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Home My WebLink About20030194.tiff RESOLUTION RE: APPROVE MEDICAL AND HOSPITAL GROUP SUBSCRIBER MASTER CONTRACT FOR HEALTH INSURANCE AND AUTHORIZE CHAIR TO SIGN - PACIFICARE OF COLORADO 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 a Medical and Hospital Group Subscriber Master Contract 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, commencing January 1, 2003, and ending December 31, 2003, with further terms and conditions being as stated in said contract, and WHEREAS, after review, the Board deems it advisable to approve said contract, a copy of which is attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the Medical and Hospital Group Subscriber Master Contract 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 be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said contract. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 15th day of January, A.D., 2003. RD OF COUNTY COMMISSIONERS W CO TY COLORADO ATTEST: / , Y • David E. Long, air Weld County Clerk to t y •l R bert D. sden, Pro-Tem BY: ',t ,. Deputy Clerk to the B.- _` ! M. J. Geile APPRCVcdAS TO.FORM: EXCUSED DATE OF SIGNING (AYE) /_ William H. Jerky Cotfnty Attorney �� ,t'7,/�+ l Glenn Vaad Date of signature: 2003-0194 cc: 60/7 PE0021 PACIFICARE OF COLORADO 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: 01/01/2003 through 12/31/2003 PLAN CODE: PLAN DESCRIPTION: 40773 Medical Plan 418143 Pharmacy Plan E4143 Vision Plan HEALTH PLAN PREMIUMS: EE $258.17 EE + Sp $516.37 EE + Ch $495.70 EE + Fam $759.94 PREMIUMS DUE ON OR BEFORE (refer to Section 3.06): First of the month prior to the month in which premium applies ANNUAL OUT OF POCKET MAXIMUM PER INDIVIDUAL: $2,500 in-network/$5,000 out-of- network(plus deductible) ANNUAL OUT OF POCKET MAXIMUM PER FAMILY: $5,000 in-network/$10,000 out-of- network(plus deductible) CONTINUATION OF BENEFITS ELECTIONS: Standard 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 20020264 10/02 2003-0194 ' Termination of Coverage: Termination of coverage varies by the date of termination. If termination occurs from the 1st through the 14th of the month, coverage terminates at the end of the current month. If termination occurs on the 15th through the end of the month, coverage terminates at the end of the following month. 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) P- Plus Schedule of Benefits (If Purchased) R- Outpatient Prescription Drug Benefit (If Purchased) V- Vision Care(If Purchased) 20020264 10/02 i PACIFICARE OF COLORADO MEDICAL AND HOSPITAL GROUP SUBSCRIBER AGREEMENT 20020264 10/02 • MEDICAL AND HOSPITAL GROUP SUBSCRIBER AGREEMENT This Medical and Hospital Group Subscriber Agreement (the"Agreement") is entered into between PACIFICARE OF COLORADO, 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 terns 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. 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 minimum of 24 hours per week, meets any applicable waiting period required by the Group, and is defined as an employee under State and Federal law; 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. 1.16 Member is any Subscriber or Dependent. 1.17 Open Enrollment Period is the period of not less than thirty(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. 2 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 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. 1.20 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 2.01.01Application 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. 2.01.02Time 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 thirty-one(31) days after becoming eligible. All applications for Enrollment which are not received by PacifiCare within the thirty-one (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 thirty-one (31)day period. Group shall provide notice to Members of the applicable Open Enrollment Periods. 3 J • - 2.01.03Notice 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 twelve (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. 2.01.04Late 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 sixty(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. 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. 4 3.02 Notices to PacifiCare. Group shall forward to PacifiCare all completed or amended Enrollment forms for each Member within thirty-one (31) days of the Member's initial eligibility. Group acknowledges that any Enrollment applications not forwarded to PacifiCare within such thirty-one (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 thirty-one (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. 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. 5 3.07 Modification of Rates and Benefits. 3.07.01Modification 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 thirty-one (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 thirty-one (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 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 thirty(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 and license fees, rounded to the nearest cent. 3.07.02Modification 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 thirty-one (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 thirty-one(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. 6 3.09 Continuation of Benefits and Conversion Coverage. 3.09.01Notice 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. 3.09.02Notice of Individual Conversion Rights. Within fifteen (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. 3.09.03Conversion 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. 3.09.04USERRA (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. 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 thirty(30) days of the termination, and to provide PacifiCare with eligibility information and data within thirty(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 (1) 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 (1) 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, 8 7. TERMINATION 7.01 Termination by Group. Group may terminate this Agreement by giving a minimum of thirty(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. 7.02.01For 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 fifteen (15) days of the date of issuance of the notice, and that if payment of all unpaid Health Plan Premiums is received within the fifteen(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. 7.02.02Partial 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. 7.02.03Nonliability 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. 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. 9 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. 7.02.04Reinstatement Following Non-Payment of Premium. Requests for Reinstatement of this Agreement must be received by PacifiCare within fifteen (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 (5)percent of the monthly premium prorated on a thirty(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. 7.02.05Termination 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 thirty(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 thirty(30) days of receiving notice of the breach from PacifiCare, PacifiCare may terminate this Agreement at the end of the thirty(30) day notice period. 7.02.06For Providing Misleading or Fraudulent Information. PacifiCare may terminate this Agreement upon thirty(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. 10 7.02.07For Ceasing to Meet Group Eligibility Criteria. PacifiCare may terminate Group upon • thirty(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 seventy-five percent (75%); b. For Subscribers without Dependents, Group fails to maintain a Group Contribution equal to seventy-five percent(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. 7.02.08For Changing the Nature of Group's Business. PacifiCare may terminate Group upon thirty(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. 7.02.09For 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 thirty(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 thirty(30) days of the change. 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 thirty(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. 11 . • 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. 8.01.01Relationship 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. 8.01.02PacifiCare 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. 8.01.03Access 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. 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. 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 thirty(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 forty-eight (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 twenty-four(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. 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 thirty(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. 15 IN WITNESS WHEREOF, the parties hereto have executed this Agreement in Greeley , Colorado, on January 15 , 2003 . GROUP: WELD COUNTY PACIFICARE OF COLORADO BY: \\FBY: -8 >V -\f(NAME: David E. Long NAME: Barbara Towle TITLE: Chair, Weld County Board of TITLE Manager, Account Services Commissioners DATE: 01/15/2003 DATE: December23, 2002 Attest: Clerk to the Boa L.49 I6 By: Deputy Clerk to the rd 16 PO3 . 0/9y HEALTH PLAN 2003 Ate apt • COLORADO Combined Evidence of Coverage & Disclosure Form Federally Qualified Plans Non-Federally Qualified Plans PacifiCare® Welcome to PacifiCare Welcome to Pacificare of Colorado PacifiCare and its predecessor companies have operated in the state of Colorado for over 25 years. This publication will 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 to 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 supplemental 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 1-800-659-2656 (TDD). NOTE:Your Combined Evidence of Coverage and Disclosure Form provides the terms and conditions of your coverage with PacifiCare and all applicants have a right to view this document 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. ii 111 Table of Contents Section One: Section Five: Getting Started: Your Medical Benefits 13 Your Primary Care Physician 3 Your Medical Benefits 13 Introduction 3 I. INPATIENT BENEFITS 13 What Is a Primary Care Physician? 3 II. OUTPATIENT BENEFITS 19 Choosing a Primary Care Physician 3 III. EXCLUSIONS AND LIMITATIONS Your Provider Directory- OF BENEFITS 32 Choice of Physicians and Hospitals (Facilities) 4 Section Six: If You Are Pregnant 4 Payment Responsibility 45 Section Two: What Are Premiums (Prepayment Fees)? 45 Seeing the Doctor 5 What Are Copayments (Other Charges)? 45 Seeing the Doctor: Scheduling Appointments 5 Annual Out-of-Pocket Maximum 45 Referrals To Specialists 5 If You Get a Bill(Reimbursement) 46 OB/GYN: Getting Care Without a Referral 6 Bills From Non-Participating Providers 46 Second Medical Opinions 6 How To Avoid Unnecessary Bills 46 Prearranging Hospital Stays 7 Your Billing Protection 47 Section Three: Coordination of Benefits _ 47 Emergency and Urgently Needed Services 8 Important Rules for Medicare and Medicare Eligible Members 52 What Are Emergency Medical Services? 8 What Is an Emergency Medical Condition? 8 Section Seven: What To Do When You Require Member Eligibility 53 Emergency Services 8 Who Is a PacifiCare Member? 53 Post Stabilization and Follow-up Care 8 Eligibility 54 Out-of-Area Services 9 Open Enrollment 54 Out-of-Area Urgently Needed Services 9 Adding Family Members To Your Coverage 55 What To Do When You Require Urgently Continuing Coverage for Student and Disabled Needed Services 9 Dependents 55 International Emergency and Urgently Notifying You of Changes In Your Plan 57 Needed Services 10 Updating Your Enrollment Information 57 Section Four: Renewal.and Reinstatement 57 Changing Your Doctor 11 Ending Coverage (Termination of Benefits) 57 Changing Your Primary Care Physician 11 Coverage Options Following Termination 60 When We Change Your Primary Care Physician 11 Continuing Care With a Terminated Physician 11 Table of Contents k Section Eight: Section Ten: Overseeing Your Health Care 64 Definitions 73 How PacifiCare Makes Important Section Eleven: Health Care Decisions 64 Your Rights and Responsibilities 80 Authorization, Modification and Denial You Have The Right To ... 80 of Health Care Services 64 Your Responsibilities Are To ... 81 Utilization Criteria 65 Quality of Care Review 66 The Appeals Process 66 Section Nine: General Information 71 What Should I Do if I Lose or Misplace My Membership Card? 71 Does PacifiCare Offer a Translation Service? 71 Does PacifiCare Offer Hearing and Speech Impaired Telephone Lines? 71 How Is My Coverage Provided Under Extraordinary Circumstances? 71 How Does PacifiCare Compensate Its Participating Providers? 71 How To Get Help 72 1 - Section One - Getting Started Getting Started: your PacifiCare and who is primarily responsible for the coordination of your health care services.A Primary Primary Care Physician Care Physician is trained in internal medicine, general practice, family practice or pediatrics. • What Is a Subscriber? Unless you need Emergency or Urgently Needed care, your Primary Care Physician is your first stop for using • What Is a Primary Care Physician? these medical benefits.Your Primary Care Physician will also seek authorization for any referrals, as well as initiate and coordinate any necessary Hospital Services. • What Is a Participating Provider? All Members of PacifiCare are required to have a Primary Care Physician. If you don't select one when • Your Provider Directory you enroll, PacifiCare will choose one for you. Except in an Urgent or Emergency situation, if you see another health care Provider without the approval of either your • Choosing Your Primary Care Physician Primary Care Physician or PacifiCare, the costs for these services may not be covered. • Continuity of Care ‘1,11O4O,O(A,zf t t# i«c i .z,: One of the first things you do when joining PacifiCare {�'is to select a Primary Care Physician. This is the doctor `° ° gip` ` in charge of overseeing your care through PacifiCare. White both a e jb tot Pa ,therJ's a difference This section explains the role of the Primary Care betweientjlb {rs t#14718tf " ndent.A Physician, as well as bow to make your choice. You'll Subset-10'r tf Din*it 04' or her also learn about your Participating Provider and bow em 9t i ft¢} g hty tegolretpentsof to use your Provider Directory. the Employe' 4`'e 44 k a f F eOG W A 5u 'may also tontf Mlle t$ d a tttepF thntrs pfd to PLEASE READ THE FOLLOWING INFORMATION SO PacifiCare for his or her health care coverage for him or YOU WILL KNOW FROM WHOM OR WHAT GROUP herself and any enrolled Dependents.An enrolled OF PROVIDERS HEALTH CARE SERVICES MAY BE Dependent is someone such as a Spouse or child whose OBTAINED. Dependent status with the Subscriber allows him or her to be a Member of PatditCare,Why ploitt pot the difference? Introduction Because Substil, i tte hewe Special pohsibiuties. Now that you're a PacifiCare Member, it's important to including:s Q #4 } become familiar with the details of your coverage. Reading Depcttd@Grttn Snit ``� n- rs al responsrbd esthitare noteatthroMghoutthispublication this publication will help you go a long way toward understanding your coverage and health care benefits. It's If you're a$ v .. ? ;Oa 4 to • uarty written for all our Members receiving this plan,whether instructtans giveahpft 'DV. you're the Subscriber or an enrolled Dependent. (Fbbrr aa'more { ddet t X}�SMIon of any t'P'�rtrtS see the DefinitinnJ "Xet'��a At R.>f4F Y a,• t. Please read this Combined Evidence of Coverage and . r #._, Disclosure Form along with any supplements you may have with this coverage.You should also read and Choosing a Primary Care Physician become familiar with your Schedule of Benefits, which When choosing a Primary Care Physician,you should lists the benefits and costs unique to your plan. always make certain your doctor is selected from the list of What Is a Primary Care Physician? Primary Care Physicians in PacifiCare's Provider Directory. When you become a Member of PacifiCare, one of the You'll find a list of our participating Primary Care first things you do is choose a doctor to be your Primary Physicians in the Provider Directory. It's also a source Care Physician. This is a doctor who is contracted with for other valuable information. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. Section One - Getting Started . �, .t - Each PacifiCare Member can choose his or her own What is Continuity of Care? Primary Care Physician, so long as the doctor is selected Under certain circumstances, new Members of from PacifiCare's list of Primary Care Physicians. PacifiCare may be able to temporarily continue receiving services from a Non-Participating Provider.This short- If a Dependent doesn't make a selection during term transition assistance is intended for new Members enrollment, PacifiCare will choose the Member's who are experiencing an acute episode of care while Primary Care Physician. (NOTE: If an enrolled making the transition to PacifiCare.Typically,this Dependent is pregnant, please read below to learn how condition requires prompt medical attention and is of to choose a Primary Care Physician for the newborn.) Limited duration.(Examples include: pregnancy in the If You Are Pregnant third trimester; being in an acute hospital or scheduled to be in the hospital immediately after your PacifiCare Every Member of PacifiCare needs a Primary Care coverage becomes effective; undergoing a course of Physician, including your newborn. If you are pregnant, chemotherapy, radiation therapy,or psychiatric we encourage you to plan ahead and pick a Primary counseling;being on a transplant list.) Care Physician for your baby. If you're a new Member and believe you qualify for Newborns remain enrolled with the mother's Primary continuity of care,please call the Customer Service Care Physician from birth until discharge from the department and request the form"Continuity of Care for hospital.You may enroll your newborn with a different New Enrollees Request."Complete and return this form Primary Care Physician following the newborn's ' to PacifiCare as soon as possible.Upon receiving the discharge by calling PacifiCare's Customer Service completed form,a medical review will be completed in department. If a Primary Care Physician isn't chosen for three 131 business days. If you qualify,you will be notified your child, the newborn will remain with the mother's by telephone of the decision and provided with the plan for Primary Care Physician. You can learn more about your care.If you don't qualify,you will be notified either by changing Primary Care Physicians in Section Four, telephone or in writing within three(31 business days of Changing Your Doctor. (For more about adding a the completed review,and alternatives will be offered. newborn to your coverage, see Section Seven, Please note:It's not enough to simply prefer receiving Member Eligibility.) treatment from a former Physician or other Non Participating Provider,even for a Chronic Condition. You should not continue care with a Non-Participating Does your Provider or Group or Hospital Provider without our formal approval.If you do not restrict any Reproductive Services? receive preauthorization by PacifiCare,payment for ' Some hospitals and other Providers do not provide one services performed by a Ilion-Participating Provider will be or more of the following services that may be covered your responsibility. under your plan contract and that you or your Dependent might need:family planning,contraceptive services, Your Provider Directory- Choice of Physicians including emergency contraception;sterilization. and Hospitals (Facilities) including tubal ligation at the time of labor and delivery; Infertility treatments;or abortion.You should obtain Every Subscriber should receive a Provider Directory. If more information before you enroll.Call:your you need a copy or would like assistance picking your prospective doctor,or call the PacifiCare Health Plan Primary Care Physician, please call our Customer Service Customer Service department at 1-800-877-9777 or department. You can also find an on-line version of the 1-800-659-2656(TDD)to ensure that you can obtain the Directory at www.pacificare.com. health care services that you need. Choosing a Primary Care Physician for Each Enrolled Dependent A STATEMENT qE5CRIBING PACIFICARE'S POi,ICIES Every PacifiCare Member must have a Primary Care AND PROCEDURtS FORPRESERVING THE Physician; however, the Subscriber and any enrolled CONFIDENTIALITY OF MEDICAL RECORDS IS AVAILABLE Dependents don't need to choose the same doctor. AND WILL BE FURNISHED TO-YOU UPON REQUEST. • Section Two - Seeing the Doctor Seeing the Doctor When you see your Primary Care Physician or use one of your health care benefits, you may be required to pay a charge for the visit. This charge is called a Copayment. • Scheduling Appointments The amount of a Copayment depends upon the health care service.Your Copayments are outlined in your • Referrals To Specialists Schedule of Benefits. More detailed information can also be found in Section Six, Payment Responsibility. • PacifiCare Express Referrals® r ritvitrrrr'$ Pacifig*,E et * rlt _ PacifiCare offers>a'ptisjraftit ed ri, • Seeing the OB/GYN Express Referraistniett is �a Vii` .s- .; Physician decides in0 4'' 11' j I > ° • Second Medical Opinions authorization id egtired r Prima Care P '' 4 • Prearranging Hospital Stays denied Your` P °t i* ' Pacif6Cala gp Now that you've chosen a Primary Care Physician,you * ri s1 111 '11 r. have a doctor or our routine health care. Your To defeehtfne'if ytrtlrirftrtaIv �„ ° f y ";4114+ �� *, Primary Care Physician will determine when you need participates in Expt 'R Lr, �_g# t 3 t a specialist, arrange any necessary hospital care, and department ory:You Can ais0 at mil$ oversee your health care needs. or fitted'a fist at#V t�il i1 y t .,* +. :i'!d Ps i� ark apastdt9. This section will help you begin taking advantage of your health care coverage. It will also answer common Referrals To Specialists questions about seeing a specialist and receiving Your Primary Care Physician is responsible for medical services that are not Emergency Services or coordinating care when it's Medically Necessary for you Urgently Needed Services. (For information on to see a specialist. (There is an exception for visits to Emergency Services or Urgently Needed Services,please obstetrical and gynecological (OB/GYN) Physicians. This turn to Section Three, Emergency and Urgently is explained below in "OB/GYN: Getting Care Without a Needed Services.) Referral.") If your Primary Care Physician does not participate in Express Referrals and determines you Seeing the Doctor:Scheduling Appointments need a referral, he or she will submit a request to To visit your Primary Care Physician, simply make an PacifiCare. If approved, the referral is authorized; if the appointment by calling your doctor's office.Your request is not approved, the referral is denied. In the Primary Care Physician is your first stop for accessing event of a denial,you can request an appeal of the care except when you need Emergency Services, or decision. For more about appeals, see Section Eight, when you require Urgently Needed Services and you are Overseeing Your Health Care. outside of the HMO Service Area. Without an authorized referral from your Primary Care Physician or PacifiCare, Standing Referrals To Specialists no Physician or other health care services will be A standing referral is a referral by your Primary Care covered except for Emergency Services and Urgently Physician that authorizes more than one visit to a Needed Services. (There is an exception if you wish to participating specialist or participating specialized visit an obstetrical and gynecological Physician. See treatment center for ongoing treatment.A standing below, "OB/GYN: Getting Care Without a Referral.") referral may be provided if your Primary Care Physician, in consultation with you, the specialist and a PacifiCare medical director, determines that as part of a treatment Questions about your benefits? Call the Customer Service department at 1-800-877-9777. `1 Section Two - Seeing the Doctor plan you need continuing care from a specialist.You Second Medical Opinions may request a standing referral from your Primary Care A second medical opinion is a reevaluation of your Physician or PacifiCare. Please note:A standing referral condition or health care treatment by an appropriately and treatment plan is only allowed if approved by qualified Provider. This Provider must be either a PacifiCare. Primary Care Physician or a specialist acting within his Your Primary Care Physician will specify how many or her scope of practice, and must possess the clinical specialist visits are authorized.The treatment plan may background necessary for examining the illness or Limit your number of visits to the specialist and the condition associated with the request for a second period for which visits are authorized. It may also require medical opinion. Upon completing the examination, the the specialist to provide your Primary Care Physician with Provider's opinion is included in a consultation report. regular reports on your treatment and condition. Either you or your treating Participating Provider may OB/GYN: Getting Care Without a Referral submit a request for a second medical opinion. To find out how you should submit your request, talk to your Women may receive obstetrical and gynecological Primary Care Physician. (OB/GYN) Physician services directly from a Participating OB/GYN or your Primary Care Physician. This means Second medical opinions will be provided or authorized you may receive these services without preauthorization in the following circumstances: or a referral. In all cases, however, the doctor must be • When you question the reasonableness or necessity of Participating with PacifiCare. recommended surgical procedures; Please remember: if you visit an OB/GYN or family • When you question a diagnosis or treatment plan for practice Physician that is not Participating with a condition that threatens loss of life, loss of limb, loss PacifiCare without preauthorization or a referral, you of bodily functions, or substantial impairment will be financially responsible for these services.Any (including, but not Limited to, a Chronic Condition); OB/GYN inpatient or Hospital Services, except Emergency or Urgently Needed Services, need to be • When the clinical indications are not clear, or are authorized in advance by your Primary Care Physician or complex and confusing; PacifiCare. • When a diagnosis is in doubt due to conflicting test The only exception to the OB/GYN direct access process results; is OB/GYN specialists whose practices primarily consist • When the treating Provider is unable to diagnose the of sub-specialty care such as Infertility or genetics. Such condition; specialists can be accessed only by referral from the Member's Primary Care Physician. • When the treatment plan in progress is not improving your medical condition within an appropriate period If you would like to receive OB/GYN Physician services, of time given the diagnosis, and you request a second simply do the following: opinion regarding the diagnosis or continuance of the • Call the Customer Service department telephone treatment; number on the front of your ID Card and request the • When you have attempted to follow the treatment plan names and telephone numbers of the OB/GYNs or consulted with the initial Provider and still have Participating with PacifiCare; serious concerns about the diagnosis or treatment. • Telephone and schedule an appointment with your Please note: The fact that an appropriately qualified selected Participating OB/GYN. Provider gives a second medical opinion and After your appointment,your OB/GYN will contact your recommends a particular treatment, diagnostic test or Primary Care Physician about your condition, treatment service does not necessarily mean that the and any needed follow-up care. recommended action is Medically Necessary or a Covered Service.You will also remain responsible for PacifiCare also covers important wellness services for our paying any outpatient office Copayments to the Provider Members. For more information, see "Health Education who gives your second medical opinion. Services" in Section Five,Your Medical Benefits. a Section Two - Seeing the Doctor If your request for a second medical opinion is denied, Prearranging Hospital Stays PacifiCare will notify you in writing and provide the reasons Your Primary Care Physician or the Provider you were for the denial.You may appeal the denial by referred to, will prearrange any Medically Necessary following the procedures outlined in Section Eight, hospital or facility care, including inpatient Transitional Overseeing Your Health Care. If you obtain a second Care or care provided in a Subacute Skilled Nursing medical opinion without preauthorization from Facility. If you've been referred to a specialist and the PacifiCare,you will be financially responsible for the specialist determines you need hospitalization,your cost of the opinion. Primary Care Physician and specialist will work together To receive a copy of the Second Medical Opinion to prearrange your hospital stay. timeline, Members may call or write PacifiCare's Your hospital costs, including semiprivate room, tests Customer Service department at: and office visits, will be covered, minus any required PacifiCare Customer Service Department Copayments as well as any deductibles. Under normal P.O. Box 6770 circumstances,your Primary Care Physician will Englewood, CO 80155 coordinate your admission to a local PacifiCare 1-800-877-9777 Participating Hospital or facility; however, if your situation requires it,you could be transported to a 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 Facility. He or she can also arrange for skilled home health care. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. fl I Section Three - Emergency it and Urgently Needed Services • '� Urgently ; Emergency and .�• _ ' r =m�x�, Needed Services Ify0utieltereyourte. encY Medic*Conator,.tataltt;or�, l i, titittO • What Is a Life or Limb Threatening Emergency areiir t, . tete; I. t v 4st€":' Medical Condition? What To Do When You Require Emergency • What To Do When You Require Emergency Services Services If you believe you are experiencing an Emergency Medical Condition, call 911 or its local equivalent, • What Are Urgently Needed Services? or go directly to the nearest hospital emergency room or other facility for treatment. PacifiCare covers all Medically Necessary Emergency Services • Post Stabilization and Follow-Up Care provided to Members in order to stabilize an Emergency Medical Condition. • Out-of-Area Services You, or someone else on your behalf, must notify PacifiCare or your Primary Care Physician within • What To Do If You're Abroad twenty-four(24)hours, or as soon as reasonably possible,following your receipt of Emergency Services Worldwide, wherever you are, and Care provides so that your Primary Care Physician can coordinate coverage for Emergency Services a Urgently Needed your care and schedule any necessary follow-up Services. This section will explain how to obtain treatment.When you call, please be prepared to give Emergency Services and Urgently Needed Services. It the name and location of the facility, and a description will also explain what you should do following receipt of the Emergency Services that you received. of these services. Post-Stabilization and Follow-up Care What Are Emergency Medical Services? Following the stabilization of an Emergency Medical Emergency Services are Medically Necessary ambulance Condition, the treating health care Provider may believe or ambulance transport services provided through the that you require additional Medically Necessary Hospital 911 emergency response system or its local equivalent. (health care) Services prior to your being safely It is also the medical screening, examination and discharged. In such a situation, the medical facility evaluation by a Physician, or other personnel—to the (Hospital)will contact PacifiCare, in order to obtain the extent provided by law—to determine if an Emergency timely authorization for these post-stabilization services. Medical Condition or psychiatric Emergency Medical PacifiCare reserves the right, in certain circumstances, to Condition exists. If this condition exists, Emergency transfer you to a Participating Hospital in lieu of Services include the care, treatment and/or surgery by a authorizing post-stabilization services at the treating facility. Physician necessary to stabilize or eliminate the Emergency Medical Condition or psychiatric medical Following your discharge from the Hospital, any condition within the capabilities of the facility. Medically Necessary follow-up medical or Hospital Services must be provided or authorized by your What Is an Emergency Medical Condition? Primary Care Physician in order to be covered by PacifiCare. Re ess of where you are in the An Emergency Medical Condition is any event which a gardl Prudent Layperson reasonably believes threatens his or world, Hospital if you Services, please ed call onal follow-up o medical y Care immediate at limb in such a manner that a need for oPhysician or PaciflCare's Out-of-Area unit to request immediate medical care is created to prevent death or Y serious impairment of health. authorization.Pac(fiCare's Out-of-Area unit can be reached during regular business hours (8 a.m. -5 p.m., MST) at 1.800-762.8456.) a Section Three - Emergency and Urgently Needed Services Out-of-Area Services Out-of-Area Urgently Needed Services PacifiCare arranges for the provision of Covered Services Urgently Needed Services are covered health care through its Participating Providers. With the exception services required to prevent the serious deterioration of of Emergency Services, Urgently Needed Services, a Member's health resulting from an unforeseen illness authorized Post-Stabilization Care, or other specific or injury for which treatment cannot be delayed until services authorized by PacifiCare, when you are away the Member returns to the HMO Service Area. from the HMO Service Area,you are not covered for any Urgently Needed Services are required in situations other medical or Hospital Services. These services are where a Member is temporarily outside the HMO covered when needed in order to prevent serious Service Area and the Member experiences a medical deterioration of your health that would result from an condition resulting from an unforeseen illness or injury, unforeseen illness or injury if you are temporarily that, while less serious than an Emergency Medical absent from the HMO Service Area and receipt of your Condition, could result in the serious deterioration of health care cannot be delayed until your return to the the Member's health if not treated before the Member HMO Service Area. If you do not know the HMO Service Area, please see the HMO Service Area map in Section returns to the HMO Service Area, or contacts PacifiCare Member Eligibility, or his or her Primary Care Physician. Seven, or please call our Customer Service department to inquire. What To Do When You Require Urgently The out-of-area services that are not covered include, Needed Services but are not Limited to: When you are temporarily outside the HMO Service Area 1. Routine follow-up care to Emergency or Urgently and you believe that you require Urgently Needed Needed Services, such as treatments, procedures, X- Services,you should, if possible, call (or have someone rays, lab work and doctor visits, Rehabilitation else call on your behalf) your Primary Care Physician or Services, Skilled Nursing Care, or home health care. PacifiCare. The telephone numbers for your Primary Care Physician and PacifiCare Customer Service 2. Maintenance therapy and Durable Medical department are on the front of your PacifiCare ID card. Equipment including, but not Limited to, routine Assistance is available twenty-four (24) hours a day, seven dialysis, routine oxygen, routine laboratory testing days a week. Identify yourself as a PacifiCare Member or a wheelchair to assist you while traveling outside and ask to speak to a Physician. If you are calling during the HMO Service Area. non-business hours, and a Physician is not immediately 3. Medical care for a known or Chronic Condition available, ask to have the Physician-on-call paged. A without acute symptoms as defined under Physician should call you back shortly. Explain your Emergency Services or Urgently Needed Services. situation and follow any provided instructions. Ambulance services are Limited to transportation to the If you are unable to contact your Primary Care Physician nearest facility with the expertise for treating your or PacifiCare, you should seek Urgently Needed Services condition. from a licensed medical professional wherever you are located. PacifiCare provides twenty-four (24) hour access to request authorization for out-of-area care.You can You, or someone else on your behalf, must notify also request authorization by calling the PacifiCare PacifiCare within twenty-four (24) hours, or as soon as Out-of-Area Unit during regular business hours reasonably possible, after the initial receipt of Urgently (8 a.m. — 5 p.m., MST) at 1-800-762-8456. Needed Services. When you call, please be prepared to give a description of the Urgently Needed Services that you received. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. fl I " Section Three - Emergency and Urgently Needed Services ,, �t 'O4 fb Ott Y .S ,",5t g4 international Emergency and Urgently Needed Services Always,Rementber If you are out of the country and require Urgently Emergency Services:Following receipttof EmenJenCy Needed Services, you should still, if possible, call your Services,you, or someone on youron y0ur,b$41.1,must notify ' PacifiCare or your Primary Lam i ,_ ,within 24 Primary Care Physician or PacifiCare.Just follow the same instructions outlined above. If you are out of the hours,or as soon as reasonably possibtwafter country and experience an Emergency Medical initially receiving these services =, Condition, either use the available emergency response Urgently Needed Services:When you``r'equ system or go directly to the nearest hospital emergency Urgently Needed Services,you should, if possible,tall room. Following receipt of Emergency Services, please (or have someone call on your behalf}your Primal- notify notify your Primary Care Physician or PacifiCare within Care'PFiysician. If you are unable to contact your twenty-four (24) hours, or as soon as reasonably Primary Care Physician attdyou,teFeive medical or possible, after initially receiving these services. Hospital Services,you musinotihiPiaSere within Notes: 24 hours or as soon es reasonably�ible f ni ly . receivingtheses tices, •„•,,t t".•11,-•.,ts In addition to our standard coverage for Emergency •• t ' ` ' xz`i` IC. '1,3 w'; Services and Urgently Needed Services, follow-up care Copayments =S•� t t V.1'41- to Emergency Services received outside the HMO There are two Copaymentl = , t,l^mtergenty Service Area are covered to the maximum Limits as Services.The higherCopayreeh' ilBwheft described in your Schedule of Benefits. services are obtained in a hospttelw z envy room, Under certain circumstances, you may need to initially , the lower Copayment=applies i t, , k=',c#rz= pay for your Emergency or Urgently Needed Services. If Services are obtained in a physicia outs.2 .. this is necessary, please pay for such services and then normal business,hours of #,urgent' re facile= advantage your `,to " yew Primary Care Physician's office when you,,have a.choice.Please keep all receipts and copies of relevant medical Y documentation.You will need these to be properly refer to you Schedule of Benefits for tht applicable reimbursed. For more information on submitting claims Copayments for these-services to PacifiCare, please refer to page Section Six, if a Member is admitted'as'an inpatienttoa' l" { Payment Responsibility, of this Combined Evidence of from urgent care or the emergentist ,fhe 1 ''-' Coverage and Disclosure Form. Or emergency Cdpaytttent`f8 imails xR ` °">`' In addition to our standard coverage for Emergency = =x Services and Urgently Needed Services, follow-up care to Emergency Services received outside the HMO Service Area are covered to the maximum Limits as described in your Schedule of Benefits. Ask the out-of- area Provider to send the bill directly to PacifiCare Customer Service Department at P.O. Box 6770, Englewood, CO 80155. If the Provider demands payment at the time of service, PacifiCare of will reimburse you, less Copayments. 10 Section Four - Changing Your Doctor Changing Your Doctor PacifiCare will also notify the Member in the event that the agreement terminates between PacifiCare and the Member's Primary Care Physician. If this occurs, • How To Change Your Primary Care Physician PacifiCare will make a good faith effort to provide forty- five (45) days notice of the termination. PacifiCare will • When We Change Your Primary Care Physician also assign the Member a new Primary Care Physician. If the Member would like to select a different Primary Care Physician, he or she may do so by contacting our • When Doctors Are Terminated By PacifiCare Customer Service department. Upon the effective date There may come a time when you want or need to of transfer, the Member can begin receiving services change your Primary Care Physician. This section from his or her new Primary Care Physician. explains how to make this change, as well as how we Please note: Except for Emergency and Urgently Needed continue your care. Services, once an effective date with your new Primary Care Physician has been established, a Member must Changing Your Primary Care Physician use his or her new Primary Care Physician to authorize When you want to change doctors, you should contact all services and treatments.Receiving services elsewhere our Customer Service department. PacifiCare will will result in PacifiCare's denial of benefit coverage. approve your request if the Primary Care Physician you've selected is participating with PacifiCare and is Continuing Care With a Terminated Physician accepting new patients. You may be eligible to continue receiving care from a The change will take effect on the first day of the terminated Physician. The care must by Medically following month. To transfer your records, contact your Necessary. The cause of termination by PacifiCare also former Primary Care Physician and follow his/her has to be for a reason other than a medical disciplinary procedures. Remember that any specialist Physician cause, fraud or any criminal activity. referral must be reissued by your new Primary Care Continued care from the terminated Physician may be Physician.You must contact him/her before you received provided for an acute or serious Chronic Condition for further specialist care. up to sixty(60) days, or a longer period until you can be safely transferred to another Provider. Continued care When We Change Your Primary Care Physician from a terminated Physician may be provided if you have a Under special circumstances, PacifiCare may require that high-risk pregnancy or a pregnancy in the third trimester. a Member change his or her Primary Care Physician. Care may be extended through completed treatment of Generally, this happens at the request of the Primary pregnancy-related and postpartum conditions, or until Care Physician after a material detrimental change in its your care can be safely provided by another Physician. If relationship with a Member. If this occurs, we will you are receiving treatment for any of these conditions, transfer the Member to another Primary Care Physician, contact our Customer Service department.You can provided he or she is medically able request permission to continue being treated by this Physician beyond the termination date. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. ID Section Four - Changing Your Doctorb. PacifiCare must preauthorize or coordinate services for v r continued care. If you have any questions, want to What is PBC ta1 "!i .Misnagsment Program? appeal a denial, or would like a copy of PacifiCare's PacifiCare has licensed registercd'nurses who, in Continuity of Care Policy, call our Customer Service collaboration with the tvtem6er,Members family and department. (To learn more about appealing a denial, the Member's Participating Medical Group help arrange see Section Eight, Overseeing Your Health Care.) care for PacifiCare Members experiencing a major illness or recurring hospitalizations.Case Management is a collaborative process that assesses, plans, Continuity of Care for new Members implements, coordinates, monitors and evaluates Under certain circumstances, new Members of options to meet an individual's health care needs based PacifiCare may be able to temporarily continue on the health care benefits and available resources. receiving services from a Non-Participating Provider. This short-term coverage is intended for new Members who are experiencing an acute episode of care while making the transition to PacifiCare. For more detail,see Section One,Getting Started. Section Five - Your Medical Benefits Your Medical Benefits With the exception of Emergency or Urgently Needed Services, a Member will only be admitted to acute care, Subacute Care, transitional • Inpatient Benefits; Outpatient Benefits inpatient care and Skilled Nursing Care facilities when authorized by PacifiCare. • Exclusions and Limitations 1. Alcohol, Drug, or Other Substance Abuse Detoxification-Detoxification is the medical • Other Terms of Your Medical Coverage treatment of withdrawal from alcohol, drug or other substance addiction. Treatment in an acute care setting is covered for the acute stage of alcohol, drug • Terms and Definitions or other substance abuse withdrawal when medical r, occur or are highly complications probable. This section explains your medical benefits, including p y what is and isn't covered by PacifiCare. You can find Detoxification is initially covered up to forty-eight some helpful definitions in the back of this publication. (48) hours and extended when Medically Necessary. For any Copayments that may be associated with a Methadone treatment for detoxification is not benefit,you should refer to your Schedule of Benefits. covered. Rehabilitation for substance abuse or Your Schedule of Benefits is explained in Section Six, addiction is covered at a facility designated and Payment Responsibility. authorized by PacifiCare. Inpatient services are those services provided to members who reside for the The benefits described in Section Five will not be course of their treatment program at the program site. Covered Services unless they are determined to be Medically Necessary by PacifiCare and are provided or Not Covered: arranged by Member's Primary Care Physician or • Rapid anesthesia opiate detoxification authorized by PacifiCare. PacifiCare may determine Medical Necessity by using precertification programs • Services which are not Medically Necessary for the and criteria as deemed appropriate by PacifiCare. Such treatment of Substance Abuse disorders programs and criteria are reviewed and updated from • Services that are required by a court order as a time to time. See Section Ten, Definitions, PacifiCare part of parole or probation, or instead of Criteria for further information. Through the incarceration, which are not Medically Necessary. precertification process, PacifiCare may encourage that certain services be directed to, and performed at, the • Methadone maintenance or treatment. most cost-effective setting. Covered benefits under your 2. Blood and Blood Products—Blood and Blood PacifiCare Health Plan are determined and interpreted Products are covered. Autologous (self donated), in accordance with (i) the Schedule of Benefits, (ii) the donor-directed, and donor-designated blood terms and conditions set forth in this Group Agreement, processing costs are Limited to blood collected for a and (iii) the actual language of the Colorado insurance scheduled procedure. Coverage includes wound laws regarding the specific mandated benefits. healing products that require preauthorization and meet criteria established by PacifiCare. Your Medical Benefits 3. Bloodless Surgery—Surgical procedures I. INPATIENT BENEFITS performed without blood transfusions or blood These benefits are provided when authorized or products, including Rho(D) Immune Globulin, for arranged by the Member's Primary Care Physician Members who object to such transfusion on or PacifiCare. All services must be Medically religious grounds are covered only when available Necessary as defined in this Combined Evidence of from a Participating Provider. Coverage and Disclosure Form. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. Section Five - Your Medical Benefits . +, y, 4. Bone Marrow and Stem Cell Transplants- a condition not related to the terminal illness, Non-Experimental/Non-Investigational Autologous PacifiCare will continue to pay for all Covered and Allogeneic bone marrow and stem cell Services. transplants are covered. The testing of immediate Hospice services include skilled nursing services, blood relatives to determine the compatibility of certified home health aid services and homemaker bone marrow and stem cells is Limited to immediate services under the supervision of a qualified blood relatives who are sisters, brothers, parents, registered nurse; bereavement services; social and natural children. The testing for compatible services/counseling services; medical direction; unrelated donors, and costs for computerized volunteer services; pharmaceuticals, medical national and international searches for unrelated equipment and supplies that are reasonable and allogeneic bone marrow or stem cell donors necessary for the palliation and management of the conducted through a registry, are covered when the terminal illness and related conditions; respiratory Member is the intended recipient. A PacifiCare services and inhalation therapy; physical and Preferred Transplant Network facility center occupational therapy and speech-language approved by PacifiCare must conduct the pathology services for purposes of symptom control, computerized searches. There is no dollar Limitation or to enable the Member to maintain activities of for Medically Necessary donor related clinical daily living and basic functional skills. transplant services once a donor is identified. Inpatient Hospice services are provided in an 5. Hospice Services—Hospice services are covered for appropriately licensed Hospice facility when the Members with a terminal illness, defined as a Member's interdisciplinary team has determined medical condition resulting in a prognosis of life of that the Member's care cannot be managed at home six months or less, if the disease follows its natural because of acute complications or when it is course,who alone in conjunction with family or necessary to relieve the family members or other Members has voluntarily requested admission. persons caring for the Member ("respite care"). Hospice services are provided as determined by the Respite care is Limited to an occasional basis and to plan of care developed by the Member's no more than five (5) consecutive days at a time. interdisciplinary team, which includes, but is not Limited to, the Member, the Member's Primary Care Not Covered: Physician, a registered nurse, a social worker and a • Services and supplies related to the terminal spiritual caregiver. Hospice services are provided in condition that are not a part of Hospice care an appropriately licensed Hospice facility when the Member's interdisciplinary team has determined • Services of a caregiver other than as provided by that the Member's care cannot be managed at home the Hospice agency as part of this benefit, because of acute complications or the temporary including, but not Limited to, someone who lives absence of a capable primary caregiver. The in the Member's home or someone who is a coverage of these services will not prevent PacifiCare relative of the Member from re-evaluating the Member's status and • Domestic or housekeeping services that are subsequently redetermining the status of care. unrelated to the Member's care The Member must choose to receive Hospice care • Services that provide a protective environment instead of standard benefits for the terminal illness. where no professional skill is required, such as It is important for the Member to realize that companionship or sitter services Hospice care is for terminal conditions and that the Hospice benefit structure is based upon the concept • Services not directly related to the medical care that those Members receiving Hospice care choose of the Member including, but not Limited to: not to avail themselves of other health care benefits —Estate planning, drafting of will, or other for care related to the terminal condition.While legal services receiving Hospice care, in the Member's home or in a Hospice facility, if a Member requires treatment for —Funeral counseling or funeral arrangements or services a Section Five - Your Medical Benefits —Food services such as Meals on Wheels • Two courses of inpatient or outpatient treatment for each Member during his/her lifetime. —Transportation services, except covered benefits for necessary professional ambulance services • Services related to the treatment of alcoholism are covered at the designated facility and will be subject 6. Inpatient Hospital Benefits/Acute Care—Medically Necessary inpatient Hospital Services authorized by to the Limits described in your Schedule of Benefits. PacifiCare or a Participating Provider are covered, • Services not related to the treatment of alcoholism including,but not Limited to: semi-private room, are covered at the designated and will be subject nursing and other licensed health professionals, to the Limits described in your Schedule of intensive care, operating room, recovery room, Benefits or until the Participating Provider has laboratory, and professional charges by the hospital determined satisfactory completion of the pathologist or radiologist and other miscellaneous inpatient program, whichever is less. hospital charges for Medically Necessary care and 9. Inpatient Rehabilitation Care—Rehabilitation treatment. Services that must be provided in an inpatient Not Covered: rehabilitation facility are covered. Inpatient • Take-home drugs rehabilitation consists of the combined and • Take-home supplies coordinated use of medical, social, educational and vocational measures for training or retraining Implants—Coverage under this benefit also include individuals disabled by disease or injury. The goal of devices that are Medically Necessary and must be these services is for the disabled Member to obtain implanted by surgical means. The may include his or her highest level of functional ability. pacemakers, replacement joints, and permanent Rehabilitation Services include, but are not Limited replacement lenses following cataract surgery. to physical, occupational, and speech therapy. Please Not Covered: refer to III., Exclusion and Limitations of Benefits, of • Experimental/investigational or cosmetic implants this section for the applicable benefit Limitations. • Penile implants This benefit does not include drug, alcohol, or other 7. Inpatient Physician and Specialist Care—Services substance abuse rehabilitation. from Physicians, including specialists and other 10. Mastectomy, Breast Reconstruction After licensed health professionals, or upon referral from, Mastectomy and Complications From PacifiCare or a Participating Provider are covered Mastectomy-Medically Necessary mastectomy and while the Member is hospitalized as an inpatient. A lymph node dissection are covered, including specialist is a licensed health care professional with Prosthetic devices and/or reconstructive surgery to advanced training in an area of medicine or surgery restore and achieve symmetry for the Member 8. Inpatient Alcohol-Drug Rehabilitation Care- incident to the mastectomy. The length of a hospital Alcohol-drug inpatient Rehabilitation Services are stay is determined by the attending Physician and covered at the participating facility designated by surgeon in consultation with the Member, consistent PacifiCare when Medically Necessary. Inpatient services with sound clinical principles and processes. are those services provided to Members who reside for Medical treatment for any complications from a a course of their treatment program at the program mastectomy, including lymphedema, is covered. site.A Medically Necessary course of treatment may be Coverage of reconstructive breast surgery as either inpatient or outpatient or a combination of described above shall include: both if authorized by the PacifiCare participating • Reconstruction of the breast on which the program site. mastectomy was performed Limits: • Surgery and reconstruction of the unaffected • One inpatient or outpatient course of treatment breast to produce a symmetrical appearance per contact year. • Surgically implanted breast prostheses Questions about your benefits? Call the Customer Service department at 1-800-877-9777. ID Section Five - Your Medical Benefits • Coverage of physical complications resulting from 12. Mental Health Services—Medically Necessary the mastectomy, including lymphedemas inpatient mental health services are covered as described under this subsection. In the case of basic Coverage for the cost of surgical bras, including coverage benefits based upon either confinement as external prostheses, in lieu of reconstructive breast an inpatient or partial hospitalization in a hospital surgery will be covered to the extent preauthorized. or psychiatric hospital licensed by the Department Surgical bras including external prostheses are of Public Health and Environment, the period of subject applicable Limits as outlined in the Schedule confinement for which benefits are payable shall be of Benefits. at least forty-five (45) days for inpatient care or 11. Maternity Care—Prenatal and maternity care ninety (90) days for partial hospitalization in any services are covered, including labor, delivery and one twelve (12)-month benefit period. "Partial recovery room charges, delivery by cesarean section, hospitalization"under this benefit is defined as treatment of miscarriage, complications of treatment for at least three (3) hours, but not more pregnancy or childbirth, and complete hospital than twelve (12) hours in a twenty-four (24)-hour postpartum care and services. Educational courses period. For purposes of computing a period for on lactation, childcare and/or prepared childbirth which benefits are payable, each two days of partial classes are not covered. hospitalization shall reduce by one day the forty-five days available for inpatient care, and each day of • Nurse midwife services are covered only when provided through a Participating OB/GYN. inpatient care shall reduce by two days the ninety days available for partial hospitalization care. • Home deliveries are not covered. 13. Newborn Care—Postnatal Hospital Services are • Normal deliveries outside the PacifiCare HMO covered, including circumcision (if desired and Service Area are not covered. Normal delivery is performed in the Hospital) and special care nursery generally considered to be within five (5) weeks of the expected due date. 14. Organ Procurement Transplant and Transplant Services—Non-Experimental and non-Investigational • Any procedure intended solely for sex organ transplants and transplant services are determination is not covered. covered when the recipient is a Member and the • A minimum forty-eight (48)-hour inpatient stay for transplant is performed at a Preferred Transplant normal vaginal delivery and a minimum ninety-six Network facility. Covered Services for living donors (96)-hour inpatient stay following delivery by are Limited to Medically Necessary clinical services cesarean section are covered. Coverage for once a donor is identified. Transportation and other inpatient hospital care may be for a time period non-clinical expenses of the living donor are less than the minimum hours if the decision for an excluded, and are the responsibility of the Member, earlier discharge of the mother and newborn is who is the recipient of the transplant. (See the made by the treating Physician in consultation definition for"Regional Organ Procurement with the mother. In addition, if the mother and Agency") Coverage under this benefit is Limited to newborn are discharged prior to the forty-eight the following: (48)-or ninety-six (96)-hour minimum time • Cornea transplants periods, a post-discharge follow-up visit for the • mother and newborn will be provided within Heart transplants forty-eight (48) hours of discharge,when • Combined heart/lung transplants prescribed by the treating Physician. Mothers with • Kidney transplants newborns released from the hospital one day early based on these guidelines are entitled to one (1) • Combined kidney/pancreas transplants visit by a registered nurse. • Liver transplants for children under age eighteen (18) with biliary atresia or other end-stage liver disease a Section Five - Your Medical Benefits • Lung transplants The following transplants are not covered: • Skin grafts (not to include skin grafts performed • Pancreas only for cosmetic purposes) • Multiple organs (except as listed as covered in this Services, materials or expenses related to liver Group Agreement) transplants for Members age eighteen (18) and over, • Non-human heart transplants, combined heart/lung transplants, lung transplants and combined kidney/pancreas • Artificial organs and their implantation transplants are excluded during the first six (6) • All other transplants not listed in this Group months after the Effective Date of Coverage under Agreement as covered benefits the plan if the Member has been a candidate for such transplant or if the condition resulting in the Transplant Guidelines— The following need for such transplant is one for which the guidelines apply to transplants: Member incurred charges, received medical • Any request for a covered transplant, except treatment, consulted a health professional or took cornea transplants and skin grafts, must be made prescription drugs during the six-month period in writing to the PacifiCare medical director. immediately preceding the Effective Date of Coverage. This Limitation is subject to credit for • The PacifiCare medical director will issue a written Creditable Coverage as required by the Health response within thirty-one (31) days. Insurance Portability and Accountability Act of 1996. • Written preauthorization of any covered transplant Transplant Criteria: benefit must be given prior to initiation of services. • All necessary services for covered transplants at • PacifiCare will not cover services received prior to designated transplant facilities. Services are issuance of its written preauthorization. covered to the extent preauthorized based on 15. Reconstructive Surgery—Plastic, reconstructive or medical criteria established by PacifiCare and cosmetic surgery, including skin lesions that are provided only upon referral by the Member's removed for cosmetic purposes are not covered. Participating Provider. Covered services include Exceptions for reconstructive surgery must be the directly related, reasonable medical and approved in writing by PacifiCare and will be hospital expenses of the donor. considered only when performed primarily to • Referrals are subject to determination by a improve the physical health and function of the Participating Provider that the service referred patient. Any non-Covered Services received prior to represents the preferred method of treatment. written approval will not be reimbursed by PacifiCare and will be the financial responsibility of • Coverage will be restricted to transplant services the Member. provided to the donor and recipient only when the recipient is a PacifiCare Member. Limits: • Neither PacifiCare nor its Participating Providers The expenses of plastic, reconstructive or cosmetic will be responsible to furnish a donor or to assure surgery will be covered if the surgery is performed the availability or capacity of designated facilities. as soon as medically feasible and it is Medically Necessary for either of the following reasons: • If, after referral, the Participating Provider determines that the Member does not satisfy its • To repair an injury sustained while the Member is criteria for the service involved, PacifiCare's a Member of PacifiCare and repair is initiated obligation is Limited to paying for Covered within one (1) year following the injury. Services provided prior to such determination. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. gel t Section Five - Your Medical Benefits . t. :. • The correction of a congenital defect that coverage in a Skilled Nursing Facility, the Member substantially impairs major organ function, or must either be out of all Skilled Nursing Facilities leads to a progressive deterioration of the health for sixty (60) consecutive days, or if the Member of a covered child. remains in a Skilled Nursing Facility, then the Member must not have received Skilled Nursing Not Covered: Care or Skilled Rehabilitation Care for sixty(60) • Reconstructive nasal surgery; including consecutive days. rhinoplasty. Skilled Nursing Facility Limits: • Revisions of a procedure performed for cosmetic • During each contract year, up to the Limits as purposes, including but not Limited to breast described in your Schedule of Benefits of these augmentation. prescribed services at approved facilities • Surgical treatment for obesity; except for cases that meet the standards of Medically Necessary • The Member's status may also be reevaluated and, care as accepted by PacifiCare for cases of morbid if it is determined that the status of the care is no longer acute, it may not be covered obesity and that are then preauthorized in writing by PacifiCare's medical director. Subacute Care Limits: • Reconstructive surgery that does not correct or • Up to sixty (60) days per contract year at an materially improve a physiological function. approved Subacute Care facility 16. Skilled Nursing/Subacute and Transitional Care— Not Covered: , Medically Necessary Skilled Nursing Care and Skilled • Custodial Care Rehabilitation Care are covered only on the order of the Participating Primary Care Physician when • Maintenance care approved by the PacifiCare medical director. Skilled • Convalescent care Nursing Facility; extended care facility; and comprehensive rehabilitation facility or unit services • Care for Chronic Conditions are covered as follows: • Private duty nursing • Only on order of the participating Primary Care • Personal comfort or convenience items, such as Physician when approved by the PacifiCare television or telephone medical director, and • Private room, except when Medically Necessary • Only when significant measurable improvement can be anticipated. The Member's Primary Care 17. Voluntary Termination of Pregnancy— Physician and PacifiCare will determine where the Costs related to an elective abortion. Skilled Nursing Care and Skilled Rehabilitation Limit: Care will be provided. Two (2) elective abortions per Member per lifetime. Skilled Nursing Facility room and board charges are This Limitation is a combined maximum under covered up to the Limits as described in your inpatient and outpatient services. No more than two Schedule of Benefits. Days spent out of a Skilled (2) elective abortions will be covered in an inpatient Nursing Facility when transferred to an acute or outpatient setting. hospital setting are not counted toward the to the Limits as described in your Schedule of Benefits when the Member is transferred back to a Skilled Nursing Facility. Such days spent in an acute hospital setting also do not count toward renewing the to the Limits as described in your Schedule of Benefits. In order to renew the room and board a t4 Section Five - Your Medical Benefits J II. OUTPATIENT BENEFITS Members must have coverage under the Outpatient The following benefits are available on an Prescription Drug supplemental benefit for medications to be covered. The outpatient outpatient basis and must be authorized or prescription drug benefit is covered only if it has arranged by your Primary Care Physician or been selected by your employer as part of the authorized by PacifiCare. All services must be subscribing group's plan. Medically Necessary as defined in this Combined Evidence of Coverage and Disclosure Form. 6. Blood and Blood Products-Blood and Blood Products are covered.Autologous (self donated), 1. Alcohol, Drug, or Other Substance Abuse donor-directed, and donor-designated blood Detoxification-Services for detoxification are processing costs are Limited to blood collected for a Limited to removal of the toxic substance or scheduled procedure. Coverage includes wound substances from the system, including diagnosis, evaluation, healing products that require preauthorization and and care of emergency or acute medical meet criteria established by PacifiCare. conditions. 7. Bloodless Surgery-Please refer to the benefit 2. Allergy Testing- Services and supplies are covered described above under Inpatient Benefits for for the determination of the appropriate course of Bloodless Surgery. Outpatient services Copayments allergy treatment. or coinsurance apply for any services received on an 3. Allergy Treatment—Services for the treatment of outpatient basis. allergies are covered according to an established 8. Chemotherapy—Outpatient injectable treatment plan. chemotherapy, when oral administration of 4. Ambulance—Coverage includes Medically prescribed medication is not medically appropriate Necessary air or ground ambulance service when is covered. Included in this benefit are Medically the destination is the nearest acute care facility, for Necessary services and materials. any of the following: 9. Clinics—Coverage to include: • Movement from the place where the Member was Pain Clinics—Outpatient services that must be injured in an accident or became ill to a facility for requested in writing by the Primary Care Physician. treatment This request must include supporting second • If Medically Necessary care is not available at a opinions from two participating specialists, one of hospital or Hospice, movement to the nearest whom is licensed mental health Provider.Any hospital where the Medically Necessary care may psychotherapy and/or physical therapy sessions as a be given part of the program will be counted toward the pain • When ordered by the Member's attending clinics listed below Physician, movement from the hospital to another Limits: facility or from the Member's home for Emergency • Treatment may not be started prior to written situations authorization from PacifiCare Not Covered: • In no event will PacifiCare pay more than $2,000 Ambulance service provided due to the absence of toward the covered charges to a pain clinic, another medically appropriate form of transportation center, or facility per Chronic Condition, per or for the Member's convenience. Member, per lifetime 5. Attention Deficit/Hyperactivity Disorder— Not Covered: The medical management of Attention Deficit/ • Convenience items and meals Hyperactivity Disorder (ADHD) is covered, including the diagnostic evaluation and laboratory monitoring • Pain centers, facilities, clinics, or centers involved of prescribed drugs. This benefit does not include in treatment of pain are not covered for inpatient non-crisis mental health counseling, or behavior care modification programs. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. fl it IL Section Five - Your Medical Benefits :, Lymphedema Clinics—Medically Necessary services 13. Diabetic and Dietary Management and for the treatment of complications of breast Treatment—Coverage includes dietary counseling, reconstruction following mastectomy. medication management, and self-management skills instruction for Members diagnosed with diabetes or Clinics not covered: those with special management needs. The diabetes • Disassociated disorders outpatient self-management training and education covered under this benefit will be provided by • Eating disorders appropriately licensed or registered health care • Headaches professionals. These services must be provided - under the direction of and prescribed by a • Lactation Participating Provider. The dietary counseling • Long-term brain injury covered under this benefit consists of one dietary • Post-traumatic stress counseling session when regulation of the diet is a significant part of the treatment program for a • Premenstrual syndrome (PMS) pathological state or illness. • Senior services Limit: • Stress management One visit per contract year 10. Cochlear Implant Device-An implantable Not Covered: cochlear device for bilateral, profoundly hearing impaired individuals who are not benefited from Dietary counseling for obesity, including weight conventional amplification (hearing aids) is covered. reduction programs Coverage is for Members at least eighteen (18) years 14. Diabetic Self-Management Items—PacifiCare of age who have either profound bilateral sensory designated equipment and supplies for the hearing loss or for prelingual Members with management and treatment of Type 1, Type 2 and minimal speech perception under the best hearing gestational diabetes are covered, based upon aided condition. Please also refer to Cochlear PacifiCare's clinical criteria, including but not Implant Medical and Surgical Services below. necessarily Limited to: blood glucose monitors; blood glucose monitors designed to assist the 11. The implantation p Implant of a cochlear chl and Surgical Services— visually impaired; blood glucose test strips; lancets pe hearing a impairedindividualsdevu for bilateral,o and ketone urine test strips. The Member's profoundly r who are Participating Provider will prescribe PacifiCare not benefited from conventional amplification(hedesignated lancets, blood glucose test strips and based eng criteria r t) is coestablished vered. Coverage by Pafor this includes benefit, ketone urine test strips to be filled at a PacifiCare services on eete d pprt the Pepping andCare, Participating pharmacy. Insulin pumps and specific services needed to support mapping functional assessment of the cochlear device at the supplies; podiatry services and devices to prevent or autreat diabetes related complications may be covered of speech Participating aye Provider. (For ra explanation if PacifiCare Criteria is met. See 16., "Durable of speech therapy benefits, please refer to 33., "Outpatient Medical Rehabilitation Therapy.") Medical Equipment (Rental, Purchase or Repair)," for the applicable Limitations. 