights regardless of your race, physical received while under the care of a Contracting or mental disability, ethnicity, gender, sexual Provider or while a patient in a facility orientation, creed, age, religion, national origin, if you have questions or concerns about your rights, cultural or educational background, economic or please call the Customer Service department at health status, English proficiency, reading skills or 1-800-877-9777 or for the hearing impaired source of payment for your health care. 1-800-360-1797. • Complete an advance directive, living will or other directive and provide it to your Contracting Provider to include in your medical record. Treatment decisions are not based on whether or not an individual has executed an advance directive. Questions about your benefits? Call the Customer Service Department at 1-800-877-9777. ED I PacifiCare P.O. Box 6770 Englewood, Colorado 80155 Customer Service Department: 1-800-877-9777 www.pacificare.com ©2003 by PacifiCare Heatth Systems, Inc. CM-1103 PC01001 PacifiCare PC0 PacifiCare SignatureValue- A select group of pbysicians Appendix A Attachment A—Schedule of Benefits Colorado Health Plan Description Form PacifiCare of Colorado Commercial HMO Copay Select(Split Copay) Plan 10764, 15-30/300a PART A: TYPE OF COVERAGE 1. TYPE OF PLAN Health Maintenance Organization(HMO). 2. OUT-OF-NETWORK CARE COVERED?' Only for emergency care. 3. AREAS OF COLORADO Plan is available only in the following counties:Adams,Arapahoe, WHERE PLAN IS AVAILABLE Boulder,Broomfield,Clear Creek, Denver,Douglas, El Paso,Elbert, Fremont,Gilpin,Jefferson,Larimer,Lincoln,Logan,Morgan, Park, Teller,Washington and Weld. PART B: SUMMARY OF BENEFITS Important Note:This form is not a contract. It is only a summary. The contents of this form are subject to the provisions of the policy,which contains all terms,covenants and conditions of coverage. Your plan may exclude coverage for certain treatments, diagnoses,or services not noted below. The benefits shown in this summary may only be available if required plan procedures are followed(e.g.,plans may require prior authorization,a referral from your primary care physician,or use of specified providers or facilities). Consult the actual policy to determine the exact terms and conditions of coverage.Coinsurance options reflect the amount the carrier will pay. IN-NETWORK ONLY (out-of-network care is not covered except as noted) 4. ANNUAL DEDUCTIBLE No deductibles. a) Individual b) Family 5. OUT-OF-POCKET ANNUAL MAXIMUM2 a) Individual $2,500(per contract year) b) Family $5,000(per contract year) 6. LIFETIME OR BENEFIT MAXIMUM No lifetime maximum. PAID BY THE PLAN FOR ALL CARE 7a. COVERED PROVIDERS PacifiCare of Colorado HMO Network. See provider directory for complete list of current providers. 7b. With respect to network plans,are all Yes. the providers listed in 7a accessible to me through my primary care physician? 8. ROUTINE MEDICAL OFFICE $15 copayment per visit with PCP; VISITS $30 copayment per visit with specialist. "Network"refers to a specified group of physicians,hospitals,medical clinics and other health care providers that your plan may require you to use in order for you to get any coverage at all under the plan,or that the plan may encourage you to use because it pays more of your bill if you use their network providers(i.e.,go in-network)than if you don't(i.e.,go out-of-network). `Out-of-pocket maximum. The maximum amount you will have to pay for allowable covered expenses under a health plan,which may or may not include the deductible or copayments,depending on the contract for that plan. PCO10764 10764 DO IN-NETWORK ONLY (out-of-network care is not covered except as noted) 9. PREVENTIVE CARE a) Children's services $15 copayment per visit with PCP; $30 copayment per visit with specialist. b) Adults' services $15 copayment per visit with PCP; $30 copayment per visit with specialist. 10. MATERNITY a) Prenatal care $15 copayment;one copayment per pregnancy. b) Delivery&inpatient well baby care $300 copay per admission 11. PRESCRIPTION DRUGS Available as separate pharmacy plan or as an optional benefit if Level of coverage and restrictions purchased by your employer,see benefit schedule attached(if on prescriptions applicable). 12. INPATIENT HOSPITAL $300 copay per admission 13. OUTPATIENT/AMBULATORY $150 copayment per visit. SURGERY 14. LABORATORY&X-RAY No copayment(100%covered)including mammograms; MRI,CT, SPECT and PET Scan$75 copayment per procedure. 15. EMERGENCY CARES Emergency room setting inside and outside the service area: $100 copayment per visit.Urgent Care and Follow-up care to emergency services received outside the HMO service area is covered to a maximum of$400 per contract year. 16. AMBULANCE $75 copayment per episode inside and outside the service area. 17. URGENT,NON-ROUTINE, $100 copayment in emergency room setting inside and outside the AFTER HOURS CARE service area;otherwise$25 copayment per visit.Urgent Care and Follow-up care to emergency services received outside the HMO service area is covered to a maximum of$400 per contract year. 18. BIOLOGICALLY-BASED Coverage is no less extensive than the coverage provided for any other physical MENTAL ILLNESS°CARE illness. 19. OTHER MENTAL HEALTH CARE a) Inpatient care $50 copayment per day,$25 copayment per partial day;coverage for maximum of 45 full or 90 partial days per contract year. b) Outpatient care No copayment for visits 1-5,$30 copayment thereafter. 20. ALCOHOL& SUBSTANCE Inpatient:$50 copayment per day,$25 copayment per partial day; ABUSE coverage for maximum of 45 full or 90 partial days per contract year. Outpatient: no copayment for visits 1-5,$30 copayment per visit thereafter. Limited to one course of treatment per contract year,two courses of treatment during the member's lifetime. 21. PHYSICAL,OCCUPATIONAL,& PhysicaUOccupational: $15 copayment per visit,coverage for maximum of SPEECH THERAPY 20 sessions per acute condition. Speech Therapy:$15 copayment per visit, coverage for maximum of 20 sessions for certain acute conditions.For children bom with congenital defects or birth abnormalities up to age 5,20 visits each of physical,occupational and speech therapy per contract year; $15 copayment per visit. 22. DURABLE MEDICAL Coverage for maximum of$2,000 per member per contract year,including EQUIPMENT oxygen. Coverage is limited to certain items. Orthopedic Braces and Podiatric Shoe Inserts are limited to a separate combined$500 maximum. Surgical bras meeting criteria are covered up to$500 per contract year. Prosthetic arms and legs will not be limited to the DME maximum;80%. 23. OXYGEN No copayment. Covered as durable medical equipment. (see#22) '"Emergency care"means services delivered by an emergency care facility which are necessary to screen and stabilize a covered person. The plan must cover this care if a prudent lay person having average knowledge of health services and medicine and acting reasonably would have believed that an emergency medical condition or life or limb threatening emergency existed. °"Biologically based mental illnesses"means schizophrenia,schizoaffective disorder,bipolar affective disorder,major depressive disorder,specific obsessive-compulsive disorder,and panic disorder. PCO10764 10764 on IN-NETWORK ONLY (out-of-network care is not covered except as noted) 24. ORGAN TRANSPLANTS Bone marrow(for certain conditions),cornea,liver(for children)and kidney transplants,and skin grafts,are covered based on criteria. Heart,heart/lung (combined),lung,kidney/pancreas(combined),and adult liver transplants,are covered based on criteria,subject to pre-existing condition limitations(see #32). 25. HOME HEALTH CARE No copayment(100%covered). 26. HOSPICE CARE No copayment(100%covered). 27. SKILLED NURSING FACILITY CARE No copayment. Covered up to 100 days per contract year. 28. DENTAL CARE Available as a separate dental care plan or as an optional benefit. 29. VISION CARE $15 copayment per visit;one visit per 12 months. 30. CHIROPRACTIC CARE Available as a separate chiropractic care plan or as an optional benefit. 31. SIGNIFICANT ADDITIONAL Allergy injections,$10 copayment; well-woman exam,$15 copayment; COVERED SERVICES(list up to 5) injectables for home use,$75 copay;cardiac rehabilitation covered to $1,000 within a 90-day period. PART C: LIMITATIONS AND EXCLUSIONS 32. PERIOD DURING WHICH PRE-EXISTING 6 months for selected transplants only;no pre-existing limitation CONDITIONS ARE NOT COVERED.5 for all other conditions. See policy for details. 33. EXCLUSIONARY RIDERS. Can an No. individual's specific,pre-existing condition be entirely excluded from the policy? 34. HOW DOES THE POLICY DEFINE A A pre-existing condition is a condition for which medical advice, "PRE-EXISTING CONDITION"? diagnosis,care, or treatment was recommended or received within the last 6 months immediately preceding the date of enrollment or,if earlier,the first day of the waiting period;except that pre-existing condition exclusions may not be imposed on a newly adopted child,a child placed for adoption,a newborn, other special enrollees,or for pregnancy. 35. WHAT TREATMENTS AND CONDITIONS Exclusions vary by policy. A list of exclusions is available ARE EXCLUDED UNDER THIS POLICY? immediately upon request from your carrier,agent,or plan sponsor(e.g.,employer). Review them to see if a service or treatment you may need is excluded from the policy. PART D: USING THE PLAN 1N-NETWORK ONLY (out-of-network care is not covered except as noted) 36. Does the enrollee have to obtain a referral and/or prior Yes. authorization for specialty care in most or all cases? 37. Is prior authorization required for surgical Yes. procedures and hospital care(except in an emergency)? 38. If the provider charges more for a covered service No. than the plan normally pays,does the enrollee have to pay the difference? 39. What is the main customer service number? Please call Customer Service at(800)877-9777 40. Whom do I write/call if I have a complaint or want to Write to: PacifiCare of Colorado Member Appeals Team, file a grievance?6 P.O.Box 6770, Englewood,CO 80155 41. Whom do I contact if I am not satisfied with the Write to: Colorado Division of Insurance, ICARE resolution of my complaint or grievance? Section, 1560 Broadway, Suite 850, Denver,CO 80202 42. To assist in filing a grievance,indicate the form Policy Form#: 10764,Large Group Waiver of pre-existing condition exclusions. State law requires carriers to waive some or all of the pre-existing condition exclusion period based on other coverage you recently may have had. Ask your carrier or plan sponsor(e.g.,employer)for details. 6 Grievances. Insurance regulation 4-2-17 establishes carrier grievance procedures and appeals process requirements. A copy of the regulation is available from the Colorado Division of Insurance. PCO10764 number of this policy;whether it is individual,small group,or large group; and if it is a short-term policy. 43. Does the plan have a binding arbitration clause? Yes. PART E: COST 44. What is the cost of this plan? Contact your agent,this insurance company,or your employer,as appropriate,to find out the premium for this plan. In some cases,plan costs are included with this form. PART F: PHYSICIAN PAYMENT METHODS,AND PLAN EXPENDITURES FOR HEALTH EXPENSES, ADMINISTRATION AND PROFIT Any person interested in applying for coverage,or who is covered by,or who purchased coverage under this plan may request answers to the questions listed below. The request may be made orally or in writing to the agent marketing the plan or directly to the insurance company and shall be answered within five(5)working days of the receipt of the request: • What are the three most frequently used methods of payment for primary care physicians? • What are the three most frequently used methods of payment for physician specialists? • What other financial incentives determine physician payment? • What percentage of total Colorado premiums are spent on health care expenses as distinct from administration and profit? NOTE: If you would like a copy of the directions used in filling out this form,which includes choices of answers and definitions of terms,please write the Colorado Division of Insurance,Rates and Forms Section,1560 Broadway,Suite 850,Denver,CO 80202. An Access Plan detailing the managed care network is available upon request.Please call Customer Service(800)877- 9777 for more information. Second opinions are covered when medically appropriate. In order to obtain a second opinion,you must obtain the necessary referrals from your Primary Care Provider. PC010764 10960.00 COLORADO PacifiCare® ATTACHMENT E - EYE REFRACTION BENEFITS EYE EXAM SUMMARY OF BENEFITS 12-MONTH Your employer has elected to offer coverage for routine eye examinations. Routine eye examinations other than the annual visual acuity exam under your medical plan are available Not Covered: under this Rider. These include refractions for Fitting of contact lenses, vision therapy and/or radial prescription lenses, and are covered once every 12 months. Services must be obtained from a Participating keratotomy, keratomilieusis and excimer laser surgery. Eye Specialists,A Block Vision Company® Provider. This information contains only highlights of the eye examination benefit and is not intended to contain the Using Eye Specialists,A Block Vision Company® is as easy as 1, 2, 3. First, locate an Eye Specialists, A Block complete provisions of these benefits. Please refer to Vision Company® Provider near you by checking your your Combined Evidence of Coverage and Disclosure Form for a complete description of this benefit. PacifiCare Provider Directory, by visiting Eye Specialists, A Block Vision Company's Web site at www.eyespec.com or by calling Eye Specialists,A Block Vision Company® at 1-800-879-6901. Second, call your doctor and make an appointment. Third, keep your scheduled appointment. A referral from your Primary Care Physician is not required for this benefit. Customer Service: 800-877-9777 02004 PacrfiCare of Colorado 6455 S. Yosemite St. 800-659-2656 (TDD) CM-104-58132 Greenwood Village, CO 80111 www.pacificare.com PC06004-001 Rev.1/04 i. . qt.sier,1110ANt ATTACHMENT PAN - PERSONAL ASSISTANT NETWORK PACIFICARE OF COLORADO ATTACHMENT TO THE COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE FORM TIIIS ATTACHMENT is made part of the PacifiCare of Colorado ("PacifiCare") Combined Evidence of Coverage and Disclosure Form (the "EOC"). Please review this attachment as it contains valuable information regarding important changes to your EOC. Unless otherwise indicated herein, all terms initially capitalized herein shall have the same meaning attributed to such terms in the EOC and references to section numbers are to section of the EOC. "PERSONAL ASSISTANT NETWORK" You and your Eligible Dependents are entitled to the following additional benefits under the PacifiCare Personal Assistant Program ("PAN"). Accessing Personal Assistant Network The following services are available 24 hours per day, every day, by calling 1-866-331-3975. Our staff will listen carefully