12. Dental Treatment Anesthesia—See 32., "Oral Surgery and Dental Services: Dental Treatment Members must have coverage under the Outpatient Anesthesia for Dependent Children." Prescription Drug supplemental benefit for insulin, insulin syringes, glucagon, and other diabetic medications to be covered. The outpatient prescription drug benefit is covered only if it has been selected by your employer as part of the subscribing group's plan. 20 Section Five - Your Medical Benefits 15. Dialysis—Acute hemodialysis services for chronic • Nebulizers renal disease and for kidney transplants, including . Oxygen and related equipment training and expendable medical supplies are covered. For chronic hemodialysis, application for • Positive airway pressure devices (C-PAP) (Bi-PAP) Medicare Part A and Part B coverage must be made. • Peak flow meters Chronic dialysis (peritoneal or hemodialysis) must be authorized by PacifiCare, and provided by a • Suction machines Participating Provider. • Traction equipment 16. Durable Medical Equipment (Rental, Purchase • Ventilators or Repair)—Durable Medical Equipment is covered when it is designed to assist in the treatment of an • Wheelchairs injury or illness of the Member, and the equipment Replacements, repairs and adjustments to Durable is primarily for use in the home. Durable Medical Medical Equipment are Limited to normal wear and Equipment is medical equipment that can exist for a tear or because of a significant change in the reasonable period of time without significant Member's physical condition. PacifiCare has the deterioration. Durable Medical Equipment, including option to repair or replace Durable Medical oxygen, must be authorized for a specified period of Equipment items. time in advance in writing by PacifiCare. The authorization will specify whether purchase or rental Insulin pumps are covered to the extent is approved.After the initial authorized period of preauthorized based on criteria established by coverage, continuation is subject to written PacifiCare. Insulin pumps are nohsubject to the reauthorization in advance for another specified Durable Medical Equipment maximum. period. The following Durable Medical Equipment is The following equipment and accessories are not covered based on criteria established by PacifiCare. covered: The criteria may include that the equipment must enable a patient who otherwise would have to be • Non-Medically Necessary optional attachments and treated in an acute care or rehabilitative facility to be modifications to Durable Medical Equipment for cared for outside such an institution: the comfort or convenience of the Member, • Apnea monitors • accessories for portability or travel, • Bilirubin lights or blankets • a second piece of equipment with or without additional accessories that is for the same or • Bone stimulators similar medical purpose as existing equipment, • Continuous passive motion machines (CPM) • and home and car remodeling. • Eye prosthetics Limits: • Feeding pumps • Please refer to your Schedule of Benefits for the • Glucose meters applicable annual dollar maximum for this benefit • Hospital beds • One (1) glucose meter per Member per lifetime • Insulin pump supplies (including cartridges, • One (1) peak flow meter per Member per lifetime extension tubing, batteries, infusion sets, and • At PacifiCare's discretion, the equipment may be customary dressings provided by the pump rented or purchased supplier to secure infusion sets) • Lymphedema pumps Questions about your benefits? Call the Customer Service department at 1-800-877-9777. ED 4 it Section Five - Your Medical Benefits st• :• Coverage for orthopedic braces, to include the Not Covered: fitting and adjustment of covered braces and repair . Pregnancy test kits and ovulation kits or replacement of covered braces unless necessitated by misuse. PacifiCare may replace or • Reversal of voluntary sterilization and related repair a brace at its discretion. Orthopedic braces procedures are covered when prescribed by a participating 18. Footwear—Coverage for podiatric shoe inserts for Physician and obtained through a designated persons with diabetes with historical ulcers or Provider and that meet all of the following criteria: presence of pre-ulcerous lesions and documented a. are required to support or correct a defect of neuropathy. In addition, for Members with form or function or a permanently non- persistent plantar facitis, or documented neuropathy functioning or malfunctioning body part, and who have documented failure of commercial over- the-counter inserts when used as a trial prior to, or b. are medically approved and in general use for in lieu of surgery. the specific condition, and Limit: c. are primarily and customarily used either as an alternative to surgery or to speed recovery of a Refer to your Schedule of Benefits for applicable patient who has had surgery, and Limitations under this benefit. Each $1 paid for podiatric shoe inserts shall reduce by$1 the amount d. can withstand repeated use, and are not available for orthopedic braces, as listed above generally useful to a patient in the absence of under 16., "Durable Medical Equipment (Rental, an injury or illness. Purchase or Repair)." Limit: Not Covered: Refer to your Schedule of Benefits for applicable Orthotic devices for podiatric use and arch support Limitations under this benefit. Each $1 paid for orthopedic braces shall reduce by$1 the amount 19. Health Education Services-PacifiCare makes health available for podiatric shoe inserts as listed below in and wellness information available to Members. For 18., "Footwear." any wellness program, call the PacifiCare Customer Service department at 1-800-877-9777, or they can 17. Family Planning-Coverage for voluntary family be accessed at www.pacificaze.com. planning to include: StopSmokine Program: • Family planning counseling PacifiCare supports the Colorado Department of • Information on birth control Health Tobacco Cessation Program. This program, • IUDs and implantable contraceptive devices, The Colorado Quinine, is a self-directed, self-paced including their insertion and removal program that includes telephonic support for the person choosing to quit tobacco use. The program • Diaphragms and cervical caps, including their is designed to be customized to each individual's fitting needs and readiness to quit. The components of the • Costs related to an elective abortion, with a Limit intervention build the participant's self confidence of two (2) elective abortions per Member per in their ability to quit smoking or to quit using other lifetime. This Limitation is a combined maximum tobacco products through goal oriented lifestyle under inpatient and outpatient services. No more modification. PacifiCare Members who are enrolled than two (2) elective abortions will be covered in in the program and have coverage under the an inpatient or outpatient setting. Outpatient Prescription Drug benefit are be eligible for Nicotine replacement therapy aids (NRT). • We- and post-abortion counseling Applicable copayment(s) will apply for NRT • Surgical procedures causing permanent coverage under this program. For more information, sterilization, including vasectomies and tubal or to enroll in the Tobacco Cessation program, ligations. please call 1-800-639-QUIT. There is no charge for this program. • Section Five - Your Medical Benefits 20. Home Health Care—Coverage includes Skilled 21. Hospice Services—Hospice services are covered Nursing Care at home when prescribed by a for Members with a terminal illness, defined as a Participating Provider and deemed Medically medical condition resulting in a prognosis of life of Necessary for treatment of a covered illness or six months or less, if the disease follows its natural injury. Home Health services are covered only when course,who alone in conjunction with family or the following two conditions are met Members has voluntarily requested admission. Hospice simultaneously: services are provided pursuant to the plan of care • The patient's Participating Provider prescribes a developed by the Member's interdisciplinary team, specific home care plan to be provided and sets which includes, but is not Limited to, the Member, forth the length of time deemed Medically the Member's Primary Care Physician, a registered nurse, a social worker and a spiritual caregiver. The Necessary to complete the treatment plan. coverage of these services will not prevent PacifiCare • This plan must be approved in writing by from re-evaluating the Member's status and PacifiCare and periodically reviewed and subsequently redetermining the status of care. reauthorized by PacifiCare or an agent acting on Hospice services include skilled nursing services, PacifiCare's behalf; and the services are provided by a Medicare certified home health agency certified home health aid services and homemaker selected or approved by PacifiCare. services under the supervision of a qualified registered nurse; bereavement services; social Not Covered: services/counseling services; medical direction; • Custodial and maintenance care volunteer services; pharmaceuticals, medical equipment and supplies that are Reasonable and • Homemaker services necessary for the palliation and management of the Limits: terminal illness and related conditions; respiratory services and inhalation therapy; physical and • After the period of time specified in the prescribed occupational therapy and speech-language treatment plan, continuation of care depends on a pathology services for purposes of symptom control, reevaluation of the patient's status for Medical or to enable the Member to maintain activities of Necessity. daily living and basic functional skills. • Therapy(Physical, Occupational, and/or Speech) Covered Hospice services are available in the home are covered as part of home health care only for on a twenty-four (24) hour basis when Medically treatment of acute conditions that are subject to Necessary, during periods of crisis, when a Member significant improvement within two (2) months requires continuous care to achieve palliation or of when treatment begins and the patient is management of acute medical symptoms. homebound. The number of visits are subject applicable Limits as outlined in II., "Outpatient Benefits," and in the Schedule of Benefits. • One-time training for a family member, household resident, or nonprofessional person employed by the patient or family. This training covers the services necessary to the custodial or maintenance levels of care. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. ID .• .. Section Five - Your Medical Benefits t, x Not Covered: —Food services such as Meals on Wheels • Services and supplies related to the terminal —Transportation services, except covered benefits condition that are not a part of Hospice care for necessary professional ambulance services • Services of a caregiver other than as provided by 22. Immunizations-Pediatric and adult the Hospice agency as part of this benefit, immunizations in accordance with the including, but not Limited to, someone who lives recommendations of the American Academy of in the Member's home or someone who is a Pediatrics and the Centers for Disease Control relative of the Member immunization guidelines. These recommendations • Domestic or housekeeping services that are are updated annually, and any changes that are not unrelated to the Member's care reflected in the table below,will be incorporated into the coverage offered by PacifiCare. • Services that provide a protective environment Routine boosters and immunizations must be where no professional skill is required, such as obtained through Member's Participating Primary companionship or sitter services Care Physician. • Services not directly related to the medical care of the Member including, but not Limited to: Work immunizations are not covered. -Estate planning, drafting of will, or other legal Immunizations recommended for travel by the Centers for Disease Control immunization services guidelines are covered. -Funeral counseling or funeral arrangements or services Covered Preventive Visits 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 prix. All Children • Immunizations. (Covered immunizations are listed at the end of this document.! • Immunization deficient children are not bound by"recommended ages -on immunization chart. . Age 0- 12 months • 1 newborn home visit during first week of life if newborn released froth hospital less than 48 hours after delivery. • 5 well-child visits' • 1PKU Age 13-35 months • 2 well-child visits Age 3-6 • 3 well-child visits Age 7- 12 • 3 welt-child visits Age 13- 18 • 1 age-appropriate health maintenance visit' every year • 1Td • Females (excluding women who have had a non-cancer related hysterectomy!: screening PAP smears not to exceed 1 per year • 1 hepatitis B vaccination if not given previously ')Well-child visit"means a visit to a primary care Provider that includes the following elements age appropriate physical exam(but not a complete physical exam unless this is age appropriate),history, anticipatory guidance and education(e.g..a ne family functioning and dynamics,injury prevention counseling,discuss dietary issues,review age appropriate behaviors,etc.),and growth and development assessment.For older children,this also includes safety and health education counseling. '"Age-appropriate health maintenance visit"means an exam which includes the following components:age appropriate physical exam Ibut not a complete physical exam unless this is age appropriate), history,anticipatory guidance and education le.g.,examine family functioning and dynamics,discuss dietary issues,review health promotion activities of the patient,etc.),and exercise and nutrition counseling(including(otate counseling for women of child bearing age). a Section Five - Your Medical Benefits Child Health Supervision Services Abbreviations: "Child health supervision services"are defined as DTP - diphtheria-tetanus-pertussis vaccine; those preventive services and immunizations required to be provided in basic and standard OPV — oral polio vaccine; health benefit plans, to Dependent children up to MMR — measles-mumps-rubella vaccine; age thirteen (13). Td — diphtheria-tetanus vaccine; DTaP — diphtheria-tetanus-acellular pertussis vaccine. Schedule of Recommended Immunizations Recommended Immunizations Comments Age Birth • Hepatitis B For infants born to mothers who are HBsAg-positive. Initial dose must be given within 12 hours.Also HBIG within 12 hours. 1 month • Hepatitis B To be given to children of HBsAg-positive mother. 2 months • DTP-HIB or Must check for immunosuppression prior to oral polio administration— DTP and HIB see special HIB schedule. May initiate Hepatitis B in HBsAg-negative • Polio(IPV or 0PVI* family. • Hepatitis B • Pneumococcal 4 months • DTP-HIB or May give all immunizations if given in different locations. DPT and HIB 6 -8 weeks minimum interval for oral polio. • Polio{IPV or 0PVI* • Hepatitis B • Pneumococcal 6 months • DTP-HIB or Note change -Total of polio remains the same.Third OPV given DTP and HIB at 6 months instead of 15 - 18 months. • Polio (IPV or OPVI* • Hepatitis B • Pneumococcal 12 months • Pneumococcal 12-18 months •Varicella It is unknown at this time whether chicken pox vaccine boosters will be needed and how often. Parents may choose instead to allow their children to catch the natural disease which provides lifelong immunity. 12-15 months • MMR Since 92% of children immunized against measles at 12- 14 months of age are protected, routine administration of measles vaccine is recommended from 12- 15 months.Tuberculin testing may be done during this visit. MMR is recommended over single virus vaccines. 15 months • HIB Any HIB may be used. 15-18 months • DTP, Polio May be given at 15-month or 18-month visit. DTaP may be used Questions about your benefits? Call the Customer Service department at 1-800-877-9777. ED Section Five - Your Medical Benefits ,., .v , t,, r= r''.-1''',',*/ ).;“":' "-7 24, l llo- *'l +ahttis i1 For high risk children. 18 years 4—6r yean5 •OTfa,Polio At or before school entry. `OTap may be used 11 -12 years •Hiepatitis B Adolescents who have not previously receive 3 doses of hepatitis B •Varicella vaccine should initiate or complete the series at this time. 1if not received earlier) 4—28'yaars ' • MMR A second dose should be give upon entry to elementary school or at any opportunity including entry to college. 12 years •Varicella For those children who have not had chicken pox by this age. 14-16 years old Repeat every 10 years throughout life. 'The ACIP recommend that the first two polio vaccinations be IPvs and the second two be ovum transplant procedures, surrogate parentage, OPVs.Schedules with all OPVs or IPVs are also safe and effective. Sources This table is based on the Jan-Dec 1999 Recommendations of the Advisory drug therapy for Infertility, and related costs of Committee on Immunization Practices and the American Academy of Family Physicians each are not covered. Benefits for child health supervision services shall be • The cost related to donor sperm and donor ova exempt from a deductible or dollar Limit provision.Any (collection, Copayment or coinsurance applicable to these benefits preparation, storage, etc.) l shall not exceed the Copayment or coinsurance • Procedures considered to be experimental/ applicable to a Physician visit. investigational 23. Infertility Services (Basic)—The Infertility services • Reversal of a sterilization procedure(s) is not a benefit is covered only if it has been selected by covered benefit. your employer as part of the subscribing group's Members must have coverage under the Outpatient plan. Please refer to the Schedule of Benefits for Prescription Drug supplemental benefit for specific coverage. The treatment of Infertility by a medications to be covered. The outpatient Participating Provider includes diagnosis, diagnostic prescription drug benefit is covered only if it has tests, and surgery by the Participating Physician. been selected by your employer as part of the Infertility is defined as either: 1) the presence of a subscribing group's plan. demonstrated condition diagnosed by a Participating 24. Infusion Therapy-Infusion therapy means the licensed Physician or surgeon as biologically therapeutic use of drugs or other substances, infertile, or 2) the inability to conceive or to carry a prepared or compounded, and administered by a pregnancy to a live birth after a year or more of Participating Provider, meeting the appropriate level regular sexual relations without contraception. of care, and given to a Member through a needle or Limit: catheter. Services must be provided in the Member's home or in a Participating infusion center. • Insemination Procedures are limited to six (6) cycles, per lifetime, unless the Member conceives, 25. Injectable Drugs (Outpatient Injectable in which case the benefit renews. Medications and Self Injectable Medications)- Outpatient injectable medications administered in Not Covered: the Physician's office (except insulin) are covered • In vitro fertilization (test tube babies), the Gamete when a part of the medical office visit. Self injectable Intrafallopian Transfer (G.I.F.T.) procedure, the medications (except insulin) are covered and Zygote Intrafallopian Transfer (Z.I.F.T.) procedure, subject to the applicable Copayment when the Artificial Reproductive Technology (A.R.T), other Member is trained in the administration of the a Section Five - Your Medical Benefits medication, and the medication has been prescribed 29. Mental Health Services—Services for Medically by a Participating Provider, and obtained at a Necessary outpatient mental health care for adults designated PacifiCare Participating Pharmacy as and children, are covered. The coverage under this authorized by PacifiCare.A Copayment will be benefit, and any coverage of services necessary to collected for up to a thirty(30)-day supply of fulfill the designated treatment program in addition medication, course of therapy or treatment of an to those services listed here, are based on Medical acute episode, whichever is shorter. No more than a Necessity as determined by the Participating thirty (30)-day supply will be dispensed at one time. Provider and are subject applicable Limits as A Copayment will also be collected when a self- outlined in the Schedule of Benefits. administered injectable is administered in the Physician office. Care for schizophrenia, schizoaffective disorder, bipolar affective disorder, major depressive disorder, Outpatient injectable medications, including self- specific obsessive-compulsive disorder, and panic injectables, must be obtained through a Participating disorder shall be covered as any other physical Provider and may require preauthorization. Insulin illness and will not be subject to the Limitations of is covered as a pharmacy benefit if you are covered Mental Health Services as described above. by an Outpatient Prescription Drug supplemental benefit. The outpatient prescription drug benefit is 30. OB/GYN Physician Care—See 38., "Physician covered only if it has been selected by your OB/GYN Care." employer as part of the subscribing group's plan. 31. Oral Surgery and Dental Services—Coverage for Oral surgery and certain medical service charges 26. Laboratory Services—Medically Necessary associated with dental services onty preventive diagnostic and therapeutic laboratory as follows: services, in accordance with criteria established by • Emergency treatment received within twenty-four PacifiCare, are covered. (24) hours of the occurrence of accidental injury 27. Maternity Care, Tests and Procedures—Physician to the jaw or mouth; visits, laboratory services, and radiology services are • Treatment of congenital conditions of the jaw that covered for prenatal and postpartum maternity care. may be demonstrated to cause actual significant Nurse midwife services are covered when provided deterioration in the Member's physical condition through a Participating OB/GYN. The office visit because of inadequate nutrition or respiration; Copayment applies to postpartum visits in the • Biopsy and excision of Physician's office. P Y cysts or tumors of the jaw and treatment of malignant neoplastic disease; Genetic Testing and Counseling are covered when • Tooth extraction prior to a major organ transplant authorized by PacifiCare as part of an amniocentesis or radiation therapy to the head or neck; or chorionic villus sampling procedure. • Surgical services in the hospital, Physician's office, Not Covered: or in a licensed outpatient surgical facility. This • Any procedure intended solely for sex includes the services of a surgical assistant and determination anesthesiologist with surgical services when • Birthing classes Medically Necessary. 28. Medical Supplies and Materials—Medical supplies and materials necessary to treat an illness or injury are covered when used or furnished while the Member is treated in the Participating Provider's office. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. I Section Five - Your Medical Benefits . , ;. • Cleft lip, cleft palate, or any condition or illness • The child has dental needs for which local that is related to or developed as a result of the anesthesia is ineffective because of acute infection, cleft lip or cleft palate will be considered to be anatomic variations, or allergy or; compensable for coverage under the provisions of • The child is extremely uncooperative, Colorado law for newborn children born with unmanageable, anxious, or uncommunicative cleft lip or cleft palate or both. The following care child or adolescent with dental needs deemed and treatment is covered to the extent Medically sufficiently important that dental care cannot be Necessary and when ordered by a participating deferred; or Physician: • The child has sustained extensive orofacial and —Oral and facial surgery, surgical management, dental trauma and follow-up care by plastic surgeons and oral surgeons The Member's dentist must obtain preauthorization from the PacifiCare before the dental procedure is —Prosthetic treatment such as obturators, speech provided. appliances, and feeding appliances Dental anesthesia in a dental office or dental clinic —Medically Necessary orthodontic treatment is not covered. Professional fees of the dentist are —Medically Necessary prosthodontics treatment not covered except for services covered by PacifiCare under the outpatient benefit 31., "Oral —Habilitative speech therapy Surgery and Dental Services." —Otolaryngology treatment 33. Outpatient Medical Rehabilitation Therapy- -Audiological assessments and treatment Services provided by a registered physical, speech or occupational therapist for the treatment of an If a dental insurance policy is in effect at the time of illness, disease or injury are covered. the birth, or is purchased after the birth of a child with cleft lip or cleft palate or both, no benefit Cardiac under this Group Agreement will be provided for Short-term cardiac rehabilitation is covered based any orthodontics or dental care needed as a result on criteria established by PacifiCare at an approved of the cleft lip or cleft palate or both. facility for the short-term follow-up of acute care Dental Services beyond emergency treatment to episode. This benefit is an extension of the stabilize an acute injury—including, but not limited treatment for an inpatient acute care episode and to, follow-up dental restoration procedures, crowns, must begin within two (2) months of discharge. fillings, dental implants, caps, dentures,braces, Limit: dental appliances and orthodontic procedures—are not covered. A maximum of$1,000 within a ninety (90)-day period 32. Oral Surgery and Dental Services: Dental Occupational/Physical Treatment Anesthesia for Dependent Children- Short-term, outpatient occupational and physical Anesthesia and associated facility charges for dental therapy by licensed therapists who are Participating procedures provided in a hospital, outpatient Providers or approved by PacifiCare. This short- surgery center, or other licensed facility pursuant to term, outpatient physical therapy is for the Colorado law are covered when: treatment of acute conditions that are subject to • The child is defined as a Dependent as defined in significant improvement within two (2) months of Colorado law; when treatment begins. • The child has a physical, mental, or medically Limits: compromising condition or; • Refer to your Schedule of Benefits for applicable visit Limitations under this benefit a Section Five - Your Medical Benefits • Requires prior written authorization of an Speech therapy for the care and treatment of approved treatment plan by PacifiCare congenital defects and birth abnormalities for The Member's status may be reevaluated and, if it is children up to age five (5),without regard to determined that the condition is no longer acute, it whether the condition is acute or chronic and without regard to whether the purpose of the may not be covered. therapy is to maintain or to improve functional Physical and occupational therapy for the care and capacity. treatment of congenital defect and birth abnormalities for children up to age five (5) are Limit: covered, without regard to whether the condition is Not to exceed twenty(20) sessions per year acute or chronic and without regard to whether the Alcohol-Drug purpose of the therapy is to maintain or to improve functional capacity Alcohol-drug outpatient Rehabilitation Services are covered at a participating facility designated by Limits: PacifiCare. Outpatient services are those services Not to exceed twenty (20) sessions for physical and provided to Members who are living at home and occupational therapy per acute condition receiving services at the program site on an ambulatory basis. Speech Services of licensed speech therapists who are Limits: Participating Providers or approved by PacifiCare are Refer to your Schedule of Benefitssfor applicable covered. This therapy is a benefit only for the short- Limitations under this benefit. term rehabilitation required immediately following 34. Outpatient Surgery—Short stay, same day or these acute episodes: stroke, accidental brain injury other similar Participating outpatient surgery (not occurring during birth), and injury or surgery facilities are covered when provided as a substitute directly affecting the larynx and/or vocal cords or for for inpatient care. treatment of vocal cord nodules in lieu of surger y Also, for treatment of speech delay in three-to five- 35. Periodic Health Evaluation—Periodic Health year-old patients, secondary to persistent otitis Evaluations are covered as recommended by media or serous otitis media documented as PacifiCare's Preventive Health Guidelines. This persisting longer than six (6) months with includes: documented bilateral twenty-five (25) decibel • Breast Cancer Screening and Diagnosis—Services hearing loss. The goal of this therapy is a significant are covered for routine and certain diagnostic improvement of a Member's condition within two screening by low-dose mammography for the (2) months. presence of breast cancer. Screening and diagnosis Limits: will be covered consistent with generally accepted medical practice and scientific evidence, upon • Refer to your Schedule of Benefits for applicable referral by the Member's Primary Care Physician. visit Limitations under this benefit Mammography for screening or diagnostic • Requires prior written authorization of an purposes is covered as authorized by the approved treatment plan by PacifiCare Member's Participating Provider. • The Member's status may be re-evaluated and, if it Coverage shall be the lesser of eighty dollars ($80) is determined that the condition is no longer per mammography screening, or the actual charge acute, it may not be covered for such screening. Coverage is provided according Not Covered: to the following guidelines: -Provision of a single baseline mammogram for Speech therapy related to a developmental or communication delay is not covered. women thirty-five (35)years of age and under forty (40) years of age; Questions about your benefits? Call the Customer Service department at 1-800-877-9777. fl Section Five - Your Medical Benefits • i —Screening not less than once every two years for 36. Phenylketonuria (PKU) and Inherited Enzymatic women forty(40) years of age, but at least once Disorders Testing and Treatment—Testing for each such year, as specified in the policy or Phenylketonuria (PKU) is covered to prevent the contract, for a woman with risk factors to breast development of serious physical or mental cancer as determined by her Physician. disabilities or to promote normal development or function as a consequence of PKU enzyme —Annual screening as specified in the policy or contract for women who are fifty (50) to sixty- deficiency Medical Foods, for the purpose of this benefit, refer exclusively to prescription metabolic five (65) years of age. formulas and their modular counterparts, obtained • Hearing Screening—Routine hearing screening by through a pharmacy Medical Foods are specifically a Participating health professional is covered to designated and manufactured for the treatment of determine the need for hearing correction. Inherited Enzymatic Disorders caused by Single Hearing aids are not covered, nor is their testing Gene Defects. or adjustment. Coverage for Inherited Enzymatic Disorders caused • Prostate Screening—Coverage for annual by Single Gene Defects shall include, but not be screening for the early detection of prostate Limited to the following diagnosed conditions: cancer in men over the age of fifty(50) years and Phenylketonuria, Maternal Phenylketonuria, Maple in men over the age of forty(40) years who are in Syrup Urine Disease, Tyrosinemia, Homocystinuria, high-risk categories. Coverage shall be the lesser Histidinemia, Urea Cycle Disorders, Hyperlysinemia, of sixty-five (65) dollars per screening or the Glutaric Acidemias, Methylmalonic Acidemia, and actual charge for such screening. Such benefits Propionic Acidemia. Covered care and treatment of shall in no way diminish or Limit diagnostic such conditions shall include, to the extent benefits otherwise allowable under the policy or Medically Necessary, medical foods for home use for contract. The screening shall consist, at a which a participating Physician has issued a written, minimum, of the following tests: oral, or electronic prescription. —A prostate-specific antigen ("PSA) blood test; The maximum age to receive this benefit for —Digital rectal examination. Phenylketonuria is twenty-one (21)years of age; except that the maximum age to receive this benefit —At least one screening per year shall be covered for Phenylketonuria for women who are child- for any man fifty(50) years of age or older. bearing age is thirty-five (35)years of age. —At least one screening per year shall be covered Limit: for any man from forty(40) to fifty (50)years of age who is at increased risk of developing Medical Foods will be subject to a fifty (50) percent prostate cancer. Copayment • Vision Screening—Annual routine eye health 37. Physician Care (Primary Care Physician and assessment and screening by a Participating Specialist)—Diagnostic and treatment services Provider are covered to determine the health of provided by the Member's Primary Care Physician the Member's eyes and the possible need for are covered. Services of a Participating specialist are vision correction.An annual retinal examination is covered upon referral by Member's Primary Care covered for Members with diabetes. Physician.A specialist is a licensed health care professional with advanced training in an area of • Well-Baby Care—See the schedule under 22., medicine or surgery. Physician's visits to the Immunizations. Member's home when Medically Necessary and only • Well-Woman Care—Medically Necessary services, if the Member is too ill or disabled to go to the including a Pap smear, are covered. The Member Physician's office are covered. may receive obstetrical and gynecological Physician services directly from a Participating OB/GYN or Participating Family Practice Physician. 30 Section Five - Your Medical Benefits wv 38. Physician OB/GYN Care—The Member may obtain • Bionic and Myoelectric prosthetics are not covered. obstetrical and gynecological Physician services Bionic prosthetics are prosthetics that require directly from a Participating OB/GYN or your surgical connection to nerves, muscles or other Primary Care Physician. tissues. Myoelectric prosthetics are prosthetics, 39. Prosthetics and Corrective Appliances— which have electric motors to enhance motion. Prosthetics (except for bionic or myoelectric as • Refer to 18., Footwear. explained below) are covered when Medically Not Covered: Necessary as determined by PacifiCare. Prosthetics are durable, custom-made devices designed to Penile prostheses and prostheses for cosmetic replace all or part of a permanently inoperative or purposes malfunctioning body part or organ. Examples of 40. Radiation Therapy(Standard and Complex): covered prosthetics include initial contact lens in an eye following a surgical cataract extraction and • Standard photon beam radiation therapy is removable, non-dental prosthetic devices such as a covered. limb that does not require surgical connection to • Complex radiation therapy is covered. This nerves, muscles or other tissue. therapy requires specialized equipment, as well as Custom-made or custom-fitted Corrective Appliances specially trained or certified personnel to perform are covered when Medically Necessary as the therapy. Examples include, but are not Limited determined by PacifiCare. Corrective Appliances are to: brachytherapy (radioactive implants), devices that are designed to support a weakened conformal photon beam radiation. Gamma knife body part. These appliances are manufactured or procedures and stereotactic procedures done on custom-fitted to an individual Member. an outpatient basis are covered as outpatient surgeries for purpose of determining Copayments. Notes: (Please refer to your Schedule of Benefits for • Preauthorized external extremity prosthetics are additional information.) covered up to applicable to the Durable Medical 41. Radiology Services: Equipment maximum, described in your Schedule of Benefits, only if the prosthesis will restore • Standard X-ray films (with or without oral, rectal, function of the extremity injected or infused contrast medium) for the diagnosis of an illness or injury are covered. • Coverage for prosthetic arms and legs is based on Standard X-ray services are X-ray(s) of an extremity, criteria and is not subject to the Durable Medical abdomen, head, chest,back, mammograms, Equipment maximum, described in your Schedule nuclear studies, barium studies, and bone density of Benefits studies.Also see 27., "Maternity Care, Tests and Coverage under this benefit is as follows: Procedures" and 35., "Periodic Health Evaluation." • Coverage for prosthetic devices that equal those • Specialized Scanning and Imaging Procedures, benefits provided under Medicare. such as CT, SPECT, PET and MRI (with or without contrast media), are covered. • Covered benefits are Limited to the most appropriate model that adequately meets the 42. Reconstructive Surgery—Plastic, reconstructive or medical needs of the Member as determined by cosmetic surgery, including skin lesions that are the Member's treating Physician. removed for cosmetic purposes are not covered. Exceptions for reconstructive surgery must be • Repair and replacement of prosthetic devices, approved in writing by PacifiCare and will be unless necessitated by misuse or loss. considered only when performed primarily to improve the physical health and function of the patient.Any non-Covered Services received prior to written approval will not be reimbursed by PacifiCare and will be the financial responsibility of the Member. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. Section Five - Your Medical Benefits #• Not Covered: Limits: • Reconstructive nasal surgery, including rhinoplasty • $125 per pair of eyeglasses • Revisions of a procedure performed for cosmetic • One (1) pair of eyeglasses per surgery purposes, but not Limited to breast augmentation • Two (2) pairs of eyeglasses per lifetime • Surgical treatment for obesity, except for cases Not Covered: that meet the standards of Medically Necessary care as accepted by Colorado for cases of morbid • Eyeglasses or contact lenses other than following obesity and that are then preauthorized in writing cataract surgery as described above, except as by PacifiCare's medical director covered as a supplemental benefit purchased by the subscribing group • Reconstructive surgery that does not correct or materially improve a physiological function • Special treatment for eyeglasses, including, but not Limited to, tinting and scratch resistant Limits: coatings The expenses of plastic, reconstructive or cosmetic surgery will be covered if the surgery is performed III. EXCLUSIONS AND LIMITATIONS as soon as medically feasible and it is Medically OF BENEFITS Necessary for either of the following reasons: Unless described as a Covered Service in an • To repair an injury sustained while the Member is attached supplement, all services and benefits a Member of PacifiCare and repair is initiated described below are excluded from coverage or within one (1)year following the surgery Limited under this Health Plan. Any supplement must be an attachment to this Combined Evidence • The correction of a congenital defect that of Coverage and Disclosure Form. (NOTE: substantially impairs major organ function or leads Additional exclusions and Limitations may be to a progressive deterioration of a covered child. included with the explanation of your benefits.) 43. Refractions—Coverage includes routine visual GENERAL EXCLUSIONS acuity exams as part of covered periodic health appraisals as well as routine eye examinations, Services that are not Medically Necessary, as defined in including refractions to determine the prescription the Definitions section of this Combined Evidence of for corrective lenses, eyeglasses or contact lenses, at Coverage and Disclosure Form, are not covered. PacifiCare designated facilities. Services not specifically included in this Combined Limit: Evidence of Coverage and Disclosure Form, or any supplement purchased by your employer, are not One routine exam per Member per contract year covered. Not Covered: 1. Services that are rendered without authorization • Fitting contact lenses from the Member's Primary Care Physician or PacifiCare (except for Emergency Services or • Vision therapy Urgently Needed Services described in this • Radial keratotomy, keratomileusis and excimer Combined Evidence of Coverage and Disclosure laser surgery Form, and for obstetrical and gynecological Coverage Physician services obtained directly from an OB/GYN under this benefit also includes eyeglasses when prescribed following cataract surgery with an or Primary Care Physician), are not covered. intra ocular lens implant. Eyeglasses must be 2. Services obtained from Non-Participating Providers, obtained through Participating Providers. when such services were offered or authorized by PacifiCare and the Member refused to obtain the services as offered by the Participating Primary Care Physician, are not covered. Section Five - Your Medical Benefits 3. Services rendered prior to the Member's effective 5. Biofeedback—Biofeedback services are not covered date of enrollment or after the effective date of except as covered under pain clinics or as related to disenrollment are not covered. acute pelvic muscle rehabilitation. 4. PacifiCare does not cover the cost of services that 6. Blood and Blood Products—Special blood handling result from a treatment plan for a non-Covered fees and the storage of cord blood are not covered. Service and that are the sole, direct and predictable 7. Bloodless Surgery Services—Bloodless surgery consequence of a non-Covered Service (as recognized by the organized medical community in services are only covered to the extent available from a Participating Provider. the State of Colorado). However, PacifiCare will cover Medically Necessary services required to treat 8. Bone Marrow and Stem Cell Transplants- an illness or injury that may be a consequence of Autologous or allogeneic bone marrow or stem cell non-Covered Services but are not predictable in transplants are not covered when they are advance, such as unexpected, life-threatening Experimental or Investigational. Unrelated Donor complications of cosmetic surgery. Searches must be performed at a PacifiCare approved transplant center. (See "Preferred OTHER EXCLUSIONS AND LIMITATIONS Transplant Network" in Section Ten, Definitions.) 1. Acupuncture and Acupressure-Acupuncture and y. Chiropractic Care-Care and treatment provided Acupressure are not covered. by a chiropractor are not covered. (Coverage for 2. Air Conditioners,Air Purifiers or Other chiropractic care may be available if purchased by Environmental Equipment-Air Conditioners, air the Subscriber's employer as a supplemental purifiers and other environmental equipment are benefit. If your Health Plan includes a chiropractic not covered. care supplemental benefit, a brochure describing it 3. will be enclosed with your materials.) Alcoholism, Drug Addiction and Other Substance Abuse Rehabilitation-One course of 10. Clinics-In no event will PacifiCare pay more than treatment per contract year. Two courses of $2,000 toward the covered charges to a pain clinic, inpatient or outpatient treatment for each Member center, or facility per Chronic Condition, per during his/her lifetime. For inpatient rehabilitation, Member per lifetime; treatment may not be started services related to the treatment of alcoholism are prior to written authorization from PacifiCare. covered at the designated facility and will be subject Convenience items and meals are not covered. Pain to the Limits as described in your Schedule of centers, facilities, clinics, or centers involved in Benefits. For services not related to the treatment of treatment of pain are not covered for inpatient care. alcoholism, services are covered up the Limits as Special service clinics, centers, or programs on an described in your Schedule of Benefits or until the inpatient or outpatient basis, except those otherwise Participating Provider has determined satisfactory listed as covered. This includes, but is not Limited completion of the inpatient program, whichever is to clinics, centers, or programs for: less. For outpatient rehabilitation, refer to your • Disassociated disorders Schedule of Benefits for applicable Limitations under this benefit. • Eating disorders 4. Behavior Modification and Non Crisis Mental • Headaches Health Counseling and Treatment—Behavior • Lactation modification and non-crisis mental health counseling and treatment are not covered. Examples • Long-term brain injury include, but are not Limited to, art therapy, music therapy and play therapy. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. I Section Five - Your Medical Benefits • Post-traumatic stress • To repair an injury sustained while the Member is • Premenstrual syndrome (PMS) a Member of PacifiCare and repair is initiated within one (1) year following the injury • Senior services • The correction of a congenital defect that • Stress management substantially impairs major organ function or 11. Communication Devices—Computers, personal leads to a progressive deterioration of health of a digital assistants and any speech-generating devices covered child are not covered. 14. Custodial Care—Custodial Care is not covered. 12. Complementary and Alternative Medicine— Custodial Care is defined as any skilled or non- Complementary and Alternative Medicine are not skilled health services, or personal comfort or covered unless purchased by your employer as a convenience related services, which provide general supplemental benefit. (See the definition for maintenance, supportive, preventive and/or Complementary and Alternative Medicine in protective care. Custodial Care: Section Ten, Definitions.) • Does not seek a cure. 13. Cosmetic Services and Surgery—Plastic, • Can be provided in any setting. reconstructive or cosmetic surgery are not covered, . May be provided between periods of acute or including skin lesions that are removed for cosmetic intercurrent health care needs. purposes. Exceptions for reconstructive surgery must be approved in writing by PacifiCare and will • Is care provided to an individual whose health be considered only when performed primarily to services requirements are stabilize$and whose improve the physical health and function of the current medical condition is not expected to patient.Any non-Covered Services received prior to significantly and objectively improve or progress written approval will not be reimbursed by over a specified period of time. PacifiCare and will be the financial responsibility of Custodial Care may include the supervision or the Member. participation of a Physician, licensed nurse, or Reconstructive nasal surgery, including rhinoplasty is registered therapist as necessary or desirable not covered. services. The mere participation of these professionals does not preclude the services as Revision of a previous procedure performed for being custodial in nature. If the nature of the cosmetic purposes including, but not Limited to services can be safely and effectively breast augmentation is not covered. performed by a trained non-medical person, the services are Surgical treatment for obesity, except for cases that custodial. Further, Custodial Care and the nature of meet the standards of Medically Necessary care as those services are not altered by the availability of accepted by PacifiCare for cases of morbid obesity the non-medical person. Custodial Care may also be and that are then preauthorized in writing by referred to as maintenance, domiciliary, respite, PacifiCare's medical director, is not covered. and/or convalescent care. Reconstructive surgery which does not correct or 15. Dental Care, Dental Appliances and materially improve a physiological function is not Orthodontics—Except as otherwise provided covered. under II., Outpatient Benefits, subsection 31., However, the expenses of plastic, reconstructive or "Oral Surgery and Dental Services,"dental care, cosmetic surgery will be covered if the surgery is dental appliances and orthodontics, and care performed as soon as medically feasible and it is provided under newborn care concerning coverage Medically Necessary for either of the following of cleft palate and cleft lip are not covered. Dental reasons: Care means all services required for prevention and • Section Five - Your Medical Benefits treatment of diseases and disorders of the teeth, 20. Drugs and Prescription Medication (Outpatient)— including, but not Limited to: oral exams, X-rays, Outpatient drugs and prescription medications are routine fluoride treatment; plaque removal, tooth not covered; however, coverage for prescription decay, routine tooth extraction, dental embryonal medications may be available as a supplemental tissue disorders, periodontal disease, crowns, benefit. If your Health Plan includes a supplemental fillings, dental implants, caps, dentures, braces, and benefit, a brochure will be enclosed with your orthodontic procedures. (Coverage for Dental Care materials. Infusion drugs and infusion therapy are may be available if purchased by the Subscriber's not considered outpatient drugs for the purposes of employer as a supplemental benefit.) this exclusion. Refer to II., Outpatient Benefits, • subsection 35., "Injectable Drugs (Outpatient 16. Dental Treatment Anesthesia—Dental treatment Injectable Medications and Self Injectable anesthesia provided or administered in a dentist's office is not covered, except as provided for children Medications)" and subsection 24., "Infusion Therapy," for benefit coverage. Pen devices for the as defined above in II., Outpatient Benefits, delivery of medication are not covered. subsection 32., "Oral Surgery and Dental Services: Dental Treatment Anesthesia for Dependent 21. Durable Medical Equipment—Coverage is Limited Children." Charges for the dental procedure(s) itself, to the equipment listed in subsection 16., "Durable including but not Limited to professional fees of the Medical Equipment (Rental, Purchase or Repair)" dentist or oral surgeon, X-ray and laboratory fees or of the Outpatient Benefits section. Replacements, related dental supplies provided in connection with repairs and adjustments to Durable Medical the care, treatment, filling, removal or replacement Equipment are Limited to normal wear and tear or of teeth or structures directly supporting the teeth because of a significant change in,the Member's are not covered except for services covered by physical condition. Replacement of lost or stolen PacifiCare under II., Outpatient Benefits, subsection Durable Medical Equipment is not covered. The 31., "Oral Surgery and Dental Services." following equipment and accessories are not covered: Non-Medically Necessary optional 17. Educational Services for Developmental Delays and Learning Disabilities-Educational services to attachments and modifications to Durable Medical Equipment for the comfort or convenience of the treat developmental delays or learning disabilities are not covered.A learning disability is a condition Member, accessories for portability or travel, a second piece of equipment with or without where there is a meaningful difference between a child's current academic level of function and the additional accessories that is for the same or similar level that would be expected for a child of that age. medical purpose as existing equipment, and home Educational services include but are not Limited to and car remodeling. language and speech training, reading, psychological 22. Elective Enhancements-Procedures, services and and visual integration training as defined by the supplies for elective, non-Medically Necessary American Academy of Pediatrics. Policy Statement- enhancements (items, devices or services to improve Learning Disabilities, Dyslexia and Vision:A appearance or performance) are not covered. This Subject Review. includes but is not Limited to, elective 18. Dialysis-Chronic dialysis (peritoneal or enhancements related to hair growth, athletic hemodialysis) is not covered outside of the performance,cosmetic changes, and anti-aging. PacifiCare HMO Service Area. 23. Follow Up Care: Emergency Services or Urgently 19. Disabilities Connected To Military Services— Needed Services—Services following discharge Treatment in a government facility for a disability after receipt of Emergency Services or Urgently Needed Services, including but not Limited to connected to military service that the Member is treatments, procedures, X-rays, lab work, Physician legally entitled to receive through a federal agency visits, rehabilitation and Skilled Nursing Care are governmental g c}; and to which Member has not covered without the PacifiCare's authorization. reasonable access, is not covered. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. Section Five - Your Medical Benefits •t. a. f The fact that the Member is outside the HMO • It is being delivered or should be delivered Service Area and that it is inconvenient for the subject to the approval and supervision of an Member to obtain the required services will not Institutional Review Board (IRB) as required and entitle the Member to coverage. defined by federal regulations, particularly those of the FDA or the Department of Health and 24. Exercise Equipment and Services—Exercise Human Services (HHS),equipment or any charges for activities, instructions or facilities normally intended or used for or developing or maintaining physical fitness are not • The predominant opinion among experts as covered. This includes, but is not Limited to, expressed in the published authoritative literature charges for physical fitness instructors, health clubs is that usage should be substantially confined to or gyms, or home exercise equipment or swimming research settings, pools, even if ordered by a health care professional. or 25. Experimental and/or Investigational Procedures, Items and Treatments—Treatments, procedures, • If the predominant opinion among experts as devices and/or drugs shall be deemed excluded as expressed in the published authoritative literature experimental, investigational, unproven, unusual, or is that further research is necessary in order to not customary if: define safety, toxicity effectiveness or effectiveness • It cannot be lawfully marketed without the compared with conventional alternatives, approval of the Food and Drug Administration or (FDA) or other governmental agency and such • It is not a covered benefit under Medicare as approval has not been granted at the time of its determined by the Centers for Medicare and use or proposed use, Medicaid Services (CMS) of HHS, or or • It is the subject of a current investigational new • It is experimental, investigational, unproven, drug or new device application on file with the unusual or not customary or is not a generally FDA, acceptable medical practice in the predominant or opinion of independent experts, • It is being administered for non FDA-approved or indications, • A majority of a representative sample of not less or than three health insurance or benefit Providers or administrators consider the requested treatment, • It is being provided pursuant to a Phase I or Phase procedure, device or drugs to be Experimental, II clinical trial or as the experimental or research Investigational, unproven, unusual or not arm of a Phase III clinical trial, customary based upon criteria and standards or regularly applied by the industry, • It is being provided pursuant to a written protocol or which describes among its objectives, • It is not Experimental or Investigational in itself determinations of safety, toxicity, effectiveness or pursuant to the above, and would not be effectiveness in comparison to conventional Medically Necessary, but for being provided in alternatives, conjunction with the provision of a treatment, or procedure, device or drug which is Experimental, Investigational, unproven, unusual or not customary. a Section Five - Your Medical Benefits Determinations under this heading will be based on • Chelation therapy, unless Medically Necessary for the following: the treatment of metal poisoning • The Member's medical records, • Cytotoxin testing • The protocol(s) pursuant to which the treatment • Hair analysis is to be delivered, • Colonies • Any informed consent documents the Member is • Gene manipulation therapy required to read and/or execute, as a condition of receiving the treatment, • Autologous bone marrow transplants and • The published authoritative medical or scientific chemotherapy requiring a bone marrow transplant literature regarding the procedure at issue as for stage I and stage N breast cancer, ovarian applied to the Member's medical condition, cancer and other solid tumors • Regulations, bulletins, letter rulings or other • Transplants not specifically listed as covered official actions and publications issued by the FDA, • Medications that are experimental, investigative, HHS, CMS, the National Institutes for Health or used in ways not approved by the Food and (NIH), the National Cancer Institute (NCI) or Drug Administration (FDA). Medications included other applicable regulatory agencies, in these categories are those prescribed for: • The opinions of independent experts, —Use in dosage forms not commercially available • Materials prepared by, for or on behalf of other —Use by routes of administratiotl not approved by health insurance or benefit Providers and the FDA administrators concerning the requested —Non-FDA-approved indications treatment, procedure, device or drug, and/or • Naturopathic services • Recognized technology assessments or evaluations by private or federal entities (e.g. Blue Cross& • Megavitamin therapy Blue Shield Association,American Medical PacifiCare shall have the discretionary authority to Association, Office of Technology Assessment) interpret this plan and determine all questions • Other materials that, in the exercise of PacifiCare's arising in the administration, interpretation, and discretion, are relevant. application of the plan including determining what procedures, devices or drugs are Experimental, No treatment, procedure, device and/or drug Investigational, unusual, not customary, or excluded by this subsection on the inception date of unproven.All such determinations shall be final, this Group Agreement shall be covered because it conclusive, and binding. subsequently ceases to meet the criteria of this section during the remaining contract year, unless 26. Eye Wear and Corrective Refractive Procedures— PacifiCare issues a written amendment expressly Corrective lenses and frames, contact lenses, contact making it a covered benefit. lens fitting and measurements are not covered (except for initial post cataract extraction and for Treatments, procedures, devices and/or drugs the treatment of keratoconus and aphakia). Surgical considered to be Experimental, Investigational, and laser procedures to correct or improve unproven, unusual, or not customary include, but refractive error are not covered. (Coverage for are not Limited to: frames and lenses may be available if the • Orthomolecular medicine Subscriber's employer purchased a vision supplemental benefit. If your Health Plan includes a • Holistic medicine vision supplemental benefit, a brochure describing • Environmental medicine it will be enclosed with your materials.) Questions about your benefits? Call the Customer Service department at 1-800-877-9777. MID • Section Five - Your Medical Benefits t 27. Family Planning-Family planning benefits, other 32. Health Care Expenses Incurred Due To Liable than those specifically listed in 17., "Voluntary Third Party-Except as set forth in this Combined Termination of Pregnancy" under I., Inpatient Evidence of Coverage and Disclosure Form in Benefits, and 17. "Family Planning" under II., Section Six, Payment Responsibility, "PacifiCare's Outpatient Benefits, are not covered. right to the repayment of a debt as a charge against routine recoveries from third parties liable for a Member's 28. Foot Care—Except as Medically Necessary, foot care—including, but not Limited to, removal or health care expenses," coverage for any health care reduction of corns and calluses, cli in of toenails, expenses incurred as the result of a liable third PP g is not covered. party are not covered. 29. Foot Orthotics/Footwear—Podiatric shoe inserts 33. Hearing Aids and Hearing Devices—Hearing aids for persons with diabetes with historical ulcers or and non-implantable hearing devices are not presence of pre-ulcerous lesions and documented covered.Audiology services (other than screening for neuropathy. In addition, for Members with hearing acuity) are not covered. Hearing aid supplies persistent plantar facitis, or documented neuropathy are not covered. Implantable hearing devices are not covered except for cochlear devices for bilaterally, who have documented failure of commercial over- the-counter inserts when used as a trial prior to, or profoundly hearing-impaired individuals or for in lieu of surgery. Coverage shall be to the Limits as prelingual Members who have not benefited from described in your Schedule of Benefits. Each $1 paid conventional amplification (hearing aids). for podiatric shoe inserts shall reduce by$1 the 34. Immunizations—Work-related immunizations are amount available for orthopedic braces. Orthotic not covered. devices for podiatric use and arch support are not a covered benefit. 35. Infertility Reversal—Reversals of sterilization procedures are not covered. 30. Genetic Testing and Counseling-Genetic testing 36. Infertility Services—The Infertility services benefit of non-Members is not covered. Genetic testing solely to determine the gender of a fetus is not covered. is covered only if it has been selected by your Genetic testing and counseling are not covered when employer as part of the subscribing group's plan. done for non-medical reasons, or when a Member Please refer to the Schedule of Benefits for specific has no medical indication or family history of a coverage. The treatment of Infertility by a genetic abnormality. General testing and counseling Participating Provider includes diagnosis, diagnostic are not covered to screen newborns, children or tests, and surgery by the Participating Physician. adolescents to determine their carrier status for Infertility is defined as either: 1) the presence of a inheritable disorders when there would be no demonstrated condition diagnosed by a Participating immediate medical benefit or when the test results licensed Physician or surgeon as biologically would not be used to initiate medical interventions infertile, or 2) the inability to conceive or to carry a during childhood. Genetic testing and counseling are pregnancy to a live birth after a year or more of not covered except when determined by PacifiCare's regular sexual relations without contraception. medical director or designee to be Medically Necessary to treat the Member for an inheritable Limit: disease. Refer to 27., "Maternity Care, Tests and Insemination Procedures are Limited to six (6) Procedures"in II., Outpatient Benefits for coverage of cycles, per lifetime, unless the Member conceives, amniocentesis and chorionic villus sampling, in which case the benefit renews. 31. Government Services and Treatment—Any services provided by a local, state or federal government agency are not covered, except when coverage under this Health Plan is expressly required by federal or state law. a Section Five - Your Medical Benefits Not Covered: • Confinement, treatment, service or supply that is • In vitro fertilization (test tube babies), the Gamete not ordinarily provided for the specific treatment Intrafallopian Transfer (G.I.ET) procedure, the which was authorized. Zygote Intrafallopian Transfer (Z.I.F.T.) procedure, • Confinement, treatment, service or supply Artificial Reproductive Technology(A.R.T.), other obtained through or required by a governmental ovum transplant procedures, surrogate parentage, agency or program. drug therapy for Infertility and related costs of • Weight control programs and treatment for each are not covered. addictions to tobacco, nicotine or food. • The cost related to donor sperm and donor ova • Treatment or psychological testing for any reading (collection, preparation, storage, etc.) or learning disorder, mental retardation, or other • Procedures considered to be Experimental/ developmental disorders as defined by the Investigational Diagnostic and Statistical Manual of Mental • Reversal of a sterilization procedure(s) is not a Disorders-IV(DSM-IV). covered benefit. • Counseling for adoption, custody, family planning Members must have coverage under the Outpatient or pregnancy in the absence of a DSM-W Prescription Drug supplemental benefit for diagnosis. medications to be covered. The outpatient • Counseling associated with or in preparation for a prescription drug benefit is covered only if it has sex change operation. been selected by your employer as part of the • Sexual therapy programs, including therapy for subscribing group's plan. sexual addiction, the use of sexual surrogates, and 37. Institutional Services and Supplies—Except for sexual treatment. Skilled Nursing Services provided in a Skilled • Vocational, pastoral or spiritual counseling. Nursing Facility, any services or supplies furnished by a facility that is primarily a place of rest, a place • Non-organic therapies including, but not Limited for the aged, a nursing home, or any similar to, bioenergetics therapy, confrontation therapy, institution, regardless of affiliation or denomination, crystal healing therapy, educational remediation, are not covered. (Skilled Nursing Services are Eye Movement Desensitation Reprocessing, covered as described in this Combined Evidence of guided imagery, marathon therapy, primal therapy, Coverage and Disclosure Form under I., "Inpatient rolfing, sensitivity training, training psychoanalysis, Benefits" and II., "Outpatient Benefits.") transcendental meditation, and Z therapy. 38. Medicare Benefits for Medicare Eligible • Organic therapies including, but not Limited to, Members—The amount payable by Medicare for aversion therapy, carbon dioxide therapy, Medicare Covered Services is not covered by environmental ecological treatment or remedies, PacifiCare for Medicare Eligible Members, whether herbal therapies, homodialysis for schizophrenia, or not a Medicare Eligible member has enrolled in vitamin or orthomolecular therapy, narcotherapy Medicare Part A and Medicare Part B. with LSD, and sedative action electrostimulation 39. Mental Health Services—The following mental therapy health services are not covered: • Surgery or acupuncture as a mental health benefit. • Confinement, treatment, service or supply that is • Laboratory fees as a mental health benefit for not authorized, except in the event of an outpatient treatment plans. Emergency. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. fl Section Five - Your Medical Benefits • Services which are not Medically Necessary for the • The drug is approved by the FDA; treatment of mental health disorders. • The drug is prescribed by a Participating Provider • Services that are required by a court order as a for the treatment of a life-threatening condition or part of parole or probation, or instead of for a chronic and seriously debilitating condition; incarceration,which are not Medically Necessary. • The drug is Medically Necessary to treat the • Long-term insight-oriented psychotherapies that condition; regress the Member emotionally or behaviorally. • The drug has been recognized for treatment of the • Personal enhancement, self-actualization therapy life-threatening or chronic and seriously or other similar treatment plans. debilitating condition by one of the following: The • Services provided by a nonlicensed Provider. American Medical Association Drug Evaluations, The American Hospital Formulary Service Drug • Neurological services and tests, including, but not Information, The United States Pharmacopoeia Limited to, EEGs, Pet scans, beam scans, MRIs, skull Dispensing Information, Volume 1, or in two X-rays and lumbar punctures. These services must articles from major peer-reviewed medical be preauthorized by the Primary Care Physician. journals that present data supporting the • Treatments which do not meet the national proposed off-label drug use or uses as generally standards for mental health professional practice. safe and effective; • Medical treatment for eating disorders. • The drug is covered under the injectable drug benefit described in the outpatient benefits • Treatment sessions by telephone or computer section of this Combined Evidence of Coverage Internet services (except as provided by and Disclosure Form. Colorado law). Nothing in this section shall prohibit PacifiCare from • Evaluation or treatment for education, the use of a formula ry, Co payment, p yment, technology professional training, employment investigations, assessment panel, or similar mechanisms as a means fitness for duty evaluations, or career counseling. for appropriately managing the utilization of a drug 40. Nurse Midwife Services—Nurse midwife services are that is prescribed for a use that is different from the covered only when provided through a Participating use for which that drug has been approved for OB/GYN. Home deliveries are not covered. marketing by the FDA. 41. Nursing, Private Duty—Private duty nursing is not 44. Oral Surgery and Dental Services—Dental covered. Services—including, but not Limited to, crowns, fillings, dental implants, caps, dentures, braces and 42. Nutritional Supplements or Formulas—Formulas, orthodontic procedures—are not covered. Other food, vitamins, herbs and dietary supplements are services not covered include but are not Limited to: not covered, (except as described under II., Outpatient Benefits, 36., "Phenylketonuria (PKU) and Inherited • General dental services and dental X-rays, Enzymatic Disorders Testing and Treatment)." including treatment on or to the teeth or gums 43. Off-Label Drug Use—Off-label drug use,which • Any services customarily provided by a general means the use of a drug for a purpose that is dentist, an oral surgeon, or any other dental different from the use for which the drug has been specialist approved for by the FDA, including off-label self- • Any procedure involving osteotomy of the jaw injectable drugs, is not covered except as follows: If the self-injectable drug is prescribed for off-label • Periodontal treatment and/or surgery use, the drug and its administration is covered only • Treatment or care for overbite or underbite when the following criteria are met: 40 • Section Five - Your Medical Benefits • Treatment or care for maxillary and mandibular 48. Phenylketonuria (PKU) and Inherited Enzymatic osteotomies, and jaw or orthognathic conditions Disorders Testing and Treatment-Food products • Dental prosthetics and metallic bone cylinder naturally low in protein are not covered, except as implants (bone screws) provided under II., Outpatient Benefits, subsection 36, "Phenylketonuria (PKU) and Inherited Enzymatic • Hospital costs for dental surgery or other dental Disorders Testing and Treatment." reasons 49. Physical or Psychological Examinations— • Orthodontic treatment, orthognathic surgery and Physical or psychological examinations for court associated costs of each related to the treatment hearings, travel, premarital, pre-adoption or other for misalignment or similar malfunction of the jaw non-preventive health reasons are not covered. joint, commonly known as temporomandibular joint problems or TM)syndrome 50. Private Rooms and Comfort Items—Personal or comfort items, and non-Medically Necessary private 45. Oral Surgery and Dental Services: Dental rooms during inpatient hospitalization, are not covered. Treatment Anesthesia—Dental anesthesia in a dental office or dental clinic is not covered, except 51. Prosthetics and Corrective Appliances— as provided in II., Outpatient Benefits, subsection Replacement of lost prosthetics or corrective 32., "Oral Surgery and Dental Services: Dental appliances is not covered. Prosthetics that require Treatment Anesthesia for Dependent Children." surgical connection to nerves, muscles or other Professional fees of the dentist are not covered. tissues (bionic) are not covered. Prosthetics that (Please see 15., "Dental Care, Dental Appliances and have electric motors to enhance motion Orthodontics" and 16., "Dental Treatment (myoelectronic) are not covered. Anesthesia.") 52. Public Facility Care—When state or local law 46. Organ Donor Services—Medical and Hospital requires treatment in a public facility, care is not Services, as well as other costs of a donor or covered; however, PacifiCare will reimburse a prospective donor, are only covered when the Member for out-of-pocket expenses incurred for any recipient is a Member. The testing of blood relatives Covered Service delivered at a public facility that to determine compatibility for donating organs is meets the definition of Emergency or Urgently Limited to sisters, brothers, parents, and natural Needed Services. Injuries or illnesses sustained while incarcerated in a State or Federal prison, in children. Donor Searches are only covered when performed by a Provider included in the Preferred legal custody, on a legal hold, or in legal detention Transplant Network facility. are not covered. Only Emergency and Urgently Needed Services are covered until the Member is 47. Organ Transplants—All organ transplants must be stabilized and placed on a police hold. Nothing in preauthorized by PacifiCare and performed in a this provision will restrict the liability of PacifiCare PacifiCare Preferred Transplant Network facility. with respect to Covered Services solely because such • Transportation is Limited to the transportation of services were provided while the Member was in a the Member and one escort to a Preferred state hospital. Transplant Network facility greater than sixty (60) 53. Reconstructive Surgery—Plastic, reconstructive or miles from the Member's Primary Residence as cosmetic surgery, including skin lesions that are preauthorized by PacifiCare. removed for cosmetic purposes are not covered. • Food and housing is not covered unless the Exceptions for reconstructive surgery must be Preferred Transplant Network center is located approved in writing by PacifiCare and will be more than sixty (60) miles from the Member's considered only when performed primarily to Primary Residence, in which case food and improve the physical health and function of the housing is Limited to $125 dollars a day to cover patient. Any non-Covered Services received prior to both the Member and escort, if any (excludes written approval will not be reimbursed by liquor and tobacco). Food and housing expenses PacifiCare and will be the financial responsibility of are not covered for any day a Member is not the Member. receiving Medically Necessary transplant services. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. in Section Five - Your Medical Benefits • Reconstructive nasal surgery, including rhinoplasty •Occupational/Physical are not covered. Refer to your Schedule of Benefits for applicable • Revisions of a procedure performed for cosmetic limitations under this benefit. purposes, but not Limited to breast augmentation, Physical and occupational therapy for the care and is not covered. treatment of congenital defect and birth • Surgical treatment for obesity is not covered, abnormalities for children up to age five (5) are except for cases that meet the standards of covered,without regard to whether the condition Medically Necessary care as accepted by Colorado is acute or chronic and without regard to whether for cases of morbid obesity and that are then the purpose of the therapy is to maintain or to preauthorized in writing by PacifiCare's medical improve functional capacity, visits not to exceed director. twenty(20) sessions for physical and occupational therapy per therapy • Reconstructive surgery that does not correct or materially improve a physiological function is not Requires prior written authorization of an covered. approved plan by PacifiCare. The expenses of plastic, reconstructive or cosmetic •Speech surgery will be covered if the surgery is performed Refer to your Schedule of Benefits for applicable as soon as medically feasible and it is Medically Limitations under this benefit. Necessary for either of the following reasons: Requires prior written authorization of an • To repair an injury sustained while the Member is approved treatment plan by PacifiCare. a Member of PacifiCare and repair is initiated within one (1) year following the surgery The Member's status may be reevaluated and, if it is determined that the condition is no longer • The correction of a congenital defect that acute, it may not be covered. substantially impairs major organ function,or leads to a progressive deterioration of a covered child. Speech therapy for the care and treatment of congenital defects and birth abnormalities for Preauthorizations for proposed reconstructive children up to age five (5), without regard to surgeries will be reviewed by Physicians specializing whether the condition is acute or chronic and in such reconstructive surgery who are competent without regard to whether the purpose of the to evaluate the specific clinical issues involved in the therapy is to maintain or to improve functional care requested. capacity, visits not to exceed twenty (20) sessions 54. Recreational, Lifestyle, Educational or Hypnotic per year. Therapy—Recreational, lifestyle, educational or hypnotic therapy, •Rehabilitation Services and Therapies and any related diagnostic testing, Not Covered is not covered except when provided as part of a covered inpatient hospitalization. —Behavior disorders —Communication delay 55. Rehabilitation Services and Therapy— —Lear'nin Rehabilitation Services and therapy are either r disability Limited or not covered, as follows: —Mental retardation and related conditions —Motor dysfunction •Cardiac —Multiple handicaps —Perceptual disorders Coverage is Limited to a maximum of$1,000 —Post-traumatic stress within a ninety (90)-day period. —Pulmonary rehabilitation —Sensory deficit —Sex addiction a Section Five - Your Medical Benefits —Speech (except as covered in II., Outpatient Member must either be out of all Skilled Nursing Benefits, subsection 33., "Outpatient Medical Facilities for sixty (60) consecutive days or if the Rehabilitation Therapy") Member remains in a facility, then the Member may —Vision not have received Skilled Nursing Care or Skilled —Special evaluation and therapies including: Rehabilitation Care for sixty (60) days. —Behavioral training 60. Supplies-Medical supplies including without -Biofeedback(except as covered under pain Limitation, on an outpatient basis, enteral feeding clinics and as related to acute pelvic muscle substance and infant formula, medical foods except rehabilitation) as specified in II., Outpatient Benefits, subsection -Cognitive therapy 36, "Phenylketonuria (PKU) and Inherited Enzymatic -Coma stimulation Disorders Testing and Treatment." -Developmental and neuroeducational testing or treatment 61. Surrogacy-Infertility and maternity services for -Educational studies non-Members are not covered. PacifiCare may seek -Hearing therapy recovery from a Member who is receiving -Hypnotherapy reimbursement for medical expenses for maternity -Myofunctional therapy services while acting as a surrogate. -Neuromuscular rehabilitation for Chronic 62. Transportation-Transportation is not a covered Conditions benefit except for Ambulance transportation as -Psychological testing defined in Emergency and Urgently Needed Services -Sleep therapy of this Combined Evidence of Coverage and -Vision therapy/orthoptics Disclosure Form. -Vocational rehabilitation 63. Treatment Alternatives-Treatment alternatives 56. Respite Care-Respite Care is not covered, unless and Limited adaptations to coverage under this part of an authorized Hospice plan and is necessary to Group Agreement are reserved to the sole discretion relieve the primary caregiver in a Member's residence. of PacifiCare.While this Group Agreement is the Respite care is covered only on an occasional basis, definitive statement of PacifiCare's legal obligation not to exceed 5 consecutive days at a time. to provide benefits, experience has shown that there 57. Services In the Home-Services in the home may be unusual and extraordinary circumstances provided by relatives or other household members that are not contemplated by this Group Agreement. are not covered. Therefore, PacifiCare specifically reserves the right, at its sole discretion and based on prudent business 58. Sex Transformations—Procedures, services, and medical judgment (with the input of its medical medications and supplies related to sex director), to adapt the coverage and benefits set transformations are not covered. forth in this Group Agreement. 59. Skilled Nursing Facility Care/Subacute and The fact that PacifiCare makes an adaptation to this Transitional Care—Skilled Nursing Facility room Group Agreement will not require or act as and board charges are excluded after the Limits as described in your Schedule of Benefits. Days spent precedent requiring that it make future adaptations in similar or other situations, or otherwise be out of the Skilled Nursing Facility when transferred prevented from administering this Group Agreement to an acute hospital setting are not counted toward in strict accordance with its terms. the Limits as described in your Schedule of Benefits when the Member is transferred back to a Skilled In addition, PacifiCare may, at its sole discretion, Nursing Facility, but the count resumes upon the reevaluate and discontinue any adaptation granted Member's return to a Skilled Nursing Facility. Such under this provision if it determines that the original days in an acute hospital setting also do not count basis for granting the adaptation is no longer valid toward renewing the Limits as described in your and supportive of the adaptation or is no longer Schedule of Benefits. In order to renew the room likely to lead to measurable improvement in the and board coverage in a Skilled Nursing Facility a health of the Member. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. ED Section Five - Your Medical Benefits �. J/ Any request for coverage of treatment alternatives 67. Weight Alteration Programs (Inpatient or and/or Limited adaptations to this Group Agreement Outpatient) -Weight loss or weight gain programs must be made in writing, by a participating are not covered. These programs include,but are not Physician or a Member, to PacifiCare's medical limited to, dietary evaluations, counseling, exercise director. The coverage decision will be made by and behavioral modification. Also excluded are PacifiCare. PacifiCare will provide a written surgery, laboratory tests, food and food supplements, response; only services specifically authorized and vitamins and other nutritional supplements received after the Member's receipt of the written associated with weight loss or weight gain. response will be covered. PacifiCare shall have the 68. Cumulative Benefits-Any service provided to a sole discretionary authority to interpret this plan Subscriber or Dependent during a Contract Year is and determine all questions arising in the limited cumulatively to the benefits covered in this administration, interpretation, and application of Group Agreement. The following changes in a the plan, and all such determinations shall be final, Member's status may not increase any restriction or conclusive, and binding. limitation on the number of services or benefits a 64. Veterans Administration Services-Except for member can receive in a contract year: Emergency or Urgently Needed Services, services • From subscriber to dependent provided in a Veterans Administration facility are not covered. • From dependent to subscriber 65. Vision Care-See III., Exclusions and Limitations of • From group coverage to continuation coverage, Benefits, subsection 26., "Eye Wear and Corrective individual plan coverage, or converkion coverage Refractive Procedures." • From employer group contract to another 66. Vision Training-Vision therapy rehabilitation and employer group contract. ocular training programs (orthoptics) are not covered. a Section Six - Payment Responsibility Payment Responsibility What Are Copayments (Other Charges)? Aside from the Premium, you may be responsible for paying a charge when you receive a Covered Service. • Premiums and Copayments This charge is called a Copayment and is outlined in your Schedule of Benefits. If you review your Schedule • What To Do If You Receive a Bill of Benefits, you'll see that the amount of the Copayment depends on the service, as well as the Provider from • Coordinating Benefits With Another Plan whom you choose to receive your care. Annual Out-of-Pocket Maximum • Medicare Eligibility For certain Covered Services, a Limit is placed on the total amount you pay for Copayments during a calendar • Workers'Compensation Eligibility year. This Limit is called your Annual Out-of-Pocket Maximum and when you reach it, for the remainder of • Other Benefit Coordination Issues the calendar year,you will not pay any additional Copayments for these Covered Services. One of the advantages of your health care coverage is that most out-of-pocket expenses are limited to You can find your Annual Out-of-Pocket Maximum in Copayments. This section explains these and other your Schedule of Benefits. If you've surpassed your health care expenses. It also explains your Annual Out-of-Pocket Maximum, submit all your health responsibilities when you're eligible for Medicare or care Copayment receipts and a letter of explanation to: Workers'Compensation coverage, and when PacifiCare PacifiCare needs to coordinate your benefits with another plan. Customer Service Department P.O. Box 6770 What Are Premiums (Prepayment Fees)? Englewood, Colorado 80155 Premiums are fees an Employer Group pays to cover the Remember, it's important to send us all Copayment basic costs of your health care package. An Employer usually receipts along with your letter. They confirm that you've Group pays these Premiums on a monthly basis. reached your Annual Out-of-Pocket Maximum.You will Often the Subscriber shares the cost of these Premiums be reimbursed by PacifiCare for Copayments p yments you make with deductions from his or her salary. By choosing the beyond your individual or family Annual Out-of-Pocket coverage specified in this Group Agreement, paying the Maximum. Premium, or accepting benefits under this Group Agreement, all Members or their legal representatives NOTE: The calculation of your Annual Out-of-Pocket expressly agree to all terms, conditions and provisions Maximum will not include supplemental benefits that of this Group Agreement, whether or not the Member may be offered by your Employer Group (e.g. coverage has signed the application of the Subscriber. for outpatient prescription drugs) or those benefits subject to a separate maximum. If you are the Subscriber,you should already know if you're contributing to your Premium payment; if you aren't sure, contact your Employer Group's health What is a "Schedule of Benefits"? benefits representative. He or she will know if you're Your Schedule of Benefits is printed separately from this contributing to your Premium, as well as the amount, document and lists the Covered Services unique to method and frequency of this contribution. your plan. It also includes your Copayments,as well as the Annual Out-of-Pocket Maximum and other important information. If you need assistance understanding your Schedule of Benefits or need a copy, please call our Customer Service department:. .. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. Section Six - Payment Responsibility . ir, •a If You Get a Bill (Reimbursement) PacifiCare Customer Service Department If you are billed for a Covered Service provided or P.O. Box 6770 authorized by your Primary Care Physician or PacifiCare, Englewood, Colorado 80155 you should do the following: Include your name, PacifiCare ID number and a brief 1. Verify that the bill is not for the applicable note that indicates your belief that you've been billed Copayment. for a Covered Service. The note should also include the 2. Call the Provider, then let them know you have date of service, the nature of the service, and the name received a bill in error and you will be forwarding of the Provider who authorized your care. No claim the bill to PacifiCare. form is required. 3. Give the Provider your PacifiCare Health Plan PacifiCare will not pay any claim that is filed more than information, including your name and PacifiCare one (1) year from the date the services or supplies were Member number. provided. PacifiCare also will not pay for excluded services or supplies unless authorized by your Primary 4. Forward the bill to: Care Physician,your Participating Medical Group or PacifiCare directly by PacifiCare. Customer Service Department P.O. Box 6770 Any payment assumes you have not exceeded your Englewood, Colorado 80155 benefit Limits. If you've reached or exceeded any Include your name, your PacifiCare ID number and a applicable benefit Limit, these bills will be your responsibility brief note that indicates you believe the bill is for a Covered Service. The note should also include the date If you receive emergency treatment from a non- of service, the nature of the service, and the name of the participating mental health provider,you may receive a Provider who authorized your care. No claim form is bill. Send PacifiCare Behavioral Health (PBH) a copy of required. If you need additional assistance, call our the bill or claim within ninety (90) days of the date of Customer Service department. service, or as soon as possible. PBH will not pay for claims submitted after one hundred twenty(120) days Please note:Your Provider will bill you for services that of the date of service. Mail bills to: PacifiCare Behavioral are not covered by PacifiCare or haven't been properly Health, Claims Department, 23046 Avenida de la authorized. You may also receive a bill if you've Carlota, Suite 700, Laguna Hills, CA 92653. If your plan exceeded PacifiCare's coverage Limit for a benefit. includes a Copayment, you are responsible to pay these Bills From Non-Participating Providers directly to the Provider. If you receive a bill for a Covered Service from a How To Avoid Unnecessary Bills Physician who is not one of our Participating Providers, Always obtain your care under the direction of and the service was preauthorized and you haven't PacifiCare or your Primary Care Physician. By doing this, exceeded any applicable benefit Limits, PacifiCare will you only will be responsible for paying any related pay for the service less the applicable Copayment. Copayments and for charges in excess of your benefit (Preauthorization isn't required for Emergency Services Limitations. Except for Emergency or Urgently Needed and Urgently Needed Services. See Section Three, Services, if you receive services not authorized by Emergency and Urgently Needed Services.)You may PacifiCare, you may be responsible for payment. This is also submit a bill to us if a Non-Participating Provider also true if you receive any services not covered by your has refused payment directly from PacifiCare. plan. (Services not covered by your plan are included in You should file a claim within twelve (12) months, or as Section Five,Your Medical Benefits.) soon as reasonably possible, of receiving any services and related supplies. Forward the bill to: a Section Six - Payment Responsibility Your Billing Protection The order of benefit determination rules below All PacifiCare Members have rights that protect them determine which Health Plan will pay as the Primary from being charged for Covered Services in the event Plan. The Primary Plan that pays first pays without PacifiCare does not pay a Provider, a Provider becomes regard to the possibility that another plan may cover insolvent, or a Provider breaches its contract with some expenses.A Secondary Plan pays after the Primary Plan and may reduce the benefits it pays so that PacifiCare. In none of these instances may the Participating Provider sendyou a bill, charge payment from all group plans do not exceed 100% of P g you, or the total allowable expense. `Allowable Expense" is have any other resource against you for a Covered Service. However, this provision does not prohibit the defined below collection of approved amounts as outlined in the PacifiCare will follow coordination of benefits guidelines Schedule of Benefits. promulgated by the Colorado Division of Insurance to In the event of a Provider's insolvency, PacifiCare will establish the order of carrier responsibility in continue to arrange for your benefits. If for any reason coordinating benefits with other Plans in force for PacifiCare is unable to pay for a Covered Service on Members, including Members covered by more than your behalf(for instance, in the unlikely event of one policy with PacifiCare. "Plan" is defined below PacifiCare's insolvency or a natural disaster), you are The benefits available to Members under any other Plan not responsible for paying any bills as long as you will be coordinated pursuant to the provisions of this received proper authorization from your PacifiCare section to avoid duplicate payment to Members for the Participating Provider.You may, however, be responsible same or similar benefits or services. for any properly authorized Covered Services from a Non-Participating Provider, or Emergency or Urgently In the event that the order of benefit determination rules set forth in this section differ from those permitted Needed Services from a Non-Participating Provider. by Colorado Insurance Regulation 4-6-2, or any NOTE: If you receive a bill because a Non-Participating successor regulation, then the order of benefit Provider refused to accept payment from PacifiCare,you determination rules set forth herein will be construed as may submit a claim for reimbursement. See above: "Bills if their terms conformed to the minimum requirements From Non-Participating Providers." of that regulation. Coordination of Benefits This Coordination of Benefits ("COB") provision applies to this Plan when a Subscriber or the Subscriber's Coordination of Benefits (COB) is a process, regulated covered Dependent has health care coverage under more by law, which determines the financial responsibility for than one Plan. "Plan"and"This Plan"are defined below payment when a person has group health care coverage under more than one plan. "Plan"is defined below. If this COB provision applies, the order of benefit COB is designed to provide maximum coverage for determination rules should be looked at first. The order medical and Hospital Services at the lowest cost by of benefit determination rules are stated in Order of avoiding excessive or duplicate payments. Benefit Determination Rules. Those rules determine whether the benefits of This Plan are determined before The objective of COB is to ensure that all group Health or after those of another Plan. The benefits of This Plan: Plans that provide coverage to an individual will pay no more than 100% of the allowable expense for services • Will not be reduced when, under the order of that are received. This payment will not exceed total benefit determination rules, This Plan determines its expenses incurred or the reasonable cash value of those benefits before another Plan; but services and supplies when the group Health Plan • May be reduced when, under the order of benefits provides benefits in the form of services rather than determination rules, another Plan determines its cash payments. benefits first. The above reduction is described in PacifiCare's COB activities will not interfere with Effect on the Benefits of This Plan. your medical care. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. ID Section Six - Payment Responsibility \ 1/ A.Definitions When there are more than two Plans covering the individual, This Plan may be a Primary Plan as to The following definitions only apply to coverage one or more other Plans, and may be a Secondary provided under this explanation of Coordination of Plan as to a different Plan or Plans. Benefits. 1. "Plan" is any of the following which provides 4. 'Allowable Expense"means a necessary, reasonable and customary item of expense for health care; benefits, indemnification or services for, or because when the item of expense is covered at least in part of, medical or dental care or treatment covered by by one or more Plans covering the individual for This Plan: whom the claim is made. • Group insurance or group-type coverage The difference between the cost of a private hospital (including other PacifiCare coverage),whether room and cost of semi-private hospital room is not insured or uninsured. This includes prepayment, considered an Allowable Expense under the above group practice or individual practice coverage. It definition unless the patient's stay in a private also includes coverage other than school accident- hospital room is Medically Necessary either in terms type coverage. of generally accepted medical practice or as • Coverage under a governmental Plan, or coverage specifically defined in the Plan. required or provided by law. This does not When a Plan provides benefits in the form of include a state Plan under Medicaid (Grants to services, the reasonable cash value of each service States for Medical Assistance Programs, Title XIX rendered will be considered both an Allowable of the United States Social Security Act, as Expense and a benefit paid. amended from time to time). When benefits are reduced under a Primary Plan • Individual automobile "no-fault"or traditional because a covered individual does not comply with "fault" type contracts. the Plan provisions, the amount of such reduction will • Hospital indemnity benefits in excess of$100 not be considered an Allowable Expense. Examples of per day such provisions are those related to second surgical opinions, precertification of admissions or services Each contract or other arrangement for coverage under any bulleted item above is a separate Plan. and preferred Provider arrangements. Also, if an arrangement has two parts and COB rules 5. "Claim Determination Period"means the period apply only to one of the two, each of the parts is a of time,which must not be less than twelve separate Plan. consecutive months, over which allowable expenses 2. "This Plan" refers to the covered benefits for health are compared with total benefits payable in the care services of the Combined Evidence of Coverage absence of COB, to determine: and Disclosure Form of which this section is a part. • Whether overinsurance exists; and 3. "Primary Plan/Secondary Plan"The order of • How much each plan will pay or provide. benefit determination rules state whether this Plan It usually is a calendar year, but a plan may use is a Primary Plan or a Secondary Plan as to another some other period of time that fits the coverage of Plan covering the person. the group contract.A person may be covered by a When This Plan is a Primary Plan, its benefits are plan during a portion of a Claim Determination determined before those of the other Plan and Period if that person's coverage starts or ends without considering the other Plan's benefits. during the Claim Determination Period. When This Plan is a Secondary Plan, its benefits are As each claim is submitted, each plan is to determined after those of the other Plan and may be determine its liability and pay or provide benefits reduced because of the other Plan's benefits. based upon allowable expenses incurred to that point in the Claim Determination Period. But that a Section Six - Payment Responsibility determination is subject to adjustment as later C.Rules. This Plan determines its order of allowable expenses are incurred in the same Claim benefits using the first of the following rules Determination Period. which applies However, it does not include any part of a year Rule a:Non-Dependent/Dependent. The benefits of the during which an individual has no coverage under Plan which covers the person as an employee, Member This Plan, or any part of a year before the date this or Subscriber (that is, other than as a Dependent) are COB provision or a similar provision takes effect. determined before those of the Plan which covers the individual as a Dependent. B.Order of Benefit Determination Rules Rule b:Dependent Child/Parents not Separated or 1. General. When there is a basis for a claim under Divorced. Except as stated in Rule c below,when This This Plan and another Plan, This Plan is a Secondary Plan and another Plan cover the same child as a Plan which has its benefits determined after those of Dependent of different persons, called "parents": the other Plan unless: • The benefits of the Plan of the parent whose • The other Plan has rules coordinating its benefits birthday falls earlier in a year are determined before with those of This Plan, and both those rules and those of the Plan of the parent whose birthday falls This Plan's rules, below, require that This Plan's later in the year; but benefits be determined before those of the other Plan; or • If both parents have the same birthday, the benefits of the plan which covered one parent longer are • The other Plan is a governmental Plan or coverage determined before those of the Man which covered required or provided by law, and This Plan is the other parent for a shorter period of time. required by law or regulation to be the Primary Plan.A basis for a claim under a governmental Plan However, if the other plan does not have the rule can exist when a Member is covered or eligible for described in the first bulleted item immediately above, coverage under that Plan,whether or not the but instead has a rule based upon the gender of the Member applies for or receives benefits thereunder. parent, and if, as a result, the Plans do not agree on the The conditions shown are current examples order of benefits, the rule of the other Plan will (subject to change) of some of the areas in which determine the order of benefits. this Plan is required to be the Primary Plan. Rule c:Dependent Child/Separated or Divorced. If two —The Member is covered under the Civilian Health or more plans cover an individual as a Dependent child and Medical Program of the Uniformed Services of divorced or separated parents, benefits for the child (TRICARE/CHAMPUS). are determined in this order: —The Member is covered under Medicaid. • First, the Plan of the parent with custody of the child; —The Member is actively at work and is age 65 or 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 • Finally, the Plan of the parent not having custody of twenty(20) or more employees. the child. —The Member is entitled to Medicare benefits on However, if the specific terms of a court decree state the basis of End Stage Renal Disease, in which that one of the parents is responsible for the health care case This Plan will be primary for the first thirty expense of the child, and the entity obligated to pay or (30) months (or such period of time as Medicare provide the benefits of the Plan of that parent has actual regulations may require) of treatment; after the knowledge of those terms, the benefits of that Plan are initial period, the benefits under This Plan will determined first. The Plan of the other parent will be be reduced to the extent that they duplicate any the Secondary Plan. This paragraph does not apply with benefits provided or available under Medicare, if respect to any Claim Determination Period or Plan Year the Member is covered or eligible to be covered during which any benefits are actually paid or provided under Medicare. before the entity has that actual knowledge. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. ED • Section Six - Payment Responsibility �. Rule d:Joint Custody. If the specific terms of a court made, exceeds those Allowable Expenses in a decree state that the parents will share joint custody, Claim Determination Period. In that case, the without stating that one of the parents is responsible for benefits of This Plan will be reduced so that they the health care expenses of the child, the Plans covering and the benefits payable under the other Plans do the child will follow the order of benefit determination not total more than those Allowable Expenses. rules outlined in Rule b. 3. Only the amount of benefit actually paid by This Rule e:Active/inactive Employee. The benefits of a Plan Plan may be charged against any applicable Limit which covers a person as an employee who is neither under This Plan. laid off nor retired (or as that employee's Dependent) are determined before those of a Plan which covers that E.Right To Receive and Release Needed person as a laid off or retired employee (or as that Information employee's Dependent). If the other Plan does not have Certain facts are needed to apply these COB rules. this rule, and if, as a result, the Plans do not agree on PacifiCare has the right to decide which facts it needs. It the order of benefits, then Rule e is ignored. may get needed facts from or give them to any other Rule f:Longer/Shorter Length of Coverage. If none of organization or individual. PacifiCare need not tell, or the above rules determines the order of benefits, the get the consent of, or provide notice to, any individual to benefits of the Plan which covered an employee, Member do this. Each individual claiming benefits under This or Subscriber longer are determined before those of the Plan must give PacifiCare any facts it needs to pay the Plan which covered that individual for the shorter term. claim. Rule g:Disputed Order of Benefits. If the plans can not F. Facility of Payment agree on the order of benefits within thirty (30) A payment made under another Plan may include an calendar days after the plans have received all of the amount that should have been paid under This Plan. If information needed to pay the claim, the plans shall it does, PacifiCare may pay that amount to the immediately pay the claim in equal shares and organization which made that payment. That amount determine their relative liabilities following payment will then be treated as though it were a benefit paid except that no plan shall be required to pay more than under This Plan. PacifiCare will not have to pay that it would have paid had it been primary. amount again. The term"payment made" includes providing benefits in the form of services, in which case D.Effect On the Benefits of This Plan "payment made" means reasonable cash value of the 1. When This Section Applies. This Subsection applies benefits provided in the form of services. when, in accordance with Order of Benefit Determination Rules, This Plan is a Secondary Plan G.Right of Recovery as to one or more other Plans. In that event the If the amount of the payments made by PacifiCare is benefits of This Plan may be reduced under this more than it should have paid under the COB section. Such other Plan or Plans are referred to as provision, it may recover the excess from one or more "the other Plans" immediately below. of: 2. Reduction in Ibis Plan's Benefits. The benefits of • The individuals it has paid or for whom it has paid; This Plan will be reduced when the sum of: • Insurance companies; or •The benefits that would be payable for the • Allowable Expense under This Plan in the absence Other organizations. of this COB provision; and The "amount of payments made" includes the •The benefits that would be payable for the reasonable cash value of any benefits provided in the Allowable Expenses under the other Plans, in the form of services. absence of provisions with a purpose like that of this COB provision, whether or not a claim is 50 Section Six - Payment Responsibility H.Motor Vehicle No-Fault Insurance I. Workers' Compensation 1. Under Colorado law, if a Member owns and 1. PacifiCare will not provide benefit services or operates a motor vehicle on the public highways, supplies required as a result of a work-related illness the Member is required to have no-fault or injury, except for those individuals who are not insurance, which covers certain medical and required to maintain or be covered by workers' rehabilitation expenses incurred if a Member or compensation insurance as defined in workers' others are injured in an automobile accident. compensation Laws. This applies to illness or injury 2. PacifiCare is required by law to coordinate its resulting from occupational accidents or sickness coverage with a Member's no-fault insurance. covered under any of the following: This means that if a Member is injured in an •Occupational disease laws automobile accident, the automobile no-fault insurance will pay first, and PacifiCare will •Employer's liability provide coverage only if the amount of no-fault •Federal, State, or municipal law coverage is insufficient to pay for all of the medical expenses. •The Workers' Compensation Act 2. To recover benefits for a work-related illness or a. PacifiCare's coverage under this Group Agreement includes the amount of the injury, the Member must pursue his/her rights under the Workers' Compensation Act or any of the above deductible under the no-fault coverage. provisions that may apply to the illness or injury. 3. If there is an automobile policy in effect, and This includes filing an appeal with the Industrial the Member waives or fails to assert his/her Commission, if necessary. rights to the no-fault benefits, PacifiCare will not pay the benefits that would have been a. When a legitimate dispute exists as to whether an injury or illness is work-related, PacifiCare available under the no-fault policy. will provide benefits during the appeal process 4. If the no-fault insurance policy provides if the Member signs an agreement to reimburse coverage in excess of the minimum required by PacifiCare for 100% of the benefits provided. law, PacifiCare will coordinate benefits with the amount of coverage provided. work-related rkfare will not provide benefit services for a work-related illness or injury even under the 5. PacifiCare reserves the right to require proof following circumstances: that the automobile policy has paid all benefits •The Member fails to file a claim within the filing required by law before PacifiCare pays any benefits. period allowed by law. 'The Member obtains care that is not authorized by 6. If there is more than one automobile policy in force, PacifiCare will coordinate with complying workers' compensation. no-fault policies as required by the state of •The Member fails to comply with any other Colorado. provisions of the law 7. After benefits under the no-fault policy have •The Member has a choice of Providers, which been exhausted, coverage under the terms of includes a PacifiCare Provider, elects to use a Non- this Group Agreement will be available only if Participating Provider and the claim is the Member obtains all medical care for covered subsequently denied by workers' compensation. benefits in compliance with this Group 4. Benefits will not be denied to a Subscriber whose Agreement from or through a participating Primary Care Physician. employer has not complied with the laws and regulations governing worker's compensation Insurance, provided that such Subscriber has sought and received services under the provisions of this Group Agreement. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. / Section Six - Payment Responsibility . . «. J. PacifiCare's right to the repayment of a debt as Important Rules for Medicare and Medicare a charge against recoveries from third parties Eligible Members liable for a Member's health care expenses You must let PacifiCare know if you are enrolled, or 1. Coverage for any portion of health care expenses eligible to enroll in, Medicare (Part A and/or Part B incurred by a Member for which a third party or coverage). PacifiCare is typically primary (that is parties or a third party's (parties') insurance PacifiCare's benefits are determined before those of company (collectively, "liable third party") is liable Medicare) to Medicare for some initial period of time, as or legally responsible by reason of negligence, a determined by the Medicare regulations. After the initial wrongful intentional act, or the breach of any legal period of time, PacifiCare will be secondary to Medicare obligation on the part of such third party, are (that is, the benefits under this Health Plan will be expressly excluded from coverage under this Health reduced to the extent they duplicate any benefits Plan. HOWEVER, in all cases, PacifiCare will pay for provided or available under Medicare, if the Member is the arrangement or provision of health care services enrolled or eligible to enroll in Medicare.) for a Member who requires such services due to a If you are eligible for Medicare, but fail to enroll in liable third party in exchange for the following Medicare,your PacifiCare coverage will be reduced by agreement: the amount you would have received from Medicare. a. If a Member is injured by a liable third party, the If you have questions about the coordination of Medicare Member agrees to give PacifiCare or its benefits, contact your Employer Group or our Customer representative, agents, and/or delegates a Service department. For questions regardi(ig Medicare security interest in any money the Member actually recovers from the liable third party by eligibility, contact your local Social Security office. way of any final judgment, compromise, settlement, or agreement, even if such money becomes available at some future time. b. If the Member does not pursue, or fails to recover (either because no judgment is entered or because no judgment can be collected from the liable third party) a formal, informal, direct, or indirect claim against the liable third party, then the Member will have no obligation to repay the Member's debt to PacifiCare, which debt shall include the cost of arranging or providing otherwise covered health care services to the Member for the care and treatment that was necessary because of a liable third party The security interest the Member grants to PacifiCare or its representative, agents, and/or delegates applies ONLY to the actual proceeds, in any form, that stem from any final judgment, compromise, settlement, or agreement relating to the arrangement or provision of the Member's health care services for injuries caused by a liable third party. Section Seven - Member Eligibility Member Eligibility • Children who are legally adopted or placed for adoption with the Subscriber or the Subscriber's Spouse who meet the requirements described • Membership Requirements above. Legal evidence of the adoption must be furnished to PacifiCare upon request; •Adding Dependents • Children for whom the Subscriber or the Subscriber's Spouse has assumed permanent legal • Late Enrollment guardianship. Legal evidence of the guardianship, such as a certified copy of a court order, must be furnished to PacifiCare upon request; • Updating Your Enrollment Information • Children for whom the Subscriber or the Subscriber's Spouse is required to provide health • Termination of Enrollment insurance coverage pursuant to a Qualified Medical Child Support Order in this section; • Coverage Options Following Termination • Children must reside inside the PacifiCare HMO This section describes bow you become a PacifiCare Service Area, or be enrolled as a full-time student at Member, as well as how you can add Dependents to an elementary school, middle school, high school, your coverage. It will also answer other questions college, university, vocational, or secondary school. about eligibility, such as when late enrollment is Verification of academic enrollment must be permitted. In addition,you will learn ways you may provided to PacifiCare on request% be able to extend your PacifiCare coverage when it • Newborns of the Subscriber are covered from the would otherwise terminate. date of birth. This does not include an adopted Who Is a PacifiCare Member? child before the child is placed with the Subscriber for adoption; and There are two kinds of PacifiCare Members: Subscribers and enrolled Dependents. The Subscriber is the person • Regardless of age, any natural, adopted, or step- who enrolls through his or her employer-sponsored child(ren), of the Subscriber, or child(ren) for whom health benefit plan. The Employer Group, in turn, has the Subscriber has assumed permanent legal signed a Group Agreement with PacifiCare. guardianship, as described above, are eligible if they are medically certified as disabled and incapable of The following family members are eligible to enroll in self-support. Proof of such incapacity and PacifiCare: dependency must be furnished at least annually as • The Subscriber's Spouse; requested by PacifiCare, and as required by the subscribing group. Such Dependents are the only • Common Law Spouses will be considered eligible exception to the age Limitation described above. Dependents if evidence satisfactory to PacifiCare is furnished upon request; Your Dependent children cannot be denied enrollment and eligibility due to the following: • The unmarried biological children of the Subscriber or the Subscriber's Spouse (step-children) through the • Was born to a single person or unmarried couple; month in which they reach the Limiting age of nineteen • Is not claimed as a Dependent on a Federal Income (19), or twenty four (24) if enrolled as a full-time Tax Return; student at high school,college, university,vocational,or secondary school.Your Employer Group may establish • Does not reside with the Subscriber or within the different criteria regarding the following Dependent PacifiCare HMO Service Area. eligibility Check with your employer or our Customer Service department for information regarding the Dependent age Limit(s) or other Dependent eligibility information applicable to your Employer Group; Questions about your benefits? Call the Customer Service department at 1-800-877-9777. El Section Seven - Member Eligibility Li imer Mild wwn 1 Morgan What Is an der n HMO Service Area? 4 Adams mom nytoo PacifiCare is licensed by the -, 2 3 Arapahoe Colorado Division of Insurance tail to arrange for medical and °g Elbert Hospital Services in certain Park I geographic areas of Colorado. L &Peso Lincoln These service areas are 1-- defined by ZIP codes. Please Fremont call our Customer Service department for information r about PacifiCare's HMO Service Area. 1•Broomfield 2-Clear Creek 3-Denver 4-Gilpin Eligibility Enrollment is the completion of a PacifiCare enrollment All form (or a nonstandard enrollment form approved by Members must meet all eligibility requirements PacifiCare) by the Subscriber on his or her own behalf, established by the Employer Group and PacifiCare. or on the behalf of any eligible family member. PacifiCare may request evidence to validate eligibility Enrollment is conditional upon acceptance by requirements. PacifiCare's eligibility requirements are: PacifiCare; the existence of a valid Employer Group • Have a Primary Residence within Colorado; Agreement; and the timely payment of applicable Health Plan Premiums. PacifiCare may in its discretion and • Meet any other eligibility requirements established subject to specific protocols, accept enrollment data by the Employer Group, such as exhaustion of a through an electronic submission. waiting period before an employee can enroll in PacifiCare. Employers will also establish the Your effective date of enrollment in PacifiCare will depend "Limiting age," the age Limit for providing coverage on when and how you enroll. These circumstances are to unmarried children, provided that it is not more explained below. (Please note: PacifiCare enrolls restrictive than the requirements set forth by the applicants in the order that they become eligible and up State of Colorado. to our capacity for accepting new Members.) Eligible Dependents must enroll in PacifiCare at the Open Enrollment same time as the Subscriber or risk not being eligible to enroll Most Members enroll in PacifiCare during the Open until the employer's next Open Enrollment Period, as explained below Circumstances when Enrollment Period established by the Employer Group. enrolling is allowed outside the Open Enrollment This is the period of time established by the employer Period is also explained below All applicants for when its Eligible Employees, and their eligible family coverage must complete and submit to PacifiCare all members, may enroll in the employer's health benefit PacifiCareplan.An Open Enrollment Period usually occurs once a applications or other forms or statements that PacifiCare year, and enrollment is effective based on a date agreed may reasonably request. upon by the employer and PacifiCare. Typically, this is at the start of a calendar year. Section Seven - Member Eligibility Adding Family Members To Your Coverage Continuing Coverage for Student and Disabled The Subscriber's Spouse and eligible children may apply Dependents for coverage with PacifiCare during the employer's Open Certain Dependents who would otherwise lose coverage Enrollment Period. If you are declining enrollment for under the Health Plan due to their attainment of the yourself or your Dependents (including your Spouse) Limiting age established by the Employer Group may because of other Health Plan or insurance coverage,you extend their coverage under the following may in the future be able to enroll yourself or your circumstances: Dependents in PacifiCare, provided that you request enrollment within thirty(30) days after your other Continuing Coverage for Student Dependents coverage ends. In addition, if you have a new Dependent An unmarried Dependent who is registered on a full-time as a result of marriage, birth, adoption or placement for basis (at least twelve [12] semester units or the equivalent adoption,you may enroll yourself and your Dependents, as determined by PacifiCare) at an accredited school or provided that you request enrollment within thirty(30) college may continue as an Eligible Dependent through days after the marriage, birth, adoption or placement for the month in which they reach the age of twenty-four adoption. (Guardianship is not a Qualifying Event for (24), or if greater, the Limiting age established by the other family members to enroll). Under the following employer for full-time students, if proof of such status is circumstances, new family members may be added provided to PacifiCare on a periodic basis, as requested outside the Open Enrollment Period. by us. If the Dependent student resides outside of the • HMO Service Area,the student must maintain a Getting married.When a new Spouse or child permanent address with the Subscriber and the student becomes an eligible family member as a result of marriage, coverage begins on the first day of the must select a Primary Care Physician within the HMO Service Area address.All health care coverage must be month following the date of marriage.An application to enroll a Spouse or child eligible as a provided or arranged in the HMO Service Area by the designated Primary Care Physician, except for Emergency result of marriage must be made within thirty (30) and Urgently Needed Services. days of the marriage. • Having a baby. Newborns are covered for the first Continuing Coverage for Certain Disabled thirty-one (31) days of life. In order for coverage to Dependents continue beyond the first thirty-one (31) days of life, Unmarried enrolled Dependents, who attain the the Subscriber must submit a Change Request Form Limiting age established by the employer, may continue to PacifiCare prior to the expiration of the thirty-one enrollment in the Health Plan beyond the Limiting age if (31)-day period. the unmarried Dependent meets all of the following: • Adoption or Placement for Adoption.To enroll a 1. The unmarried Dependent resides with the new Dependent acquired through legal adoption, Subscriber or the Subscriber's separated or divorced the Subscriber must submit written application for Spouse; Dependent coverage within thirty (30) days of when the child is placed with the Subscriber for adoption. 2. The unmarried Dependent is medically certified as The Subscriber also must submit a copy of the disabled; and adoption papers. Coverage is effective on the date of 3. The unmarried Dependent is chiefly dependent adoption or placement for adoption. upon the Subscriber for support and maintenance. • Guardianship.To enroll a Dependent child for In order to continue coverage under this section for whom the Subscriber has assumed permanent legal qualifying disabled Dependents, proof of such disability guardianship,the Subscriber must submit a Change and dependency must be provided to PacifiCare by the Request Form to PacifiCare along with a certified Member at the onset of the disability, attainment of the copy of a court order granting guardianship within Limiting age or at the time of the Subscriber's initial thirty(30) days of when the Subscriber assumed legal enrollment in PacifiCare. guardianship. Coverage will be retroactively effective to date the Subscriber assumed legal guardianship. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. ED Section Seven - Member Eligibility :• Proof of such incapacity and dependency must be vii. An individual who is employed by a PacifiCare furnished at least annually as requested by PacifiCare, subscribing group and who previously declined and as required by the Employer Group. This proof may enrollment is entitled to enroll if the employee has include supporting documentation from a state or a new Dependent by birth, marriage, adoption, or federal agency, or a written statement by a licensed placement for adoption. The election to enroll must psychologist, psychiatrist, or other Physician to the be made within thirty (30) days following the birth, effect that such disabled Dependent is medically marriage, adoption, or placement for adoption. certified as disabled. NOTE: PacifiCare reserves the right to make it a Late Enrollment condition of enrollment that PacifiCare receives written proof of loss of coverage due to one of the In addition to a special enrollment period due to the following circumstances: addition of a new Spouse or child, there are certain circumstances when employees and their Eligible •Termination of job or reduction in hours; Dependents may enroll outside of the employer's Open •Insurance carrier termination of coverage for the Enrollment Period. These circumstances include: Spouse's employer; 1. The Eligible Employee (on his or her own behalf, or •Death of the Spouse, leaving other Dependents on behalf of any Eligible Dependents) declined in without coverage. writing to enroll in PacifiCare when they were first eligible because they had other health care 3. A court has ordered that coverage be provided for a coverage; and Dependent under a covered employee's health benefit plan. 2. The other health care coverage is no longer available due to: 4. A court has ordered that coverage be provided under an eligible, but not enrolled, employee's i. The employee or Eligible Dependent has health benefit plan. The employee is required to exhausted COBRA Continuation Coverage enroll at the same time as the Dependent. under another group Health Plan; or If the employee or an Eligible Dependent meets these ii. The termination of employment or reduction in conditions, the employee must request enrollment with work hours of a person through whom the PacifiCare no later than thirty (30) days following the employee or Eligible Dependent was covered; or termination of the other Health Plan coverage. iii. The termination of the other Health Plan PacifiCare may require proof of loss of the other coverage; or coverage. Enrollment will be effective the first day of the calendar month following receipt by PacifiCare of a iv. The cessation of an employer's contribution completed request for enrollment. toward the employee or Eligible Dependent coverage; or v. The death, divorce or legal separation of a person through whom the employee or Eligible Dependent was covered; or vi. The Spouse of a Subscriber has coverage through his/her employment, and Dependents of the Subscriber are covered under the Spouse's insurance. Then the Spouse involuntarily loses this coverage.At this time, the Spouse, if alive, and any Dependents of the Subscriber previously covered by the Spouse's insurance may enroll in PacifiCare as Dependents, with the consent of the subscribing group; or a Section Seven - Member Eligibility -,1,-O311miltoreutireinular Renewal and Reinstatement About Your PacifiCare F ;$•' tare Your Employer Group's Group Agreement with Your PacifiCare ID carts is important for Stet identifying you 6 PacifiCare renews automatically, on a yearly basis, as a Member of PacifiCare. Possession off Otis tai subject to all terms of the Group Agreement. If the does not entitle a Member to services*Wadi 14 Group Agreement is terminated by PacifiCare, under this Health Plan.AMember sl jd show;Ints, "„ reinstatement is subject to all terms and conditions of card each time he orshe:y t a " i the Group Agreement. Physician or, upon �„a Kq' Provider.At the time of service,afi ember Ending Coverage (Termination of Benefits) identify him/herself lee toneetetWtenntreet &itler= Usually,your enrollment in PacifiCare terminates when as a PacifiCare members if a/she doe51'ibt o so, or if` the Subscriber or enrolled Dependent is no longer the member misrepresents his/her m ip ;` eligible for coverage under the employer's health Attt status, claims payment sale l tt benefit plan. Coverage can be terminated, however, because of other circumstances as well, which are IMPORTANT NOTE:Anypanda t lard t ; described below. receive benefits or )Ant ,, entitled will be charged` such ben n r s r�iee.1 Continuing coverage under this Health Plan is subject to If any Member permits the use of td§ Ei , the terms and conditions of the employer's Group identification card by any othel` n. ` , " Tr, Agreement with PacifiCare. immediately termiinatethat e* �q When the Group Agreement between the Employer 4r;. Group and PacifiCare is terminated, all Members covered under the Group Agreement become ineligible Notifying You of Changes In Your Plan for coverage on the date of termination. If the Group Amendments, modifications or termination of the Agreement is terminated by PacifiCare for nonpayment Group Agreement by either the Employer Group or of Premiums, coverage for all Members covered under PacifiCare do not require the consent of a Member. the Group Agreement will be terminated effective the PacifiCare may amend or modify the Health Plan, last day for which Premiums were received.According including the applicable Premiums, at any time by to the terms of the Group Agreement, the Employer providing a thirty (30)-day written notice to the Group is responsible for notifying you if and when the Employer Group prior to the effective date of any Group Agreement is terminated for any reason, amendment or modification.Your Employer Group may including the nonpayment of Health Plan Premiums. also change your Health Plan benefits during the PacifiCare is not obligated to notify you that you are no contract year. In accordance with PacifiCare's Group longer eligible or that your coverage has been Agreement, the Employer Group is obliged to notify terminated. Upon termination of the Group Agreement employees who are PacifiCare Members of any such for nonpayment of Premium, Members in groups with amendment or modification. fifty (50) or fewer employees, or as required by small group health insurance laws, are entitled to conversion Updating Your Enrollment Information coverage. Members in groups with more than fifty (50) Please notify your employer of any changes to the employees are not entitled to conversion coverage upon information you provided on the enrollment application termination of the group plan. within thirty(30) days of the change.This includes PacifiCare may terminate this Agreement if any one of changes to your name, address, telephone number, the following events occurs: i) fraud or intentional marital status or the status of any enrolled family misrepresentation of material fact; ii) failure to comply members. For reporting changes in marital and/or with contribution or participation rules; movement Dependent status, please see"Adding Family Members to iii) outside of the HMO Service Area by all Members of the Your Coverage." If you wish to change your primary care subscribing group; iv) cessation of membership of a Physician,you may contact PacifiCare's Customer Service sub-group in an association; v) failure to comply with department at 1.800-877-9777 or 1-800-659-2656 (TDD). the requirements set forth in this Group Agreement; or vi) as otherwise specified in this Group Agreement. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. ID , CSection Seven - Member Eligibility i. In addition to terminating the Group Agreement, • Fraud or Misrepresentation.Your coverage may be PacifiCare may terminate a Member's coverage for any terminated immediately if you knowingly provide of the following reasons: false information (or misrepresent a meaningful • The Member no longer meets the eligibility fact) on your enrollment form or fraudulently or requirements established by the Group Employer deceptively use services or facilities of PacifiCare or and/or PacifiCare. other health care Providers (or knowingly allow another person to do the same), including altering a • The Member establishes his or her Primary prescription. If coverage is terminated for any of the Residence outside the State of Colorado. above reasons,you forfeit all rights to enroll in the • The Member establishes his or her Primary Residence PacifiCare conversion plan (discussed below) or outside the PacifiCare HMO Service Area and does not COBRA Plan and lose the right to re-enroll in work inside the PacifiCare HMO Service Area(except PacifiCare in the future. The termination is effective for a child subject to a qualified child medical support immediately on the date PacifiCare mails the notice order, for more information refer to"Qualified of termination, unless PacifiCare has specified a later Medical Child Support Order" in this section). date in that notice. • Disruptive Behavior.Your coverage may be Termination for Cause: terminated after not less than a ten (10) day written Coverage of any Member will end on the earliest one of notice from PacifiCare, if you conduct yourself in a the following dates: manner that is deemed to be threatening, violent or • The date specified in the Group Subscriber abusive towards, or jeopardizes the safety of, Agreement; PacifiCare employees, or its Providers, their their staff, or other patients. If coverage is terminated for any of • The last day of the month in which the Subscriber the above reasons,you forfeit all rights to enroll in terminates employment; the PacifiCare conversion plan (discussed below) or • The last day of the month that the required COBRA Plan and lose the right to re-enroll in Premium has been paid; PacifiCare in the future. The termination is effective immediately on the date PacifiCare mails the notice • The last day of the month in which the Member of termination, unless PacifiCare has specified a later request 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 PacifiCare as explained below hospital/patient relationship, including leaving an inpatient facility against medical advice, and in the PacifiCare has the right to terminate your coverage judgement of two or more Participating Providers, under this Health Plan in the following situations: no professionally acceptable covered treatment • Failure To Pay.Your coverage may be terminated if alternative exist, then the Member will be so advised. you fail to pay any required Copayments and/or If you still refuse to accept the recommended coinsurance, within ten (10) days of being properly procedure and/or treatment, then the Participating notified and you failed to comply with or are Provider, and PacifiCare will have no further liability or unwilling to make appropriate payment responsibility to provide care for the condition under arrangements. If coverage is terminated for any of treatment and/or the Member and/or any Dependents the above reasons,you forfeit all rights to enroll in may be terminated after not less than ten (10) days the PacifiCare conversion plan (discussed below) or written notice from PacifiCare to the Member and the COBRA Plan and lose the right to re-enroll in Subscribing Group. If termination results from refusal PacifiCare in the future. The termination is effective of compliance, the Member and any of his/her immediately on the date PacifiCare mails the notice Dependents will not be eligible to re-enroll, in any of termination, unless PacifiCare has specified a later PacifiCare plan, in any capacity, until the first group date in that notice. Open Enrollment Period following termination. a ru Section Seven - Member Eligibility J • If you are unable to establish and maintain a • Except as specifically described above, all rights to satisfactory Physician-patient relationship with a covered benefits will end on the effective date of Participating Provider,your coverage may be termination. If a Member is confined to a hospital or terminated with not less than ten (10) days written inpatient facility on the Member's termination date, notice from PacifiCare. If termination results from coverage will be extended until the Member is failure to establish a Primary Care Physician discharged from the hospital or inpatient facility, relationship, the Member and any of his/her unless the termination was due to nonpayment of Dependents will not be eligible to re-enroll, in any Premium or fraud. Prenatal and maternity care are PacifiCare plan, in any capacity until the first group not considered confinement. Therefore, PacifiCare Open Enrollment Period following termination. will not continue coverage past the termination date for a Member receiving prenatal or postnatal care. • If you permit the use of your PacifiCare ID card by any other person, the card will be reclaimed by NOTE: If a Group Agreement is terminated by PacifiCare and all rights of the Member and his/her PacifiCare, reinstatement with PacifiCare is subject to all Dependents under this Combined Evidence of terms and conditions of the Group Agreement between Coverage and Disclosure Form will immediately be PacifiCare and the employer. terminated. Payment for services or other benefits Ending Coverage: Special Circumstances for received improperly through the use of an ID card are the financial obligation of the individual who Enrolled Family Members: used the ID card improperly. If termination of a Subscribers must terminate Dependent's coverage Member results from the misuse of the ID card, the because of the Dependent's death, divorce, marriage, Subscriber and any of his/her Dependents will not induction into active military service, or failure to be eligible to re-enroll, in any PacifiCare plan, in any maintain the eligibility conditions in this section. The capacity, at any time. Subscriber must submit an enrollment change form to PacifiCare within thirty (30) days of the change in status. • Your coverage may be terminated if a Subscriber's The termination is effective on the last day of the month working hours are reduced by his/her employer to in which the change in status occurred, regardless of less than twenty-four (24) hours per week.An whether the subscribing group gives PacifiCare timely employee whose working hours are reduced as notice of the changes. described below, may be entitled to Continuation Coverage as described in this section.The The Subscriber shall be responsible for any services 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 stated in this section. The subscribing group agrees to same terms of the Group Subscriber's Agreement and assist PacifiCare in obtaining reimbursement for any this Combined Evidence of Coverage and Disclosure amounts paid when a Subscriber's Dependent is not Form if all of the following conditions are true: eligible. The Subscriber has been continuously employed as All 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 PacifiCare will refund a maximum of one month's Agreement replaces, for at least six (6) months Premium, if paid in advance for a Dependent whose immediately before the reduction in working hours; coverage is terminated, if the following are true: The reduction of working hours is due to economic • Notification of the change is received by PacifiCare conditions; and within thir ty (30) days of the change; The employer intends to increase the Subscriber's • PacifiCare has not paid any claims for the working hours to the full forty (40) hour work Dependent within thirty (30) days; and schedule as soon as economic conditions improve. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. fl Section Seven - Member Eligibility +• • Termination of the Dependent results in a change to 3. Divorce or legal separation from your Spouse; or the Premium rate. 4. Your Spouse becomes entitled to Medicare. Please refer to "Coverage Options Following In the case of a Dependent child of a Subscriber Termination" for additional coverage which may be enrolled in this Health Plan, he or she has the right to available to you. Continuation Coverage if group health coverage under Coverage Options Following Termination this Health Plan is lost for any of the following five reasons: If your coverage through this Combined Evidence of Coverage and Disclosure Form ends,you and your 1. The death of the Subscriber; enrolled Dependents may be eligible for additional 2. A termination of the Subscriber's employment (for Continuation Coverage: reasons other than gross misconduct) or reduction Federal COBRA Continuation Coverage in the Subscriber's hours of employment to less than the number of hours required for eligibility; If the Subscriber's Employer Group is subject to Colorado law, Section 10-16-108 C.R.S., and the Consolidated 3. The Subscriber's divorce or legal separation; Omnibus Budget Reconciliation Act of 1985, as amended 4. The Subscriber becomes entitled to Medicare; or (COBRA),you may be entitled to temporarily extend your coverage under the Health Plan at group rates, plus an 5. The Dependent child ceases to be a Dependent eligible for coverage under this Health Plan. administration fee, in certain instances where your coverage under the Health Plan would otherwise end. Under COBRA, the Subscriber or enrolled Dependent This discussion is intended to inform you, in a summary has the responsibility to inform the Employer Group fashion, of your rights and obligations under COBRA. (or, if applicable, its COBRA administrator) of a divorce, However,your Employer Group is legally responsible for legal separation, disability determination or a child informing you of your specific rights under COBRA. This losing Dependent status under the Health Plan within section is a general notice and should not be regarded as sixty (60) days of the date of the event.Your Employer a complete discussion of the applicable provisions. Group has the responsibility to notify its COBRA Therefore, please consult with your Employer Group administrator of the Subscriber's death, termination, regarding the availability and duration of COBRA reduction in hours of employment or Medicare Continuation Coverage. entitlement. Similar rights may apply to certain retirees, If you are a Subscriber covered by this Health Plan,you Spouses, and Dependent children if your employer have a right to choose COBRA Continuation Coverage if commences a bankruptcy proceeding and these you lose your group health coverage because the individuals lose coverage. termination of your employment (for reasons other than when the COBRA administrator is notified that one of gross misconduct on your part) or the reduction of these events have happened, the COBRA administrator hours of employment to less than the number of hours will in turn notify you that you have the right to choose required for eligibility. Continuation Coverage. Under the law,you have at least If you are the Spouse of a Subscriber covered by this sixty (60) days from the date you would lose coverage Health Plan, you have the right to choose COBRA because of one of the events described above to inform Continuation Coverage for yourself if you lose group the COBRA administrator that you want Continuation health coverage under this Health Plan for any of the Coverage. For Members in groups with less than twenty (20) employees, notification is required within thirty following four reasons: (30) days. 1. The death of your Spouse; If you do not choose Continuation Coverage on a 2. A termination of your Spouse's employment (for timely basis, your group health insurance coverage reasons other than gross misconduct) or reduction under this Health Plan will end. in your Spouse's hours of employment to less than the number of hours required for eligibility; 60 Section Seven - Member Eligibility If you choose Continuation Coverage,your Employer 5. The Qualified Beneficiary extends coverage for up to Group is required to give you coverage which, as of the twenty-nine (29) months due to disability and there time coverage is being provided, is identical to the has been a final determination that the individual is coverage provided under the plan to similarly situated no longer disabled. employees or family members. COBRA permits you to Under the law,you may have to pay all of the Premium maintain Continuation Coverage for thirty-six (36) for your Continuation Coverage. Premiums for COBRA months, unless you lost group health coverage because Continuation Coverage is generally 102% of the of a termination of employment or reduction in hours. applicable Health Plan Premium. However, if you are on In that case, the required Continuation Coverage period a disability extension, your cost will be 150% of the is eighteen (18) months. This initial eighteen (18)-month applicable Premium.You are responsible for the timely period may be extended for affected individuals up to submission of the COBRA Premium to the Employer thirty-six (36) months from termination of employment Group or COBRA administrator. Your Employer Group if other events (such as a death, divorce, legal separation, or COBRA administrator is responsible for the timely Medicare entitlement), or Dependent child ceases to be submission of Premium to PacifiCare. At the end of the an Eligible Dependent under this Health Plan occur eighteen (18)-month, twenty-nine (29)-month or thirty- during that initial eighteen (18)-month period. In six (36)-month Continuation Coverage period, qualified addition, the initial eighteen (18)-month period may be beneficiaries will be allowed to enroll in a PacifiCare extended up to twenty-nine (29) months if you are individual conversion Health Plan (see the explanation determined by the Social Security Administration to be under"Extending Your Coverage: Converting to an disabled at any time during the first sixty(60) days of Individual Conversion Plan"). COBRA Continuation Coverage. Please contact your Employer Group or its COBRA administrator for more If you have any questions about COBRA, please contact information regarding the applicable length of COBRA your Employer Group. Continuation Coverage available. Extending Your Coverage: Converting To an A child who is born to or placed for adoption with the Individual Conversion Plan Subscriber during a period of COBRA Continuation Availability:Any Member who is no longer eligible for Coverage will be eligible to enroll as a COBRA Qualified part as coverageof a subscribing Beneficiary. These COBRA qualified beneficiaries can be g group may convert to individual conversion membership without regard to added to COBRA Continuation Coverage upon proper health status or requirement for health care services. notification to the Employer Group or COBRA The Member cannot elect conversion coverage if he/she administrator of the birth or adoption. is eligible for continuation or COBRA coverage (See However, under COBRA, the Continuation Coverage Limitations, below for additional information). may be cut short for any of the following five reasons: The Subscriber must convert his/her membership 1. Your Employer Group no longer provides group according to the policies that PacifiCare has in effect at health coverage to any of its employees; the time of application for conversion. 2. The Premium for Continuation Coverage is not paid Conversion coverage plans offered are the Basic and on time; Standard Health Benefit plans mandated by the State of 3. The Qualified Beneficiary becomes covered-after the Colorado. date he or she elects COBRA Continuation Coverage Notification Requirements: The Employer Group is -under another group Health Plan that does not solely responsible for notifying former employees contain any exclusion or Limitation with respect to or Dependent Spouses (including former Spouses any pre-existing condition he or she may have; as defined above) of the availability of the coverage 4. The Qualified Beneficiary becomes entitled to at least one hundred eighty(180) calendar days Medicare or Medicaid after the date he or she elects before COBRA is scheduled to end. To elect this COBRA Continuation Coverage; or coverage, the former employee must notify the plan in writing at least thirty(30) calendar days before COBRA is scheduled to end. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. ED Section Seven - Member Eligibility . . Limitations: Notwithstanding provisions in this section, Uniformed Services Employment and a Subscriber and/or Dependents will have no conversion Reemployment Rights Act rights if the Subscriber is no longer eligible to continue Continuation of Benefits under USERRA. Continuation as a Member of the subscribing group for any of the Coverage under this Health Plan may be available to you following reasons: through your employer under the Uniform Services • Termination of entire group if the group has fifty- Employment and Reemployment Rights Act of 1994, as one (51) or more employees, or as required by amended (USERRA). The Continuation Coverage is small group health insurance laws equal to, and subject to the same Limitations as, the benefits provided to other Members regularly enrolled • Termination for nonpayment of applicable in this Health Plan. These benefits may be available to Premiums or Copayments you if you are absent from employment by reason of • Termination due to failure to comply with service in the United States uniformed services, up to recommended procedures or treatments the maximum eighteen (18)-month period if you meet • Gross abuse of PacifiCare's plan rules and the USERRA requirements. USERRA benefits run concurrently with any benefits that may be available regulations through the Consolidated Omnibus Budget • Falsifying membership information Reconciliation Act (COBRA) of 1985, as amended.Your employer will provide written notice to you for USERRA Election: The Member must convert his/her membership within thirty-one (31) days of the date Continuation Coverage. he/she becomes ineligible for coverage under the If you are called to active military duty and are stationed subscribing group. The conversion is effective outside of the HMO Service Area, you or your Eligible retroactive to the date of ineligibility. Dependents must still maintain a permanent address inside the HMO Service Area and must select a Out-of-Area: PacifiCare may designate an insurance carrier Participating Primary Care Physician. For HMO Coverage to provide conversion benefits to those persons Only: To obtain coverage, all care must be provided or who cease to be eligible for coverage because they no arranged in the HMO Service Area by the designated longer maintain residence within the HMO Service Area. Participating Primary Care Physician, except for Benefits, terms, and Premiums of the conversion contract Emergency and Urgently Needed Services. will be determined by the designated insurance carrier. The Health Plan Premium for USERRA Continuation of Certificate of Creditable Coverage benefits is the same as the Health Plan Premium for According to the requirements of the Health Insurance other PacifiCare Members enrolled through your Portability and Accountability Act of 1996 (HIPAA), a employer plus a 2% additional surcharge or Certificate of Creditable Coverage will be provided to administrative fee, not to exceed 102% of your the Subscriber by either PacifiCare or the Employer employer's active group Premium.Your employer is Group when the Subscriber or a Dependent ceases to responsible for billing and collecting Health Plan be eligible for benefits under the employer's health Premiums from you or your Dependents and will benefit plan.A Certificate of Creditable Coverage may forward your Health Plan Premiums to PacifiCare along be used to reduce or eliminate a preexisting condition with your employer's Health Plan Premiums otherwise exclusion period imposed by a subsequent Health Plan. due under this Group Agreement.Additionally, your Creditable Coverage information for Dependents will be employer is responsible to maintain accurate records included on the Subscriber's Certificate, unless the regarding USERRA Continuation Member Health Plan Dependent's address of record or coverage information Premium, Qualifying Events, terminating events and any is substantially different from the Subscriber. Please other information that may be necessary for PacifiCare contact the PacifiCare Customer Service department if to administer this continuation benefit. you need a duplicate Certificate of Creditable Coverage. a Section Seven - Member Eligibility • . Qualified Medical Child Support Order Except for Emergency and Urgently Needed Services, to A Member (or a person otherwise eligible to enroll in receive coverage, all care must be provided or arranged PacifiCare) may enroll a child who is eligible to enroll in in the PacifiCare HMO Service Area by the designated PacifiCare upon presentation of a request by a District Participating Primary Care Physician, as selected by the Attorney, State Department of Health Services or a court custodial parent or person having legal custody order to provide medical support for such a Dependent child without regard to any enrollment period restrictions. A person having legal custody of a child or a custodial parent who is not a PacifiCare Member may ask about obtaining Dependent coverage as required by a court or administrative order, including a Qualified Medical Child Support Order, by calling PacifiCare's Customer Service department.A copy of the court or administrative order must be included with the enrollment application. Information including, but not Limited to, the ID card, Combined Evidence of Coverage and Disclosure Form or other available information, including notice of termination, will be provided to the custodial parent, caretaker and/or District Attorney Coverage will begin on the first of the month following receipt by PacifiCare of an enrollment form with the court or administrative order attached. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. ID Section Eight - Overseeing , k. Your Health Care Overseeing Your Health Care • Decisions to approve, modify, or deny requests for authorization of health care services based on Medical Necessity will be made in a timely fashion • How PacifiCare Makes Important Decisions appropriate for the Member's condition. Decisions will be made within a time frame that does not exceed 5 business days from PacifiCare's receipt of • What To Do If You Have a Problem any reasonably necessary and requested information. • Quality Care Review • If the Member's condition poses an imminent and serious threat to his or her health (including, but •Appeals and Grievances not Limited to, potential loss of life, limb, or other major bodily function, or if lack of timeliness would • New Treatments and Technologies be detrimental to the Member's life or health or jeopardize his or her ability to regain maximum This section explains bow PacifiCare authorizes or function), the decision will be made in a timely makes changes to your health care services, how we fashion appropriate for the Member's condition. evaluate new health care technologies and how we Decisions will be made within a time frame that reach decisions about your coverage. does not exceed seventy-two (72) hours from You will also find out what to do if you're having a PacifiCare's receipt of any reasonably necessary problem with your health care plan, including how to and requested information. appeal a health care decision by PacifiCare or one of PacifiCare or the Participating Medical Group will notify our Participating Providers. You'll learn the process the Provider and the Member in writing when a decision that's available for filing a formal grievance, as well as cannot be made within the required time frame for any bow to request an expedited decision when your of the following reasons: condition requires a quicker review. • PacifiCare is not in receipt of all of the information How PacifiCare Makes Important reasonably necessary and requested; Health Care Decisions • PacifiCare requires consultation by an expert Authorization, Modification and Denial of reviewer; or Health Care Services • PacifiCare has asked an additional examination or PacifiCare has established processes to review, approve, test, provided the examination or test is reasonable modify, or deny requests by Providers for authorization and consistent with good medical practice. of the provision of health care services to Members The notification will specify the information requested based on Medical Necessity. PacifiCare uses criteria or but not received, or the additional examinations or tests guidelines based on Medical Necessity to reach a required. It will also include the anticipated date by determination. Any criteria or guidelines used to modify which a decision will be rendered. Upon receipt of all or deny requested health care services in specific types information reasonably necessary and requested by of cases will be disclosed to the Member, the Provider, PacifiCare, PacifiCare will approve, modify or deny the and the public upon request request for authorization within the applicable time Decisions to deny or modify requests for authorization frame specified above. of health care services for a Member, based on Medical At a minimum, PacifiCare will notify requesting Necessity, are made only by licensed Physicians or other Providers of a decision to approve, modify, or deny a appropriately licensed health care professionals.At a request for the authorization of health care services minimum, PacifiCare makes these decisions within the within twenty-four (24) hours of the decision. Members following time frames required by state law: are notified of decisions to deny, delay or modify a Section Eight - Overseeing Your Health Care requested health care services in writing within two (2) • PacifiCare Technology Assessment Guidelines (TAG) business days of the decision. This notification will and Benefit Interpretation Policies (BIP). include a description of the reasons for the decision, Those cases that meet the criteria for coverage and level the criteria or guidelines used, the clinical reasons for of service are approved as requested. Those not meeting decisions regarding Medical Necessity, and information the utilization criteria are referred for review to a about how to file an appeal of the decision with PacifiCare medical director. PacifiCare. PacifiCare's Appeals Process is outlined later in this section. Denial, delay or modification of health care services based on Medical Necessity must be made by a licensed •' "`° "" Physician or a licensed health care professional who is PacifiCare's Utilization Management t, competent to evaluate the specific clinical issues PacifiCare distributes its policy on-financial incentives involved in the health care services requested by the to all its Participating Providers Men s and -.{`4&. Provider. employees. PacifiCare also requires t(taz,Parttcipatulg.t Denials may be made for administrative reasons that Providers and staff who make utifization*siena.. include, but are not Limited to, the fact that the patient and those who supervise them,sign•a.document•„; . is not a PacifiCare Member, or that the service being acknowledging receipt of this policy,The policy requested is not a benefit provided by the Member's affirms that a utilization management decision is . plan based solely on the appropriateness ofka g}ven xw treatment and service,as well as theeiastenee of.., Preauthorization determinations are made once the coverage. PacifiCare does not specifically reward PacifiCare medical director or designee receives all Participating Providers or other individuals reasonably necessary medical information. PacifiCare conducting utilization review for issuing denials of makes timely and appropriate initial determinations coverage. Financial incentives for Utilization based on the nature of the Member's medical condition Management decision makers do not encourage in compliance with State and Federal Requirements. decisions that result in either the dehiaC,or 2 Member agrees that their Provider will be their modification of Medically Necessary Covered Service;. "authorized representative" (pursuant to ERISA) regarding receipt of approvals or requests for health A copy of PacifiCare's policies and procedures may be care services for purposes of medical management. requested, as well as a description of the processes used for the authorization, modification or denial of health A58@ssment of New TechnehQQleB ' •w 't` care services. Copies of PacifiCare's criteria or guidelines are also available. Please contact the PacifiCare regularly reviews"newprocedures,'t4eVtces Customer Service department at 1-800-877-9777. and drugs to determine whether or not theyare;safe , Ana:effective for:Pier Members.The,Tecfnology, ,# Utilization Criteria ;Assessment and Guideline Committee --F c*n§iststg L ' PacifiCare,mefical directors, Primary Care When a Provider or Member requests preauthorization of a procedure/service requiring preauthorization, a Physicians, pharmacists and specialists — cgndudt¢,`b licensed professional reviews the request. The licensed •scare#ul reviews of case studies,clinical literatu e,and, professional applies the applicable criteria including, opinions of review organizations,such asGRI ,.;.. (formerly the Emergency Care Research institute),the, but not Limited to: Health Technology Assessment Information M _ l, • InterQual• Criteria (Nationally published criteria for the HAYE$ New Technology Summaried the ltQ utilization management) 'Nehlth Care Policy and Research,t ka1 ,t*nf '-` • HCIA-Sachs Length of Stay°Guidelines (Average 't t fled l Drug Administration decisions ss length of hospital stays by medical or surgical diagnoses); Questions about your benefits? Call the Customer Service department at 1-800-877-9777. ID Section Eight - Overseeing 9IL Your Health Care `. What To Do If You Have a Problem other PacifiCare departments.We also review medical PacifiCare's top priority is meeting our Members' needs, records as necessary, and you may need to sign an but sometimes you may have an unexpected problem. authorization to release your medical records. When this happens,your first step should be to call our We will notify you in writing regarding your quality of Customer Service department. We'll assist you and care review. The results of the quality of care review are attempt to find a solution to your situation. A complaint confidential and protected from legal discovery in form will be provided to the Member if the Member accordance with Colorado law wishes to register a written complaint. The Appeals Process If you have a concern about your treatment or a decision regarding your medical care,you may be able to request Claims Involving Utilization Review a second medical opinion.You can read more about If you are not satisfied with a determination and wish to requesting, as well as the requirements for obtaining a pursue the issue further,you or the Member's second opinion, in Section Two, Seeing the Doctor. authorized representative may either submit a verbal or If you feel that we haven't assisted you or that your written request to initiate the appeal process.Written situation requires additional action, you may also requests, which may include comments, documents, request a formal Appeal or Quality Review. To learn records, and any other information relating to your more about this, read the following section, "Appealing appeal regardless of whether this information was a Health Care Decision." submitted or considered in the initial determination, should be directed to PacifiCare Member Appeals Team. Appealing a Health Care Decision An appeal must be initiated within one hundred and Our appeals and quality of care review procedures are eighty (180) days of the date of the initial denial. designed to deliver a timely response and resolution to plan Internal Review Committee (PIRC) your complaints. This is done through a process that includes a thorough and appropriate investigation, as This committee shall include a minimum of three well as an evaluation of the complaint. To initiate an people, and will be composed of employees of appeal or quality of care review, call our Customer PacifiCare who have appropriate education, training, Service department or write the Appeals Department at: and professional expertise in the field of medicine. The PIRC will make a decision within thirty (30) days from PacifiCare Administrative Offices the date of the Member or Member's authorized Member Appeals Team representative original request. PO Box 4306 Englewood, Colorado 80155-4306 Expedited Review Your request initiates the appeal and/or the quality of In cases where the time frame set forth below,would care review processes described below. If the complaint seriously jeopardize the life or health of the Member, or involves the Medical Necessity of a treatment, the issue would jeopardize the Member's ability to regain will be determined by a medical reviewer with the maximum function, subject the Member to severe pain education, training and relevant expertise necessary to that cannot be adequately managed with the care or evaluate the specific clinical issues that are the basis of treatment, PacifiCare will conduct an Expedited Review. your concern. This review shall be provided to all requests concerning an admission, availability of care, continued stay or Quality of Care Review health care service for a Member who has received All quality of care complaints requiring clinical review Emergency Services but has not been discharged from a are reviewed by PacifiCare's Health Services department. facility. In an expedited review, PacifiCare shall make a Complaints affecting your immediate condition are decision and notify the Member or ordering Provider as reviewed immediately. PacifiCare conducts this review by expeditiously as the Member's medical condition investigating the complaint and consulting with your requires, but no later than seventy-two (72) hours after the request is received. If the Expedited Review is Participating Medical Group, treating Providers, and a Section Eight - Overseeing Your Health Care conducted during the Member's hospital stay or course will deliver a copy of the request to the Division of of treatment, the service shall be continued without Insurance (DOI) within two (2) working days, or within liability to the Member until the Member has been one (1)working day for an expedited independent notified of the decision; for cases where a twenty-four external review Within two (2) working days (or one (1) (24)-hour advance notice was provided, the Member or working day for an expedited review) from the time a ordering Provider will be notified of the decision within request for external review is received from PacifiCare, twenty-four (24) hours. If additional information is the DOI will assign an approved Independent External required in order to decide the request, the Member or Review Entity(the "review entity") to conduct the authorized representative will be notified within twenty- external review, and shall notify PacifiCare of such entity. four (24) hours of receipt of the request of what specific Within two (2) working days (or within one (1) working information is necessary in order to make a decision. In day for an expedited review) of receiving notice of the all cases, PacifiCare will provide written confirmation of review entity from the DOI, PacifiCare shall notify the its decision within two (2) working days of providing Member or the authorized representative, electronically, notification of the decision, if the initial notification was by facsimile, or by telephone, followed by a written not in writing. confirmation. Standard Independent External Review Within two (2) working days of receipt of notice from If the Member is not satisfied with the decision of the PacifiCare, the Member or the authorized representative PIRC, the Member or the Member's authorized may provide the DOI with documentation regarding a representative may request an independent external potential conflict of interest of the review entity, electronically, by facsimile, or by telephone, followed by review. The Independent External Review process is available to all PacifiCare Members who have completed a written confirmation. each of the internal appeals review levels offered by If the DOI determines that the review entity presents a PacifiCare or have completed an expedited review of a conflict of interest, the DOI shall assign, within one (1) denial of a benefit pursuant to state regulation. working day, another review entity to conduct the Expedited Independent External Review external review. The DOI shall notify the Member and PacifiCare of the name and address of the new review A Member or the Member's authorized representative entity to which the appeal should be sent. may make a request for an expedited external review if the Member has a medical condition where the time Within six (6) working days (or within three (3) working frame for completion of a standard external review days for an expedited review) of the date the DOI would seriously jeopardize the life or health of the notifies PacifiCare of the review entity, PacifiCare shall Member,would jeopardize the Member's ability to deliver to the assigned review entity the documents and regain maximum function, subject the Member to severe information considered in making the determination. pain that cannot be managed adequately without the Within two (2) working days (or within one (1) working care or treatment, or, for Members with a disability, day for an expedited review) of receipt of the materials, create an imminent and substantial limitation of their the review entity shall deliver to the Member or the existing ability to live independently. The Member or authorized representative, the index of all materials that the authorized representative's request for an expedited PacifiCare has submitted to the review entity. PacifiCare review must include a Physician's certification that the shall provide to the Member or authorized Member's medical condition meets the criteria. representative, upon request, all relevant information supplied to the review entity that is not confidential or Review Time Frames privileged under state or federal law concerning the All requests for an independent external review must be case under review made within sixty (60) calendar days of the date the The review entity shall notify the Member or the Member receives the PIRC denial. The Member, the authorized representative, the health care professional, Member's Physician, or the Member's authorized and PacifiCare of any additional medical information representative may submit a written request for an required to conduct the review Within five (5) working independent external review. PacifiCare, upon receipt of days (or within two (2) working days for an expedited a completed request for an independent external review review) of such a request, the Member or the authorized Questions about your benefits? Call the Customer Service department at 1-800-877-9777. ID Section Eight - Overseeing k Your Health Care `° representative or the health care professional shall If the Member is not satisfied with the decision of the submit the additional information, or an explanation of Standard or Expedited Independent External Review why the additional information is not being submitted Panel, the Member may, one hundred and eighty(180) to the review entity and PacifiCare. If the Member or days of the decision from the Independent External authorized representative or the health care Review Panel, submit the claim to binding arbitration, as professional fails to provide the additional information described in below If a written request is not submitted or the explanation of why additional information is not as stated, then the action or claim denial will be final. being submitted within the time frame specified, the Arbitration assigned review entity shall make a decision based on the information submitted by PacifiCare. If a Member is not satisfied with the resolution of a legal claim after exhausting all levels of the appeals process The reviewer's decision will be in writing and will applicable to the claim, PacifiCare and the Member include the reasons why the service or procedure is or is agree that they shall submit the claim to binding not Medically Necessary, or is or is not Experimental or arbitration in accordance with the Commercial Investigational, as applicable. The determinations of the Arbitration Rules of the American Arbitration Association reviewer shall be binding on the health coverage plan. unless both PacifiCare and the Member agree in writing Where a determination is made in favor of the covered to use another form of alternative dispute resolution individual requesting an independent external review, (e.g. mediation). The results of the binding arbitration coverage for the treatment and services required shall be shall be final, with no further recourse in a court of law provided subject to the terms and conditions applicable or otherwise available to either PacifiCare or the to benefits under PacifiCare's health coverage plan. Member.Judgement upon the award rendered by the Within thirty (30) working days (or within seven (7) arbitrator(s) shall be entered in any court having working days for an expedited review) after the date of jurisdiction. PacifiCare and the Member shall equally receipt of the request for external review, the review share the costs of arbitration; however, each party shall entity shall provide written notice of its decision to be individually responsible for the expenses related to uphold or reverse PacifiCare's final adverse its attorney, experts and evidence. Binding arbitration is determination to the Member or the Member's Limited to appeals that are not subject to ERISA. authorized representative, PacifiCare, the Physician or other health care professional and the DOI. The Benefit Denials reviewer may request that the DOI extend the deadline This section is applicable to complaints and appeals not for the written notice of the review entity up to ten (10) related to claims involving Utilization Review as working days (or five (5) working days for an expedited described above. review) for the consideration of additional information. If you are not satisfied with the resolution and wishes to Upon PacifiCare's receipt of the independent external pursue the issue further, the Member or the Member's review entity's notice of a decision reversing PacifiCare's authorized representative must submit a written or final adverse determination, PacifiCare shall approve the verbal request to initiate the Member appeal process. coverage that was the subject of the final adverse Written requests, which may include comments, determination. For concurrent and prospective reviews, documents, records, and any other information relating and for expedited reviews, PacifiCare shall approve the to your appeal regardless of whether this information coverage with one (1) working day. For retrospective was submitted or considered in the initial reviews, PacifiCare shall approve the coverage within determination, should be directed to the PacifiCare five (5) working days of the receipt of the Independent Member Appeals Team.Verbal requests should be External Review entity's decision. For all reviews, directed to our Customer Service department. An PacifiCare shall provide written notice of the approval to appeal must be initiated within one hundred and eighty the Member or the authorized representative within one (180) days of the date of the initial denial. (1) working day of PacifiCare's approval of coverage. The coverage shall be provided subject to the terms and conditions applicable to benefits under the health coverage plan. a Section Eight - Overseeing 1 Your Health Care Member Relations Committee Review except as Colorado law provides for judicial review of The Member Relations Committee will provide a formal arbitration proceedings. Member and PacifiCare are review and respond to the Member or authorized giving up their constitutional rights to have any such representative within thirty (30) calendar days of dispute decided in a court of law before a jury, and are PacifiCare's receipt of the original request. In addition, instead accepting the use of binding arbitration by a the internal criteria or benefit interpretation policy, in single arbitrator in accordance with the Commercial any, relied upon in making this decision will be made Arbitration Rules of the American Arbitration Association available upon request by the Member. (AAA), and administration of the arbitration shall be performed by the American Arbitration Association or If you are not satisfied with the decision of the Member such other arbitration service as the parties may agree in Relations Committee, the Member may,within one writing. The parties will endeavor to mutually agree to hundred and eighty (180) days of the decision from the the appointment of the arbitrator, but if such agreement Member Relations Committee, submit the claim to cannot be reached within thirty (30) days following the binding arbitration. If a written request is not submitted date demand for arbitration is made, the arbitrator as stated, then the action or claim denial will be final. appointment procedures in the Commercial Arbitration Arbitration Rules will be utilized. If a Member is not satisfied with the resolution of a legal Arbitration hearings shall be held in Arapahoe County, claim after exhausting all levels of the Member appeals Colorado or at such other location as the parties may process applicable to the claim, PacifiCare and the agree in writing. Civil discovery may be taken in such Member agree that they shall submit the claim to arbitration as provided by Colorado law. The arbitrator binding arbitration in accordance with the Commercial selected shall have the power to control the timing, Arbitration Rules of the American Arbitration Association scope and manner of the taking of discovery and shall unless both PacifiCare and the Member agree in writing further have the same powers to enforce the parties' to use another form of alternative dispute resolution respective duties concerning discovery as would a (e.g. mediation). The results of the binding arbitration Superior Court of Colorado including, but not Limited shall be final, with no further recourse in a court of law to, the imposition of sanctions. The arbitrator shall have or otherwise available to either PacifiCare or the the power to grant all remedies provided by Colorado Member.Judgment upon the award rendered by the law The parties shall divide equally the expenses of AAA arbitrator(s) shall be entered in any court having and the arbitrator. In cases of extreme hardship, jurisdiction. PacifiCare and the Member shall equally PacifiCare may assume all or part of the Member's share share the costs of arbitration; however, each party shall of the fees and expenses of AAA and the arbitrator, be individually responsible for the expenses related to provided the Member submits a hardship application to its attorney, experts and evidence. Binding arbitration is AAA. The approval or denial of the hardship application Limited to appeals that are not subject to ERISA. will be determined solely by AAA. The arbitrator shall prepare in writing an award that Binding Arbitration includes the legal and factual reasons for the decision. "Any and all disputes of any kind whatsoever, including, The requirement of binding arbitration shall not preclude but not Limited to, claims for medical malpractice (that a party from seeking a temporary restraining order or is as to whether any medical services rendered under preliminary injunction or other provisional remedies the Health Plan were unnecessary or unauthorized or from a court with jurisdiction; however, any and all other were improperly, negligent, or incompetently rendered) claims or causes of action including, but not Limited to, between Member (including any heirs or assigns) and those seeking damages, shall be subject to binding PacifiCare except for claims subject to ERISA shall be arbitration as provided herein. The Federal Arbitration submitted to binding arbitration. Any such dispute will Act, 9 U.S.C. SS 1-16, shall also apply to the arbitration. not be resolved by a lawsuit or resort to court process, Questions about your benefits? Call the Customer Service department at 1-800-877-9777. 0 Section Eight - Overseeing �. L Your Health Care Complaints Against Participating Providers, In the event of a dispute between you and a Participating Physicians and Hospitals Provider for claims not involving benefits, PacifiCare Claims against a Participating Physician, or Provider, agrees to make available the Member appeals process for Physician or Hospital—other than claims for benefits resolution of such dispute. In such an instance, all under your coverage—are not governed by the terms parties must agree to this resolution process.Any of this plan. You may seek any appropriate legal action decision reached through this resolution process will not against such persons and entities deemed necessary. be binding upon the parties except upon agreement between the parties. The grievance will not be subject to binding arbitration except upon agreement between the parties. Should the parties fail to resolve the grievance, you or the Participating Provider may seek any appropriate legal action deemed necessary. Member claims against PacifiCare will be handled as discussed above under`Appealing a Health Care Decision." 70 Section Nine - General Information General Information within the limitation of such facilities and personnel. Neither PacifiCare nor any Participating Medical Group shall have any liability or obligation for delay or failure • How To Replace Your Card to provide or arrange for medical and Hospital Services if such delay or failure is the result of any of the • Translation Assistance circumstances described above. How Does PacifiCare Compensate Its • Speech and Hearing Impaired Assistance Participating Providers? PacifiCare itself is not a Provider of health care. • Coverage In Extraordinary Situations PacifiCare has a working relationship between its Members and a network of more than 4,300 health care • Compensation for Providers Physicians, including Primary Care Physicians (who are internists, pediatricians, and family practitioners) and What follows are answers to some common and specialists.As an HMO, PacifiCare's obligation to its uncommon questions about your coverage. If you have Members is to furnish benefits in the form of medical any questions of your own that haven't been answered, services through its contract Providers. Therefore, it is please call our Customer Service department. important to you that you follow PacifiCare procedures and use the Providers that have contracts with PacifiCare. What Should I Do if I Lose or Misplace My Membership Card? NOTE: PacifiCare contract Providers are independent contractors and are not agents or employees of PacifiCare. If you should lose your card, simply call our Customer Service department.Along with sending you a Many of PacifiCare's participating Physicians are replacement card, they can make sure there is no organized into groups of primary care Physicians and interruption in your coverage. specialists who have joined together to provide services to PacifiCare Members. This unique arrangement has Does PacifiCare Offer a Translation Service? benefits for patients and doctors alike. For those PacifiCare uses a telephone translation service for Physicians affiliated in this manner primary care almost one hundred forty (140) languages and dialects. Physicians belong to just one group, but some That's in addition to select Customer Service specialists may have more than one affiliation.When department representatives who are fluent in Spanish. you need specialty care, your Primary Care Physician may refer you to a specialist with whom he or she is Does PacifiCare Offer Hearing and Speech affiliated. Primary Care Physicians typically have Impaired Telephone Lines? established relationships with other doctors to whom PacifiCare has a dedicated telephone number for the they will most likely refer patients when specialized care is needed. Primary care Physicians work closely with the hearing and speech impaired. This phone number is: 1-800-659-2656. specialty Physicians they know and trust—to ensure that each Member receives the care he or she needs. How Is My Coverage Provided Under This system of referring creates a framework for Extraordinary Circumstances? effective coordinated care and communications There are circumstances not reasonably within the regarding patient health, supported by trusting control of PacifiCare, such as major disasters, epidemics, Physician relationships—all important elements of a complete or partial destruction of facilities, wars, riots quality health care system. Referring to a specialist with or civil insurrection, which results in the unavailability whom your Primary Care Physician is familiar makes it of PacifiCare, its personnel, facilities, or the Participating easy for your Primary Care Physician to communicate Medical Group. In such situations, PacifiCare, the with both you and your specialist and coordinate your Participating Medial Group and facilities shall provide or care. PacifiCare's policy is to encourage Primary Care attempt to arrange for medical and Hospital Services Physicians to consider patients' input in care decisions. insofar as practical, according to their best judgment, This arrangement benefits patients and doctors alike. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. D Section Nine - General Information . An Access Plan detailing the managed care network is The following is the address for the Customer Service available upon request. Please contact our Customer department: Service department at 1-800-877-9777. PacifiCare Customer Service Department How To Get Heip P O. BOX 6770 Englewood, CO 80155 Customer Service Mental Health/Substance Abuse Assistance You can contact PacifiCare's Customer Service department (PacifiCare Behavioral Health) for assistance concerning anything about PacifiCare and your benefits. The following are examples of the Toll Free: 1-888-777-2735 subjects you might call about: " Jz 1 ,.R c 1 F* dives • You have changed your address. . • tr`td t decisions. includes the You cannot find a specific detail about your F coverage in your Combined Evidence of Coverage ,,„ ,x 'rttl+trrMare written and Disclosure Form. ih tter n ishe5 about your v t tiertt efto !nictions are used in the • You want to change your Primary Care Physician (PCP). 001 U lMM* kh health care • You need an updated copy of the Provider Directory Obial4iiiirldithdiiiiiigtOtt required to have The Customer Service department staff can usually any adVanfe'direCtiice i i �jqitecinmceive care and answer your question while you are on the line. If not, Areatrriertt:YOU MW4ioR ► 5{'Ifirkrriedobout them. they will get the answer you need and promptly return your call. ,, ether or not you , oca directives,you will erve th'e f catieiat f eatment appropriate for To Call f t (Qk 74 �W Stour consent. You may call our Customer Service department at '° kt u ► 1 eCdirectives before 'yooge<t,toOtick<to i}-o4ermtrrtunicate clearly. The 1-800-877-9777 Monday through Friday during the s, �, hours of 7 a.m. to 8 p.m. Call early to receive the most kinds of;adv iota: dt l directives recognized in Colorado are the NiiinifvalL"(which applies in cases of prompt service. Please have your membership number #erminai.illnessk,itiei"txiettira!durable power of (usually the Subscriber's Social Security number) from , ,:attorney hich y named agent to make your ID card ready. 