to your concerns and direct you to a wealth of informational resources. Information and resources are also available online at www.pbhi.com. Included Services The Personal Assistant Network offers you access to the resources and information you may need to reduce stress associated with balancing family life, childcare, and legal and financial issues with work.With one toll-free phone call, you can access resources, and receive information and referrals for professional advice to help you to reduce these stresses.These services and resources include: 1. Financial Planning Consultation with a Certified Financial Advisor: 30 minutes per topic at no charge. (You may request additional services which will be provided at a discounted rate for which you will be financially responsible.) • Debt management • Budgeting • Financial Planning • Investment planning • Retirement Planning • Estate Planning 2. Legal Assistance Consultation with an attorney: 30 minutes per topic at no charge. (You may request additional services at a discount rate for which you will be financially responsible.) • Divorce • Landlord/Tenant Conflicts • Wills • Consumer Issues • Referrals to Legal Specialists PacifiCare 3. Resources for Seniors You may receive information concerning a number of items of particular concern to the elderly. You may access this informational service as frequently as you wish,without limitation. Information on the following services is provided to you at no additional cost. • Senior housing options • Assisted living options • Adult day care • Meal services • Transportation services • Community services and resources 4. Community Support Services You may receive access to information concerning other community support services of general interest.You may access this informational service as frequently as you wish,without limitation. This information is provided to you at no additional cost. • Career development • Various support groups • Food programs • Special needs programs 5. Parenting, Child Care and Schools You may receive access to information concerning childcare issues at no additional cost. • Parenting/Exploring Adoption • Strategies for working parents • Day care options • Nursery and Pre-Kindergarten options • Public and private schools • College planning 6. Convenience Services You may receive access to information concerning other services of convenience at no additional cost. • Assistance locating services such as home remodeling and repair, pet care, house sitting, relocation assistance, funeral services and more. • Information and assistance locating personal enrichment programs such as dance lessons, music training, physical fitness and massage therapy • Research and information concerning restaurants, parks, entertainment and sporting events THE INFORMATION OR SERVICE PROVIDED TO MEMBERS UNDER THE PERSONAL ASSISTANT NETWORK PROGRAM DO NOT IMPLY,AND SHALL NOT BE CONSTRUED TO BE AN ENDORSEMENT, RECOMMENDATION OR APPROVAL OF THAT PARTICULAR INFORMATION OR SERVICE BY PACIFICARE. Please keep this Attachment with your PacifiCare EOC for future reference. If you have any questions or need further information regarding this Attachment,please call PacifiCare Customer Service Department at 1-800-877-9777. Representatives are available to help you Monday through Friday,from 7:00 a.m. to 8:00 p.m. ©2003 by PacifiCare Health Systems,Inc. CM-403-43445 PacifiCare SignatureValue A select getup of pbysicians Selected Benefit Descriptions Attachment R—Outpatient Prescription Drug Benefit Colorado Health Plan Description Form Addendum PacifiCare of Colorado Pharmacy Plan 19DW4, Weld County BENEFIT BENEFIT LEVEL 11.PRESCRIPTION DRUGS $15 formulary generic,$40 formulary brand-name,$60 non-formulary. If Level of coverage and restrictions on brand-name is dispensed when a generic equivalent is available and listed on prescriptions the drug formulary,member pays the non-formulary copayment for the brand name medication. Prepackaged units will have one applicable copayment apply per prepackaged unit. A 90-day supply of maintenance medications,or a three-cycle maximum of oral contraceptives, is available through the mail-order prescription pharmacy for two applicable copayments. Prepackaged units dispensed through the mail-order prescription pharmacy will have one applicable copayment apply per two prepackaged units. For more information on the mail-order prescription drug program,or for information on drugs on our approved formulary list,call Customer Service at(800)877-9777. NOTE: PacifiCare's prescription drug coverage relies on a framework provided by a drug formulary. Quite simply,a formulary is a list of preferred or recommended drugs that have been carefully selected by physicians and pharmacists based upon the safety and effectiveness of those drugs. You pay your applicable copayment for prescriptions filled at network pharmacies: • Formulary Generic • Formulary Brand • Non-Formulary PCAwowi 1 1910.4 W ATTACHMENT R-YOUR OUTPATIENT PRESCRIPTION DRUG BENEFIT Pharmacy Schedule of Benefits Pharmacy Plan 19DW4 Summary of Benefits Generic Brand Formulary Non-Formulary Formulary Retail Pharmacy Copayment(per Prescription Unit or up to 30 $15 $40 $60 days) Retail Pharmacy Pre-Packaged Unit Copayment(per Defined or $15 $40 $60 Pre-Packaged Unit;up to a 30 day supply max) Mail Service Pharmacy Copayment(up to 3 Prescription Units or $30 S80 $120 up to 90 days) Mail Service Pharmacy Pre-Packaged Unit Copayment(per two $15 $40 $60 [2]Defined or Pre-Packaged Units;up to a 90 day supply max) This Schedule of Benefits provides specific details about your • Diabetic Supplies:Insulin, insulin syringes,glucagon kits prescription drug benefit,as well as the exclusions and and glucose testing strips on the Formulary. Insulin is limitations that apply. Together this document and the limited to two(2)vials of the same kind of insulin per Supplement to the Combined Evidence of Coverage and applicable Copayment at a Participating Retail Pharmacy. Disclosure Form as well as the medical Combined Evidence of Insulin is limited to three(3)vials of the same kind of Coverage and Disclosure Form determine the exact terms and insulin per applicable Copayment at a participating mail conditions of your prescription drug coverage. order pharmacy. What Do I Pay When I Fill a Prescription? Glucose and Ketone test strips and lancets on the Formulary are dispensed in pre-packaged units and are You will pay a Copayment every time a prescription is filled. subject to the applicable Copayment per pre-packaged Your benefits are shown in the above grid. If you choose a unit. brand-name medication when an equivalent generic is available,you will pay your non-formulary Copayment for the Coverage of glucose and ketone test strips is limited to brand-name medication. 200 strips per thirty(30)days. Clinical Review for Selected Drugs Coverage of lancets is limited to 200 units per thirty(30) days. Selected medications require clinical review. The Clinical Review process uses criteria based upon FDA approved • Federal Legend Drugs:Any medicinal substance which indications,medical findings and the current availability of the bears the legend:"Caution: Federal law prohibits medication. PacifiCare reviews requests for these selected dispensing without a prescription." medications to ensure that they are Medically Necessary, • Immunosuppressants to prevent organ rejections. being prescribed according to treatment guidelines consistent with standard professional practice and are not otherwise • Miscellaneous Prescription Drug Coverage: For the excluded from coverage. purposes of determining coverage,the following items are considered prescription drug benefits: glucagon insulin, For a list of the selected medications that require PacifiCare's insulin syringes,blood glucose test strips, lancets, inhaler clinical review,please contact PacifiCare's Customer Service extender devices urine test strips,and anaphylaxis Department. prevention kits(including,but not limited to, EpiPen®, Medication Covered By Your Benefit Ana-Kits®,and Ana-Guard®). See the medical benefit portion of the Combined Evidence of Coverage and When prescribed by your Participating Physician or Disclosure Form for coverage of other injectable Authorized Non-Plan Physician as Medically Necessary and medications. filled at a Participating Pharmacy,subject to all the other terms and conditions of this outpatient prescription drug benefit,the • Oral contraceptives:Federal Legend oral contraceptives, following medications are covered. prescription diaphragms,cervical caps and oral medications for emergency contraception. • State Restricted Drugs: Any medicinal substance that may be dispensed by prescription only according to State law. 20030108 9/03 1 PCO1482 Exclusions and Limitations • infertility: All forms of prescription medication for the treatment of infertility are not covered. If your employer While the prescription drug benefit covers most medications, has purchased coverage for infertility treatment, there are some that are not covered or limited. These drugs are prescription medications for the treatment of infertility listed below. Some of the following excluded drugs may be may be covered under that benefit. covered under your medical benefit. Please refer to Section Five of your Combined Evidence of Coverage and Disclosure • Injectable Medications are not covered except as listed Form. in this Schedule of Benefits in the section entitled "Medication Covered By Your Benefit". Injectable • Allergy serum is not covered. Allergy serum may be Medications including but not limited to self-injectables, available under your medical benefits. Refer to your infusion therapy,allergy serum, immunization agents and medical Combined Evidence of Coverage and Disclosure blood products may be covered under your medical Form. benefit.Injectable medications may be subject to • Administered Drugs: Drugs or medicines delivered or PacifiCare's pre-authorization requirements. Refer to your administered to the Member by the prescriber or the medical Combined Evidence of Coverage and Disclosure prescriber's staff is not covered. Injectable drugs is Form. covered under your medical benefit when administered • Inpatient Medications:Medications administered to a during the course of a physician's office visit or self- Member while an inpatient receiving skilled care in a administered pursuant to training by an appropriate health medical facility,hospital,rest home,nursing home, care professional. Please refer to Section Five of your sanitarium,skilled nursing facility,or extended care Combined Evidence of Coverage and Disclosure Form. facility not covered. Inpatient pharmacy benefits are • Compounded Medication: Compounded medication(s) covered as a basic medical benefit. Refer to your medical that are made up of at least one prescription drug.(All Combined Evidence of Coverage and Disclosure Form for compounded medications require preauthorization). additional information. • Diagnostic Drugs:Drugs used for diagnostic purposes • Investigational or Experimental Drugs:Medication are not covered. prescribed for experimental or investigational therapies are not covered.For non-Food and Drug Administration • Dietary or nutritional products and food supplements, approved indications,see Off Label Drug exclusion. whether prescription or non-prescription, including Further information about Investigation and Experimental vitamins(except prenatal),and fluoride supplements, therapies can be found in the medical Combined Evidence health or beauty aids,herbal supplements and/or of Coverage and Disclosure Form. alternative medicine are not covered. • Medications dispensed by a non-Participating • Diabetic supplies: All diabetic supplies such as insulin Pharmacy are not covered except for prescriptions pens,penfills,pumps and associated supplies,are not required as a result of an Emergency or Urgently Needed covered except those supplies specifically covered in this Service for an acute condition. Pharmacy Schedule of Benefits in the section entitled Medication Covered By Your Benefit. • Medications prescribed by non-Participating Physicians are not covered except for prescriptions • Drugs prescribed by a dentist or drugs used for dental required as a result of an Emergency or Urgently Needed treatment. Service for an acute condition. • Elective or voluntary enhancement procedures, • New procedures,services,supplies,and medications services,supplies and medications including but not until they are reviewed for safety,efficacy and cost limited to: weight loss, hair growth,sexual performance, effectiveness and approved by PacifiCare are not covered. athletic performance,cosmetic purposes,anti-aging, discolored nails and mental performance. Examples of • Non-Covered Services: Any prescription drug prescribed these drugs include but are not limited to: Pcnlac®,Retin- in connection with a service excluded under your Health A®, Renova®,Vaniqa®, Propecia®, Lustra®,Xenical®, Plan is not covered. or Meridia®. This provision does not exclude Medically • Non covered medical condition: Prescription medication Necessary medications directly related to non-covered for the treatment of a non-covered medical condition. services when complications exceed routine follow-up care such as life-threatening complications of cosmetic • Non-Approved Drugs:Drugs determined by the surgery. PacifiCare Pharmacy and Therapeutics Committee to be ineffective,duplicative or to have preferred therapeutic • Immunizations are not covered. Immunizations except alternatives available are not covered. oral typhoid. 20030108 9/03 2 PCO1482 • Off-Label Drug Use. Off Label Drug Use means that the • Sexual dysfunction Medication:All forms of Provider has prescribed a drug approved by the Food and medications prescribed for the treatment of sexual Drug Administration(FDA)for a use that is different than dysfunction,which includes,but is not limited to erectile that for which the FDA approved the drug. PacifiCare dysfunction,impotence and anorgasmy or hyporgasmy. excludes coverage for Off Label Drug Use,including off An example of such medications would include Viagra. label self-injectable drugs,except as described in the Combined Evidence of Coverage and Disclosure Form • Smoking cessation products including,but not limited and any applicable Attachments. If a drug is prescribed to,nicotine gum,nicotine patches,and nicotine nasal spray are not covered unless such products are available for Off-Label Drug Use,the drug and its administration will be covered only if it satisfies all of the following through and the member is enrolled in,a smoking criteria: (I)The drug is approved by the FDA. (2)The cessation program approved by PacifiCare. drug is prescribed by a participating licensed health care • Take Home Use From a Facility:Drugs received from a professional for the treatment of a life-threatening hospital, Skilled Nursing facility,convalescent home or condition or for a chronic and seriously debilitating similar facility for take home use are not covered. condition.(3)The drug is Medically Necessary to treat the condition. (4)The drug has been recognized for treatment • Therapeutic devices or appliances including but not of the life-threatening or chronic and seriously debilitating limited to support garments and other non-medical condition by one of the following: The American Medical substances, insulin pumps and related supplies(these Association Drug Evaluations,The American Hospital services are provided as durable medical equipment) Formulary Service Drug Information,and The United hypodermic needles and syringes not related to diabetic States Pharmacopoeia Dispensing Information. (5)The needs,penfills,pen needles or cartridges.Birth control drug is administered as part of a core medical benefit as devices,supplies or preparations that do not require a determined by PacifiCare. See Section Five of your Participating Physician's or Authorized non-Plan Combined Evidence of Coverage and Disclosure Form for Physician's prescription by law are also not covered,even a description of your medical benefits. Nothing in this if prescribed by a Participating Physician or Authorized section shall prohibit PacifiCare from use of a Formulary, non-Plan Physician. Copayment,pre-authorization process,technology • Unit/Convenience Dosage Forms:Unit dose,pre- assessment panel,or similar mechanism as a means for packaged medications,individual packets,etc are not appropriately controlling the utilization of a drug that is covered. prescribed for a use that is prescribed for a use that is different from the use for which that drug has been • Worker's Compensation:Medication for which the cost approved for marketing by the FDA. is recoverable under any Workers' Compensation or Occupational Disease Law or any state or government • Over the Counter Drugs: Medications(except insulin) agency,or medication furnished by any other drug or available without a prescription(over-the-counter)or for medical service for which no charge is made to the patient which there is a non-prescription equivalent available, arc not covered. even if ordered by a physician are not covered. All non- prescription(over-the-counter)contraceptive jellies, • Work-Related Medications: Medications recommended ointments, foams,or devices are not covered. because of increased risk due to type of employment are not covered. • Progesterone and Estrogen Products: Specially compounded progesterone and estrogen products • Other Exclusions and Limitations: All exclusions and including progesterone suppositories are not covered. limitations as listed in this Supplement or in your Evidence of Coverage and Disclosure Form,Section Five, • Prior to Effective Date: Drugs or medicines purchased Your Medical Benefits are not covered. and received prior to the Member's effective date or subsequent to the Member's termination are not covered. PacifiCare reserves the right to expand the prior authorization requirement for any drug product. • Recreation or travel: Medications when used for the purpose(s)of recreation and/or travel,other than those Note: PacifiCare may determine medical necessity by using medications recommended for travel by guidelines pre-authorization programs as deemed appropriate by established by the Centers for Disease Control are not PacifiCare. Coverage is based on PacifiCare criteria. If you covered. have any questions,please contact our Customer Service Department at 1-800-877-9777 or 1-800-360-1797(TDHI). • Replacement of lost, stolen,or destroyed medications are not covered. • Saline and irrigation solutions are not covered. 20030108 9/03 3 PCO1482 ATTACHMENT R-YOUR OUTPATIENT PRESCRIPTION DRUG BENEFIT SUPPLEMENT TO THE COMBINED EVIDENCE OF COVERAGE and DISCLOSURE FORM Understanding Your Outpatient Prescription Formulary Drugs Drug Benefit What is a Formulary? This brochure contains important information for our A Formulary is a list of medications that are covered members about the PacifiCare outpatient prescription under your prescription drug benefit. drug benefit.As part of PacifiCare's commitment to you, we want to provide you with the tools that will help you Are there different types of Formularies? better understand and utilize your Pharmacy and Prescription Drug Plan. In an effort to eliminate PacifiCare uses one Formulary for our prescription drug confusion,PacifiCare has provided you with answers for benefits. Your coverage for Formulary and non- Formulary drugs depends on the level of pharmacy your pharmacy questions such as: benefits purchased by your employer. Certain pharmacy • What is a Formulary? benefit plans provide coverage only for Formulary drugs and non-Formulary drugs when Medically Necessary and • What is the difference between a name brand and approved by PacifiCare through the pre-authorization generic drug? process described in this document and your Schedule of • Who can write my prescription? Benefits. Please refer to your Pharmacy Schedule of Benefits to determine how the Formulary applies to your • What happens in emergency situations? benefits. • What is the Mail Service Pharmacy Program? Why are Formularies necessary? • What is pre-authorization? Medication costs continue to rise. Formularies list those What Else Should I Read To Understand My medications that offer value while maintaining quality of Pharmacy Benefits? care to help reduce health care and premium costs. We want our members to get the most from their Who decides which medications are on the prescription drug benefit plan,so please read this Formulary? Supplement to the Combined Evidence of Coverage and Medications are added or deleted from the Formulary Disclosure Form("Supplement")carefully. You need to only after careful review by a committee of Practicing become familiar with the terms used for explaining your Physicians and pharmacists.This committee,called a coverage,because understanding these terms is essential Pharmacy and Therapeutics(P&T)Committee,has the to understanding your benefit. Along with reading this responsibility of reviewing new and existing drugs.This publication,be sure to review your Pharmacy Schedule of committee decides which drugs provide quality treatment Benefits.Your Pharmacy Schedule of Benefits provides at the best value. Updates occur quarterly;however,in the details of your particular pharmacy benefit plan, certain situations,drugs may be added to or removed from including the exclusions and limitations,applicable the Formulary more frequently. You may obtain a copy Copayments and PacifiCare's pre-authorization process. of the formulary by contacting Customer Service or from Together,these documents explain your coverage.These PacifiCare's web site at www.pacificare.com. documents should be read completely and carefully for a comprehensive understanding of your medical and Please remember that the inclusion of a specific drug on pharmacy benefits. the Formulary does not guarantee that your Participating Physician or Authorized non-Plan Physician will Your medical Combined Evidence of Coverage and prescribe that drug for treatment of a particular condition. Disclosure Form and Medical Schedule of Benefits together with this Supplement to the Combined Evidence of Coverage and Disclosure Form and the Pharmacy What if my outpatient prescription Schedule of Benefits provide the terms and conditions of medication is not on the Formulary? your benefit coverage.All applicants have a right to view these documents prior to enrollment. Formularies list alternative medications,which are safe and effective. These medications often have the same PacifiCare does not coordinate benefits for outpatient action on your body. If your medication is not listed,ask prescription drugs. your Participating Physician or Authorized non-Plan Physician or Participating Pharmacist for an alternative. 20030109 9/03 1 PCO1549 How is a medication added or deleted from Therapeutic substitution of medication the Formulary? If there is no generic equivalent available for a specific - A medication must first demonstrate safety and brand name drug,your physician may prescribe a effectiveness to be added to the Formulary. Only after this 'therapeutic substitute'instead. Unlike a generic,which is determined is the cost of the medication considered. has the identical active ingredient as the brand name Some medications have similar safety and effectiveness, version,a therapeutic substitute has a chemical however,are available at a lower cost.In these cases,the composition that is different but acts similarly in clinical least costly medications are added to the Formulary. and therapeutic ways when compared to competing brand name counterparts. When does the Formulary change? If a change occurs, will! have to pay more to use Filling Your Prescription: a drug I had been using? Who can write my prescription? The National Pharmacy and Therapeutics Committee Generally,to be eligible for coverage,your prescription meets regularly to review the Formulary and add or must be written by a Participating Physician. There are remove medications.Our Formulary books are printed two exceptions to this rule. The first is when the and distributed to Participating Physicians or Authorized prescription is written by a non-Participating Physician non-Plan Physicians on a regular basis and any changes to who has been pre-approved by PacifiCare to treat you. the Formulary are also communicated to your The second exception is when a drug is prescribed for Participating Physician or Authorized non-Plan Physician Emergency or Urgently Needed Services when you are non a regular basis. We also make available on our web out of the area. Emergency Service or Urgently Needed site a listing of the most recent Formulary changes. See Service is defined in your medical Combined Evidence of the section"Recent Formulary Changes"on the pharmacy Coverage and Disclosure Form. page of our Web site.Refer to your Pharmacy Schedule of Benefits to find out if your Copayments are dependent How Do I Use My Prescription Drug Benefit? on Formulary status. Your outpatient prescription drug benefit helps to cover Generic Prescription Drugs the cost for some of the outpatient medications prescribed by a PacifiCare Participating Physician or Authorized What is the Difference Between Generic and non-Plan Physician.Using your benefit is simple. Brand Name Drugs? • Obtain your prescription from your PacifiCare When a new drug is put on the market,for many years it Participating Physician or Authorized non-Plan is typically available only under a manufacturer's brand Physician. name. At first,this new drug is protected by a patent. • Present your prescription for a covered outpatient Only after the patent expires are competing manufacturers medication and PacifiCare Member ID card at any allowed to offer the very same drug. This type of drug is PacifiCare Participating Pharmacy. If ordering by called a generic drug. phone,be sure to mention that you are a PacifiCare While the name of the drug may not be familiar to you,a Member. Note that some prescription medications generic drug has the same medicinal benefits as its brand must be pre-authorized by PacifiCare. name competitor. In fact,a manufacturer must provide . Pay the Copayment for a Prescription Unit or its proof to the Food and Drug Administration(FDA)that a retail cost,whichever is less. generic drug has the identical active chemical compound as the brand name product. A generic product must meet • Receive your medication. rigid FDA standards for strength,quality,purity,and potency. Where do I go to fill a prescription? Only when a generic drug meets these standards is it PacifiCare has a well-established network of pharmacies considered the brand name drug's equivalent. When the including most major pharmacy and supermarket chains FDA approves a new generic drug,PacifiCare may as well as many independent pharmacies.A complete choose to replace the brand name drug on the Formulary listing of Participating pharmacies is available in your with the generic drug. Provider Directory. Contact our Customer Service Department at 1-800-877-9777 or TDHI 1-800-360-1797 NOTE:If you have a question about our Formulary or a to help locate a Participating Pharmacy near you or visit particular drug,please contact PacifiCare's Customer our web site at www.pacificare.com for an up-to-date list. Service Department at 1-800-877-9777 TDHI 1-800-360- 1797 or visit PacfiCare's web site at www.pacificare.com. 20030109 9/03 2 PCO1549 When Do I Request a Refill? Call the Customer Service Department at 1-800-877- 9777,TDHI 1-800-360-1797 or visit PacifiCare's web site You may refill a prescription when a minimum of 75%of at www.pacificare.com to obtain the Direct the quantity is consumed based on the days supply. Reimbursement form. Provide the following:Direct I take medication on a continuing basis. How Member Reimbursement form,copies of the prescription receipts showing the prescription number,name of the can I have my prescriptions filled when I am medication,date filled,pharmacy name,name of the on vacation? member for whom the prescription was written,proof of The most convenient and affordable way to do this is to payment and a description of why a PacifiCare take advantage of our mail service program(for additional Participating Pharmacy was not available. Send these details refer to the Mail Service section in this document). documents to: PacifiCare Pharmacy Department,P.O. It is important to plan ahead,because it takes Box 6037,Cypress,CA 90630. approximately seven days to receive your 90 day supply You must submit the Direct Reimbursement Form within from the mail service program.Vacation overrides are 12 months from the date of service. Payment will be also available in certain circumstances—talk with your forwarded to you once your request for reimbursement is pharmacist about obtaining a vacation override.Our determined by PacifiCare to be appropriate. Customer Service Associates can also help you with planning for your medication needs while traveling call 1- Emergency After Hours 800-877-9777,TDHI 1-800-360-1797. PacifiCare will cover a one time only emergency after What if I am sick and need a prescription hours prescription without pre-authorization in the following situations: when I'm away from home? If • The prescription is for medication in conjunction you are sick and need an outpatient prescription medication filled when away from home,you may visit with a hospital discharge,emergency room,or urgent care facility visit limited to a seven day supply except one of our Participating Pharmacies within our national for antibiotics which may be dispensed in up to a 14 pharmacy network and receive the medication for the applicable Copayment.For the nearest network pharmacy, day supply. contact the Customer Service Department at 1-800-877- • Medications used for acute treatment and immediate 9777,TDHI 1-800-360-1797 or visit our web site at use is required. www.pacificare.com. • Any time the prescribing physician states that failure What happens in an Emergency Situation? to supply the medication will result in a severe medical event or hospital admission. If you receive an outpatient prescription medication out of the Pharmacy Network due to an emergency or urgent Note: After hours pre-authorization will not be approved situation,you must pay for the total cost of the for any of the following situations: prescription at the time of service.For possible • Continuation of a restricted medication based solely reimbursement,you must submit a Direct Member on a previous authorization or previous use. Reimbursement Form.You are only eligible for reimbursement for prescriptions related to urgent or • A change to an existing pre-authorization to extend emergency situations as defined by PacifiCare(refer to the days'supply. your medical Combined Evidence of Coverage and Disclosure Form). • A change to an existing pre-authorization to correct erroneous information. Remember: You should only fill a prescription at a Non- Participating Pharmacy-when absolutely necessary. • Early refills of maintenance medications. How do I obtain reimbursement? • Early refills for signature changes or dosage changes. 20030109 9/03 3 PCO1549 • When I Fill a Prescription, How Much Here's how to fill prescriptions through the Mail Service Medication Do I Receive? Pharmacy Program. 1. Call your Participating Physician or Authorized non- For a single Copayment,Members receive one Plan Physician to obtain a new prescription for each Prescription Unit which represents a maximum of one month's(30 days supply)fill of outpatient prescription medication. When you call,ask the physician to medication that can be obtained at one time. For most write the prescription for a 90 day supply which oral medications,a Prescription Unit is up to a 30 day represents three Prescription Units with up to three supply of medication. additional refills. The doctor will tell you when to pick up the written prescription. (Note:Prescription Medications dispensed in quantities other than the 30 day Solutions must have a new prescription to process supply maximum are listed below: any new mail service request.) • Medications with quantity limitations: The 2. After picking up the prescription,complete the Mail Prescription Unit for some medications may be set at a Service Form included in your enrollment materials. smaller quantity to promote appropriate medication (To obtain additional forms or for assistance in use and patient safety. These quantity limits are based completing the form,call PacifiCare's Customer on generally accepted pharmaceutical practices and Service Department at 1-800-877-9777,TDHI 1-800- the manufacturer's labeling.For example,antibiotics 360-1797. You can also find the form at the web site typically require less than a 30 day supply;and certain address www.rxsolutions.com.) drugs such as controlled substances and migraine 3. Enclose the prescription and appropriate Copayment medications may be limited due to the expectation of via check,money order,or credit card.Your patient need and in accordance with manufacturer's Pharmacy Schedule of Benefits will have the recommended dosages. Drugs with quantity applicable Copayment for the Mail Service Pharmacy limitations may be dispensed in greater quantities if Program. Make the check or money order payable to Medically Necessary and pre-authorized by Prescription Solutions. No cash please. PacifiCare. When you receive your prescription,you'll get detailed • Defined or pre-packaged units of medications: instructions that tell you how to take the medication, Prescriptions such as vials,eye drops,creams or other possible side effects and any other important information types of medications that are normally dispensed in about the medication.If you have questions,registered pre-packaged or defined units of 30 day or less will be pharmacists are available to help you by calling considered a single Prescription Unit. Prescription Solutions at 1-800-562.6223 or TDHI 1-800- • Medication obtained through PacifiCare's Mail 498-5425. Service Program:If you use the PacifiCare Mail Note: Medications such as antibiotics,drugs used for Service Pharmacy Program,you will receive three short-term or acute illnesses,and drugs that require Prescription Units or up to a 90 day supply of special packaging,are not available through our Mail maintenance medications(except for pre-packaged Service Pharmacy Program. medications as described above). Important Tip:If you are starting a new medication, Pacificare's Mail Service Program please request two prescriptions from your Participating Physician or Authorized non-Plan Physician. Have one What is the Mail Service Pharmacy filled immediately at a Participating Pharmacy while program? mailing the second prescription to PacifiCare's Mail PacifiCare offers a Mail Service Pharmacy Program Service Pharmacy. Once you receive your medication through Prescription Solutions®. The Mail Service through the mail service,you should stop filling the Pharmacy Program provides convenient service and prescription at the Participating Pharmacy. savings on maintenance medications that you may take on a regular basis by allowing you to purchase certain drugs for receipt by mail. You get high quality medications mailed directly to your home or address of your choice within the United States,in a discreetly labeled envelope to ensure privacy and safety. Shipping and handling is at no additional charge. If you use our Mail Service Pharmacy Program,you will generally get your maintenance medication within seven working days after receipt of your order. All orders are shipped in discreetly labeled envelopes for privacy and safety. 20030109 9/03 4 PCO1549 What is pre-authorization? What do I do if I need pre-authorization? While your prescription drug benefit covers most We understand that situations may arise in which it may - medications,there are some medications that are excluded be medically necessary to take a medication above the or require pre-authorization. For example,medications preset limits or for a particular condition/circumstance.In used for cosmetic purposes such as wrinkle creams are these instances,since your Participating Physician or not generally covered.Medication quantities may also be Authorized non-Plan Physician understands your medical limited to ensure that they are being used safely and history and health conditions,he/she can request pre- effectively.Copayments,exclusions and restrictions vary, authorization.We have made the process simple and easy. so be sure to read your Pharmacy Schedule of Benefits for Your Participating Physician or Authorized non-Plan additional details.Prescriptions that require pre- Physician can call or fax the pre-authorization request to authorization will be charged at the applicable Copayment Prescription Solutions®,PacifiCare's pharmacy benefit if approved. manager.The pre-authorization staff of qualified pharmacists and technicians is available Monday through We want to make sure our members receive optimal care Friday from 6:00 a.m. to 6:00 p.m. to assist Participating and appropriate medication use is a big part of physicians or Authorized non-Plan Physicians.Most maintaining your overall health.That is why we have authorizations are completed within 24 hours.The most systems in place to make sure your medication is common reason for delay in the authorization process is prescribed according to treatment guidelines consistent insufficient information. Your Participating Physician or with standard professional practice.We want to make Authorized non-Plan Physician may need to provide sure you are not taking more medication or medication for information on diagnosis and medication history and/or a longer period of time than is necessary,as well as evidence in the form of documents,records or lab tests receiving follow-up care.PacifiCare reserves the right to which establish that the use of the requested medication require pre-authorization and/or limit the quantity of any meets plan criteria. prescription to ensure that the following coverage criteria are met. Does this plan limit or exclude certain drugs • The prescription is for the treatment of a covered my health care provider may prescribe or medical condition and the expected beneficial effects encourage substitutions for some drugs? of the prescription outweigh the harmful effects. Your PacifiCare pharmacy benefit provides you access to • There is sufficient evidence to draw conclusions a wide range of FDA-approved brand and generic about the effect of the prescription on the medical medications.The Formulary is developed with the input condition being treated and on your health outcome. from Participating Physicians,Authorized non-Plan Physicians and pharmacists and is based on assessment of • The expected beneficial effects of the prescription the drug's quality,safety,effectiveness and cost.When outweigh the expected harmful effects. we don't include a medication, it's usually because an • The prescription represents the most cost-effective approved alternative can be prescribed for the same method to treat the medical condition. condition. For example,PacifiCare may cover the generic product,rather than its brand-name equivalent.It is also • The prescription drug is prescribed according to important to remember there may be other options established,documented and approved indications available for treating a particular medical condition. that are supported by the weight of scientific evidence. What should I do if I want a change from limitations, exclusions, substitutions or cost PacifiCare understands that situations arise in which an exception to pre-authorization requirements may be increases for drugs specified in this plan? Medically Necessary. In these instances,your In some cases,your provider may request an exception to Participating Physician Authorized non-Plan Physician an exclusion,limitation or substitution through the pre- may request an exception by calling or faxing the request authorization process. In addition,as a PacifiCare to PacifiCare. The Participating Physician or Authorized member you have the right to appeal any coverage non-Plan Physician may need to provide evidence to determination. Contact Customer Service at 1-800-877- PacifiCare in the form of documents,lab results,records 9777,TDHI 1-800-360-1797 for details on the pre- or clinical trials which establish that use of the requested authorization or appeals process. All appeals are handled medication meets plan criteria for coverage. Prescriptions within 30 days;however; emergency requests are that require pre-authorization will be charged at the processed within three business days. Please refer to your applicable Copayment if approved. medical Combined Evidence of Coverage and Disclosure Form for more details on the appeals process. 20030109 9/03 5 PCO1549 What is covered,what is not? Participating Provider-Any Physician,Physician specialist,hospital,Skilled Nursing Facility,extended PacifiCare covers most FDA-approved generics and a care facility,individual,organization,agency or other broad selection of brand name drugs. Refer to your Provider who/which has entered into a contractual Pharmacy Schedule of Benefits for a listing of covered arrangement with PacifiCare to provide health services to medications as well as limitations and exclusions for Member. PacifiCare may contract with a Provider for a certain medications. specified Member,a specified period of time and/or a Helpful tips: specified services. In that case,the Provider is a Participating Provider only for the services(s)contracted • Take your medications list with you to the doctor's and/or for the designated period. office. Participating Pharmacy-A pharmacy that has • Ask your doctor before leaving his office if the drug contracted with PacifiCare to provide outpatient he prescribed is on the PacifiCare Formulary. prescription drugs to our members. • Talk with your doctor about Formulary alternative Participating Physician -A physician that has contracted medications to treat your medical condition. with PacifiCare to provide health care services to our members. • You and your practitioner can access the most current Formulary information on our Web site at Pre-authorization-PacifiCare's review process that www.pacificare.com including information on determines the coverage of a prescription drug prior to the Formulary altematives. member receiving the prescription drug. Definitions Prescription Unit-The maximum amount(quantity)of prescription medication that may be dispensed per single Contract or Plan Year-The twelve-month period that Copayment. For most oral medications,a Prescription begins on the first day of the month the Agreement Unit represents up to.a 30 day supply of medication. The becomes effective Prescription Unit for some medications may be set at a Calendar Year-The time period beginning on January smaller quantity to promote appropriate medication use 1"and ending on December 31'. and patient safety. Quantity limits are based on generally accepted pharmaceutical practices and the manufacturer's Formulary-A list of prescription medications covered labeling. Prescriptions that are normally dispensed in pre- by PacifiCare for use in the member's treatment.The packaged or commercially available units of 30 days or Formulary contains a broad range of FDA approved less will be considered a single Prescription Unit generic and some brand name medications that under including but not limited to,one inhaler,one vial of State or Federal law are to be dispensed by a prescription ophthalmic medication,one tube of topical ointment or only. The Formulary does not include all prescription cream. medications. Selected Brands List-The brand-name drugs included Non-Participating Pharmacy-A pharmacy that has on the PacifiCare Formulary in place of their generic NOT contracted with PacifiCare to provide outpatient equivalents. These drugs are available at the generic drug prescription drugs to our members. Copayment amount. Non-Participating Physician-A physician that has NOT Non-Formulary Preferred Drug:Non-Formulary drug contracted with PacifiCare to provide health care services that is more cost effective than a similar non-Formulary to our members. drug. Non-Participating Providers-A hospital or other health care entity,a Physician or other health care professional, or a health care vendor that has not entered into a written agreement to provide Covered Services to PacifiCare's members. 20030109 9/03 6 PCO1549 PHARMACY LISTING For the most up to date list visit the web site at www.pacificare.com • ALBF.RTSONS PHARMACY • CITY MARKET PHARMACY • CUB PHARMACY • GOOD DAY PHARMACY • HOFFMAN DRUGS • K MART PHARMACY • KING SOOPERS PHARMACY • LONGS DRUG STORE • MEDICINE SHOPPE PHARMACY • PHAR-MOR • RITE AID PHARMACY • SAFEWAY PHARMACY • SAMS PHARMACY • SHOPKO PHARMACY • TARGET • WALGREEN DRUG STORE • WAL-MART PHARMACY Questions? Call PacifiCare's Customer Service Department at 1-800-877-9777,1-800-360-1797 (TDHI). PacifiCare® 6455 South Yosemite Street Greenwood Village,Colorado 80111 M-F,7 a.m.to 8 p.m. www.pacificare.com 20030109 9/03 7 PCO1549 Hello