4 ecia to of k—' q U le to make them) a c � z, r � .,.: Spanish language assistance is available by calling our `And (►e CPR d 1 i(1h atloWs you to reject Customer Service department at 1-800-877-9777 Monday cardlop iiineraty r uir Mlon1;these documents do through Friday during the hours of 7 a.m. to 8 p.m. Call not take away your right to decide what you want, if early to receive the most prompt service. Please have you are able to dq so,'< your membership number (usually the Subscriber's Should a PacifiCare Metnber execute an advance Social Security number) from your ID card ready directive,your physicien'or any other medical Provider, Se offrece assistencia en Espanol, si llama al Centro de including Medicare-and Medicaid-certified hospitals, Servicio 1-800-877 9777 I,unes a Viernes durance las Skilled Nur sing'f�3dilkies,`homeheelth agencies, horas de 7 a.m. a 8 p.m. Favor de llamar temprano para hospice programs,aRtt3 stance personnel, should recibir servicio rapido. Se requiera que tenga su numero be informed in order toinciude a notation in your de identificacion de su tarjeta disponible para recibir record.a c ordii gty.A copy of your executed .advance directive should be sent to your Primary Care servicio (numero igual a su numero de Seguro Social). Physician.not PacifiCgre. To Write =tYogr d,cls o i to dOdvance directive has no If you need to write to the Customer Service efledeh'your Pact `b leflts or eligibility. department please note your membership number , PacifiCare will not dlikOlininate against a Member (usually the Subscriber's Social Security number) from based on whether he Oahe has or has not executed your ID card on any correspondence. an advance directive.:; r a Section Ten - Definitions Definitions Complementary and Alternative Medicine-Defined by the National Center for Complementary and PacifiCare is dedicated to making its services easily Alternative Medicine as the broad range of healing philosophies (schools of thought), approaches, and accessible and understandable. To help you therapies that Conventional Medicine does not understand the precise meanings of many terms used to explain your benefits, we have provided the commonly use, accept, study, or make available. following definitions. These definitions apply to the Generally defined, these treatments and health care capitalized terms used in your Combined Evidence of practices are not taught widely in medical schools and Coverage and Disclosure Form, as well as the Schedule not generally used in hospitals. These types of therapies used alone are often referred to as "alternative."When of Benefits. used in combination with other alternative therapies, or Annual Out-of-Pocket Maximum-The maximum in addition to conventional therapies, these therapies amount of Copayments a Member is required to pay for are often referred to as "complementary." certain Covered Services in a contact year. (Please refer Continuation Coverage-Coverage provided to to your Schedule of Benefits.) a terminated Subscriber and/or his/her eligible Case Management-A collaborative process that Dependents as mandated or required by Section assesses, plans, implements, coordinates, monitors and 10-16-108 C.R.S., Tide X, Consolidated Omnibus evaluates options to meet an individual's health care Budget Reconciliation Act of 1985, as amended, or needs based on the health care benefits and available any other applicable law resources in order to promote a quality outcome for the Contracting Medical Group—An independent practice individual Member. association (IPA) or medical group of Physicians that has Chronic Care—A pattern of care that focuses on long- entered into a written agreement with PacifiCare to term care of individuals with chronic (long-standing, provide Physician services to PacifiCare's Members.An persistent) diseases or conditions. It includes care IPA contracts with independent contractor Physicians specific to the problem as well as other measures to who work at different office sites.A medical group encourage self-care, to promote health, and to prevent employs Physicians who typically all work at one or loss of function. several physical locations. Chronic Condition-A medical condition that is Under certain circumstances, PacifiCare will perform continuous or persistent over an extended period of time administrative services performed by the Member's and requires ongoing treatment for its management. Contracting Medical Group as described in this Claim Determination Period-Usually a calendar year, Combined Evidence of Coverage and Disclosure Form. This includes, but is not Limited to, when the Member's please refer to Section Mx, Payment Responsibility. Primary Care Physician contracts directly with PacifiCare Common Law Marriage-Evidence of cohabitation as and there is no Contracting Medical Group. husband and wife, and general reputation that the two individuals are living together as husband and wife and Conventional Medicine-Defined by the National claiming to be such. By general reputation is meant the Center for Complementary and Alternative Medicine as understanding among the neighbors and acquaintances medicine as practiced by holders of M.D. (medical with whom the parties associate in their daily lives, that doctor) or D.O. (doctor of osteopathy) degrees. Other they are living together as husband and wife, and not terms for conventional medicine are allopathic,Western, that they are merely living together. regular, and mainstream medicine. Common Law Spouse—Party to a Common Law Copayments—The fee that a Member is obligated to Marriage. pay, if any, at the time he or she receives a Covered Service. Copayments are a predetermined amount or percentage to be paid to the Provider by the Member for a specific service. It will not exceed the amount permitted by applicable regulation. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. Section Ten - Definitions .� Covered Services—Medically Necessary services or Dependent—The Subscriber's Spouse and any person supplies provided under the terms of this Combined related to the Subscriber or Spouse by blood, marriage, Evidence of Coverage and Disclosure Form,your adoption or guardianship.An enrolled family member is Schedule of Benefits, and supplemental benefit materials. a family member who is enrolled with PacifiCare, meets all the eligibility requirements of the Subscriber's Creditable Coverage—Benefits or coverage provided under Medicare or Medicaid; an employee welfare Employer Group and PacifiCare, and for whom benefit plan or group health insurance or health benefit Premiums have been received by PacifiCare.An eligible plan; an individual health benefit plan; a state health family member is a family member who meets all the benefits risk pool (including, but not Limited to eligibility requirements of the Subscriber's Employer CoverColorado [formerly Colorado Uninsurable Health Group and PacifiCare. Insurance Plan); or Chapter 55 of title 10 of the United Durable Medical Equipment-Items of medical States code, a medical care program of the federal equipment owned or rented that are placed in the Indian health service or of a tribal organization, a home of the patient to facilitate treatment and/or Health Plan offered under Chapter 89 of title 5, United rehabilitation. Generally, these are items that can States code, a public Health Plan, or a health benefit withstand repeated use, are primarily and customarily plan under Section 5(e) of the federal"Peace Corps Act" used to serve a medical purpose, are usually not useful (22 U.S.C. Sec. 2504 (e)); if there was no gap in to an individual in the absence of illness or injury. coverage of more than sixty-three (63) days between Effective Date of Coverage-The date that coverage such individual policies, and the most recent coverage under this Group Agreement becomes effective. The ended not more than ninety (90) days prior to the Effective Date of Coverage for the subscribing group is effective date of this coverage. shown on the Group Subscriber er Agreement. The Custodial Care-Any skilled or non-skilled health Effective Date of Coverage for a Member is in the services, or personal comfort or convenience related subscribing group's records. services,which provide general maintenance, supportive, Eligible Dependent-A Member of a Subscriber's preventive and/or protective care. Custodial care: family who meets all the eligibility requirements of the • Does not seek a cure. Subscriber's Employer Group and PacifiCare. • Can be provided in any setting. Eligible Employee-is a full time permanent employee • May be provided between periods of acute or of a Employer Group, who has a regular work week of intercurrent health care needs. twenty-four or more hours and includes a sole proprietor and a partner of a partnership if the sole • Is care provided to an individual whose health proprietor or partner is included as an employee under services requirements are stabilized and whose a health benefit plan of a small employer, but does not current medical condition is not expected to include an employee who works on a temporary or significantly and objectively improve or progress substitute basis. over a specified period of time. Emergency Medical Condition-An event or medical Custodial Care may include the supervision or condition which the Member, acting as a Prudent participation of a Physician, licensed nurse, or Layperson, reasonably believes threatens his or her life registered therapist as necessary or desirable services. or limb in such a manner that a need for immediate The mere participation of these professionals does not medical care is created to prevent death or serious preclude the services as being custodial in nature. If the impairment of health. nature of the services can be safely and effectively performed by a trained non-medical person, the services Emergency Services-Health care services provided in are custodial. Further, Custodial Care and the nature of connection with an event which the enrollee reasonably those services are not altered by the availability of the believes threatens his or her life or limb in such a manner that a need for immediate medical care is created to non-medical person. Custodial Care may also be referred to as maintenance, domiciliary, respite, and/or prevent death or serious impairment of health. (For a convalescent care. detailed explanation of Emergency Services, see Section Three, Emergency and Urgently Needed Services.) a Section Ten - Definitions Employer Group—A bona fide employer covering and/or other licensed health facility. Hospice services employees of such employer for the benefit of persons include but shall not necessarily be Limited to the other than the employer; an association, including a following: nursing, Physician, certified nurse aide, labor union, which has a constitution and bylaws and nursing services delegated to other assistants, which is organized and maintained in good faith for homemaker, physical therapy, pastoral counseling, purposes other than that of obtaining insurance. trained volunteer, and social services. ERISA—The Employee Retirement Income Security Act Hospital Services—Services and supplies performed or (ERISA) of 1974 is a federal law designed to protect the supplied by an institution licensed and operated rights of participants and beneficiaries of employee pursuant to law which is primarily engaged in providing welfare benefit plans. Please contact your employer's health services on an inpatient basis for the care and benefit administrator to determine whether your treatment of injured or sick individuals through employer is subject to ERISA. medical, diagnostic and surgical facilities (including a surgical facility which has a bona fide arrangement, by Experimental or Investigational—Defined in the agreement or otherwise, with an accredited hospital to "Exclusions and Limitations of Benefits" section of this Combined Evidence of Coverage and Disclosure Form. Perform such surgical procedures) by, or under the supervision of, a staff of Physicians and which has Group Agreement—The written documents, issued by twenty-four (24)-hour nursing services.A hospital is not PacifiCare to the subscribing group, consisting of primarily a place for rest or custodial care of the aged, Sections One, Two, Three, Four, Five, Six, Seven, and is not a nursing home, convalescent home or Eight, Nine, Ten and Eleven of the Combined similar institution. Evidence of Coverage and Disclosure Form, the Group Infertility—Either: 1) the presence,pf a demonstrated Subscriber Agreement, the application of the condition diagnosed by a Participating licensed subscribing group, the individual applications of the Physician or surgeon as biologically infertile, or 2) the Members, and any written amendments constitute the inability to conceive or to carry a pregnancy to a live entire contract between the parties. birth after a year or more of regular sexual relations Health Plan—A policy, contract, certificate, or without contraception. agreement entered into by, offered to, or issued by a Intermittent Services—See definition for Part-Time or carrier to provide, deliver, arrange for, pay for, or Intermittent Services. reimburse any of the costs of health care services.Your benefit plan as described in this Combined Evidence of Late Enrollee—An Eligible Employee or Dependent Coverage and Disclosure Form,Schedule of Benefits, who requests enrollment in a group health benefit plan and supplemental benefit materials. following the initial enrollment period for which such individual is entitled to enroll under the terms of the HMO Service Area—The geographic area encompassing health benefit plan, if such initial enrollment period is a Adams, Arapahoe, Boulder, Broomfield, Clear Creek, period of at least thirty (30) days.An Eligible Employee Denver, Douglas, El Paso, Elbert, Fremont, Gilpin, or Dependent shall be considered a Late Enrollee if: Jefferson, Larimer, Lincoln, Logan, Morgan, Park, Teller, Washington and Weld Counties of the State of Colorado (a) The individual: and such other area in which PacifiCare is licensed and (I) Was covered under other Creditable Coverage at qualified to conduct the business of an HMO. the time of the initial enrollment period and, if Hospice—A facility or service licensed by the required by the carrier or issuer, the employee Department of Public Health and Environment under a stated at the time of initial enrollment that this centrally administered program of palliative supportive, was the reason for declining enrollment; and and interdisciplinary team services providing physical, (II) Lost coverage under the other Creditable psychological, spiritual, and bereavement care for Coverage as a result of termination of terminally ill individuals and their families within a employment or eligibility reduction in the continuum of inpatient and home care available twenty- number of hours of employment, the four (24) hours, seven (7) days a week. Hospice services involuntary termination of the Creditable shall be provided in the home, a licensed Hospice, Questions about your benefits? Call the Customer Service department at 1-800-877-9777. Section Ten - Definitions . Coverage, death of a Spouse, legal separation or A service or item will be covered under the PacifiCare divorce, or employer contributions towards Health Plan if it is an intervention that is an otherwise such coverage was terminated; and covered category of service or item, not specifically excluded, and Medically Necessary. An intervention may (III)Requests enrollment within thirty(30) days be medically indicated yet not be a covered benefit or after termination of the other Creditable meet the definition of Medical Necessity. Coverage; or (b) A court has ordered that coverage be provided for a In applying the above definition of Medical Necessity, the following terms shall have the following meanings: Dependent under a covered employee's health benefit plan and the request for enrollment is made (i) 73-eating Physician means a Physician who has within thirty (30) days after issuance of such court personally evaluated the patient. order; or (ii) A health intervention is an item or service (c) A person becomes a Dependent of a covered person delivered or undertaken primarily to treat (that is, through marriage, birth, adoption, or placement for prevent, diagnose, detect, treat or palliate) a adoption and requests enrollment no later than medical condition or to maintain or restore thirty (30) days after becoming such a Dependent. functional ability.A medical condition is a disease, In such case, coverage shall commence on the date illness, injury, genetic or congenital defect, the person becomes a Dependent if a request for pregnancy, or a biological or psychological enrollment is received in a timely fashion before condition that lies outside the range of normal, such date. age-appropriate human variation.A health intervention is defined not only by the intervention Limits—Any provision, other than an exclusion, which itself, but also by the medical condition and the restricts coverage under this Group Agreement, patient indications for which it is being applied. regardless of Medical Necessity. (iii) Effective means that the intervention can Medically Necessary (or Medical Necessity)—refers reasonably be expected to produce the intended to an intervention, if, as recommended by the treating Physician results and to have expected benefits that outweigh and determined by the medical director of potential harmful effects. PacifiCare or the Participating Medical Group, it is all of the following: (iv) Health outcomes are outcomes that affect health status as measured by the length or quality (a) A health intervention for the purpose of treating a (primarily as perceived by the patient) of a medical condition; person's life. (b) The most appropriate supply or level of service, (v) Scientific evidence consists primarily of controlled considering potential benefits and harms to the clinical trials that either directly or indirectly Member; demonstrates the effect of the intervention on (c) Known to be effective in improving health health outcomes. If controlled clinical trials are not outcomes. For existing interventions, effectiveness is available, observational studies that suggest a determined first by scientific evidence, then by causal relationship between the intervention and professional standards, then by expert opinion. For health outcomes can be used. Partially controlled new interventions, effectiveness is determined by observational studies and uncontrolled clinical scientific evidence; and series may be suggestive, but do not by themselves (d) If more than one health intervention meets the demonstrate a causal relationship unless the requirements of(a) through (c) above, furnished in magnitude of the effect observed exceeds anything the most cost-effective manner that may be provided that could be explained either by the natural safely and effectively to the Member. "Cost-effective" history of the medical condition or potential does not necessarily mean lowest price. Experimental biases. For existing interventions, the scientific evidence should be considered first and, to the greatest extent possible, should be the basis for determinations of Medical Necessity. If no a Section Ten - Definitions scientific evidence is available, professional Non-Participating Providers—A hospital or other standards of care should be considered. If health care entity, a Physician or other health care professional standards of care do not exist, or are professional, or a health care vendor that has not outdated or contradictory, decisions about existing entered into a written agreement to provide Covered interventions should be based on expert opinion. Services to PacifiCare's Members. Giving priority to scientific evidence does not mean Open Enrollment Period—The time period that coverage of existing interventions should be determined by PacifiCare and the Subscriber's Employer denied in the absence of conclusive scientific Group when all Eligible Employees and their eligible evidence. Existing interventions can meet the family members may enroll in PacifiCare by submitting definition of Medical Necessity in the absence of an enrollment application to PacifiCare. scientific evidence if there is a strong conviction of effectiveness and benefit expressed through up-to- PacifiCare—PacifiCare, dba PacifiCare of Colorado, is a date and consistent professional standards of care state licensed health maintenance organization offering or, in the absence of such standards, convincing Federally qualified and non-Federally qualified products. expert opinion. PacifiCare Criteria—Written guidelines established by (vi) A new intervention is one that is not yet in PacifiCare to determine Medical Necessity and/or widespread use for the medical condition and coverage for certain procedures and treatments. patient indications being considered. New PacifiCare Criteria are based on research of scientific interventions for which clinical trials have not been literature, collaboration with Physician specialists and conducted because of epidemiological reasons (i.e. compliance with federal and national regulatory agency rare or new diseases or orphan populations) shall guidelines. Criteria are approved by pe PacifiCare be evaluated on the basis of professional standards Health Care Standards and Education Committee and of care. If professional standards of care do not are reviewed and revised on a regular basis. Criteria are exist, or are outdated or contradictory, decisions available for review by the Member's participating about such new interventions should be based on Physician, the Member or the Member's representative. convincing expert opinion. Part-Time or Intermittent Services-Skilled (vii) An intervention is considered cost-effective if the Rehabilitation Care and Skilled Nursing Care services benefits and harms relative to costs represent an furnished any number of days per week as long as the economically efficient use of resources for patients cumulative total is less than eight (8) hours each day, with this condition. In the application of this and twenty-eight (28) or fewer hours each week. criterion to an individual case, the characteristics of Participating Hospital-Any general acute care hospital the individual patient shall be determinative. licensed by the State of Colorado, accredited as a Medicare (Original Medicare)-The Hospital hospital by the Joint Commission on Accreditation of Insurance Plan (Part A) and the supplementary Medical Health Care Organizations and maintains contractual Insurance Plan (Part B) provided under Title XVIII of arrangements with PacifiCare, and that has entered into the Social Security Act, as amended. a written agreement with PacifiCare to provide Hospital Services to PacifiCare's Members. PacifiCare may contract Medicare Eligible—Those Members that meet eligibility requirements under Title XVIII of the Social with a hospital for a specified Member, a specified period of time and/or a specified service. In that case, Security Act, as amended. the hospital is a Participating Provider only for the Medicare Member—Any Member entitled to benefits service(s) contracted and/or for the designated period. under both parts of Medicare (part A—hospital coverage, part B—Physician coverage). Member—The Subscriber or any Dependent who is eligible, enrolled, and covered by PacifiCare. Questions about your benefits? Call the Customer Service department at 1-800-877-9777. ID Section Ten - Definitions Participating Provider—Any Physician, Physician Primary Residence—The home or address where the specialist, hospital, Skilled Nursing Facility, extended Member actually lives most of the time. A residence will care facility, individual, organization, agency or other no longer be considered a Primary Residence if: (1) the Provider who/which has entered into a contractual Member moves without intent to return, (2) the arrangement with PacifiCare to provide health services Member is absent from the residence for ninety(90) to Members. PacifiCare may contract with a Provider for consecutive days, or (3) the Member is absent from the a specified Member, a specified period of time and/or a residence for more than one hundred (100) days in any specified service. In that case, the Provider is a six-month period. Participating Provider only for the service(s) contracted Primary Workplace—The facility or location where the and/or for the designated period. Member works most of the time and to which the Physician—Any licensed allopathic or osteopathic Member regularly commutes. If the Member does not Physician. regularly commute to one location, then the Member Preferred Transplant Network—A network of does not have a Primary Workplace. transplant facilities that are: Provider—Any Physician, dentist, optometrist, • licensed in the State of Colorado; anesthesiologist, hospital,X-ray, laboratory and ambulance services, or other person who is licensed or • certified by Medicare as a transplant facility for a otherwise authorized in the State of Colorado to furnish specific organ transplant; health care services. • designated by PacifiCare as a transplant facility for a Prudent Layperson—A person without medical specific organ program; training who reasonably draws on practical experience • able to meet the reasonable access standards for when making a decision regarding whether Emergency organ transplantation based on the Regional Organ Services are needed. Procurement Agency statistics within the transplant Qualified Beneficiary—Any individual who, on the day facility's geographic location. A Regional Organ before a Qualifying Event, is covered under a group Procurement Agency is a geographic area designated Health Plan maintained by the employer of a covered by a state-licensed organ procurement organization employee. This can be: for transplants in the State of Colorado. • The covered employee Premiums—The payments made to PacifiCare by an Employer Group on behalf of a Subscriber and any • The Spouse of the covered employee enrolled family members for providing and continuing • The Dependent child of the covered employee. enrollment in PacifiCare, under this Group Agreement. Often the Subscriber shares the cost of these Premiums Qualifying Event—A Qualifying Event refers to an occurrence which triggers a person's right to continuation with deductions from his or her salary. of coverage under the Consolidated Omnibus Budget Prevailing Rates—As determined by PacifiCare, the Reconciliation Act of 1985 (COBRA) as amended. usual, customary, and reasonable rates for a particular Redetermination of Status—The right of and process health care service in the HMO Service Area. by which PacifiCare may review the level of care to Primary Care Physician—A Participating Provider who identify changes in a Member's status and prognosis. is a Physician trained in internal medicine, general This may result in a different determination of level of practice, family practice or pediatrics, and who has care and a different level of PacifiCare's responsibility accepted primary responsibility for coordinating a for covered benefits. Each such determination will Member's health care services, initiates all referrals for supersede earlier determinations and PacifiCare's specialist care and maintains continuity of patient care. obligation for coverage provided. a Section Ten - Definitions Rehabilitation Services-The combined and Spouse-The Subscriber's husband or wife who is coordinated use of medical, social, educational and legally recognized as a husband or wife under the laws vocational measures for training or retraining and of the State of Colorado. restoration to normal or near-normal functions for Subacute and Transitional Care-Subacute and individuals disabled by disease or injury. Transitional Care are levels of care needed by a Member Schedule of Benefits-An important part of your who does not require hospital acute care, but who Combined Evidence of Coverage and Disclosure Form requires more intensive licensed Skill Nursing Care than that provides benefit information specific to your Health is provided to the majority of the patients in a Skilled Plan, including Copayment information. Nursing Facility. Skilled Nursing Care-Those home health care Subscriber-The person enrolled in the Health Plan services that: for whom the appropriate Premiums have been received by PacifiCare, and whose employment or other status, • Can only be provided by an RN or LPN; except for family dependency, is the basis for • Can produce the best possible and most timely enrollment eligibility. outcome for a disease process and/or treatment Transitional Care-See "Subacute Care."regimen according to a professional assessment and plan; Urgently Needed Services-Covered Services that are required in order to prevent serious deterioration of a • Cannot be made available outside of the home Member's health that results from an unforeseen illness because of the immediate home-bound nature of or injury if: the Member; • The Member is temporarily absent from PacifiCare's • Can furnish reliable information to the participating HMO Service Area; Physician and PacifiCare's medical director sufficient for proper determination of the status of the • The receipt of the health care service cannot be Member's condition and the level of care required delayed until the Member's return to the PacifiCare for that condition. HMO Service Area. Skilled Nursing Facility—A comprehensive NOTE: THIS COMBINED EVIDENCE OF COVERAGE freestanding rehabilitation facility, or a specially AND DISCLOSURE FORM CONSTITUTES ONLY A designed unit within a hospital, licensed by the State of SUMMARY OF THE PACIFICARE HEALTH PLAN. THE Colorado to provide Skilled Nursing Care. GROUP AGREEMENT BETWEEN PACIFICARE AND THE EMPLOYER GROUP MUST BE CONSULTED TO Skilled Rehabilitation Care-The care provided DETERMINE THE EXACT TERMS AND CONDITIONS directly by or under the direct supervision of licensed OF COVERAGE.A COPY OF THE GROUP nursing personnel or licensed physical, occupational or AGREEMENT WILL BE FURNISHED UPON REQUEST speech therapist. AND IS AVAILABLE AT PACIFICARE AND YOUR EMPLOYER GROUP'S PERSONNEL OFFICE. 4f Questions about your benefits? Call the Customer Service department at 1-800-877-9777. ID Section Eleven - Your Rightsik and Responsibilities Your Rights and • Receive information about your medications-what they are, how to take them and possible side effects. Responsibilities • Be advised if a Physician proposes to engage in As a Member of PacifiCare you have the right to receive Experimental or Investigational procedures affecting your care or treatment. You have the right to refuse information about, and make recommendations regarding, your rights and responsibilities. to participate in such research projects. You have the right to: Treatment With Dignity and Respect • Be treated with dignity and respect and have your Timely, Quality Care right to privacy recognized. • Choose and seek care through a qualified • Exercise these rights regardless of your race, Contracting Primary Care Physician and Contracting physical or mental disability, ethnicity, gender, Hospital. PacifiCare can advise you if a specific sexual orientation, creed, age, religion, national contracted Primary Care Physician is not accepting origin, cultural or educational background, new patients at a particular time. Your Contracting economic or health status, English proficiency, Primary Care Physician will discuss with you the reading skills, or source of payment for your health Contracting Hospital that best fits your needs in the care. Expect these rights to be upheld by PacifiCare event you need Hospital Services. and Contracting Medical Providers. • Timely response to your requests for covered • Refuse any treatment or leave a medical facility, even healthcare services; access to your Contracting against the advice of a Physician. Your refusal in no Primary Care Physician; and referrals to contracted way limits or otherwise precludes you from specialists for Covered Services when Medically receiving other Medically Necessary Covered Necessary. Services for which you consent. • Receive Emergency Services when you, as a Prudent • Complete an advance directive, living will or other Layperson acting reasonably, believe that an directive and provide it to your Contracting Primary Emergency Medical Condition exists. Payment will Care Physician or medical Provider to include in not be withheld in cases where you have acted as a your medical record. Treatment decisions are not Prudent Layperson with an average knowledge of based on whether or not an individual has executed health and medicine in seeking Emergency Services. an advance directive. • Receive Urgently Needed Services when traveling outside the plan's HMO Service Area or in the plan's Information About PacifiCare and Their HMO Service Area when unusual or extenuating Contracting Medical Providers circumstances prevent you from obtaining care from • Receive information about PacifiCare and the your Contracting Primary Care Physician. Covered Services under your Plan. • Discuss with your contracting Provider the full range • Receive information about your Contracting of appropriate or Medically Necessary treatment Practitioners and Providers involved in your medical options for your condition, regardless of cost or treatment, including names and qualifications. benefit coverage. • Receive information from your Contracting Medical • Participate actively in decision-making regarding Providers about an illness, the course of treatment your health with your Contracting Medical Provider. and prospects for recovery in language you can understand. This may include information about any • Receive reasonable continuity of care, including proposed treatment or procedures necessary for you information about continuing health care to give an informed consent or to refuse a course of requirements following discharge from inpatient or treatment. Except in case of an Emergency, this outpatient facilities. And to know, in advance, the information shall include a description of the time and location of an appointment, as well as the procedure or treatment, the medically significant Physician providing care. risks involved, any alternate course of treatment or 80 Section Eleven - Your Rights and Responsibilities y nontreatment and the risks involved in each, and • Know that if you are unable to give consent, you the name of the person who will perform the may extend your rights to any person who has legal procedure or treatment. responsibility to make decisions on your behalf, • Receive information regarding how medical regarding your medical care or the release of treatment decisions are made by your Contracting personal health information. Primary Care Physician, medical group or PacifiCare, • Review your medical records. If you would like to including payment structure. review, correct or copy your medical records,you • Receive and examine a billing explanation for non- should contact your Contracting Primary Care Covered Services, regardless of payment source. Physician or other health care Provider who created the medical record directly • Request information about PacifiCare's Quality • Improvement Program, its goals, processes and/or Know that PacifiCare may accommodate employer outcomes. requests for information by providing de-identified aggregated data. Only as permitted by law, PacifiCare Timely Problem Resolution may release information to self-funded employers • Submit com taints and re uest a where needed to administer the provisions of the p q appeals without plan. If required to supply this information to self- discrimination, about PacifiCare or care provided funded employers, they agree to protect the to you. individual's data from internal disclosure that would • Expect problems to be fairly examined and affect the individual. appropriately addressed within the time frames set by the plan. Your Responsibilities Are To: • Choose to have a service or treatment decision, if it • Review information regarding Covered Services, meets certain criteria, reviewed by a Physician or any exclusions, deductibles or Copayments and panel of Physicians who are not affiliated with policies and procedures as stated in your Member PacifiCare. This process is referred to as an materials or Combined Evidence of Coverage and independent external review. Disclosure Form. Protection of Privacy In All Settings • Provide PacifiCare, your Physicians, other health care professionals and Contracting Medical • Know that PacifiCare protects the privacy and Providers, to the degree possible, the information security of personal health information in all - needed to provide care to you. settings from unauthorized or inappropriate use via •its policies and procedures and agreements with Follow treatment plans and care instructions as Contracting Providers. agreed upon with your Contracting Medical Provider. Actively participate, to the degree possible, • Know that when you or your legal representative in understanding and improving your own medical sign your application/Individual election form, you and/or behavioral health condition and, in provide routine consent to PacifiCare. Routine developing mutually agreed upon treatment goals. consent covers the use of your personal health • information needed for Plan operations, such as: Behave in a manner that supports the care provided treatment, coordination of care, use of to other patients and the general functioning of the measurement and survey data to improve care and facility. service, utilization review, billing or fraud detection. • Accept your financial responsibility for Plan • Know that PacifiCare does not disclose medical Premiums, any other charges owed, and any information related to your mental health, genetic Copayment or coinsurance associated with services testing results and drug and alcohol abuse treatment received while under the care of a Physician or records, to third parties without your special consent/ while a patient in a facility authorization or as required or permitted by law Questions about your benefits? Call the Customer Service department at 1-800-877-9777. fl Section Eleven - Your Rights . , and Responsibilities • Ask your Contracting Primary Care Physician or PacifiCare questions regarding your care. If you would like information about Contracting Medical Providers or have a suggestion,complaint or payment issue,we recommend you call the PacifiCare Customer Service department at 1.800-877.9777 or for the hearing impaired TDD 1-800-659-2656. Our Customer Service Associates are available Monday through Friday 7:00 a.m. to 8:00 p.m. a Pacif Care® Appendix A Attachment A-Schedule of Benefits Colorado Health Plan Description Form PacifiCare of Colorado 40773 —Plus Plan—Residing In Area PART A:TYPE OF COVERAGE 1. TYPE OF PLAN Point of Service(i.e.,an HMO plan with some out-of-network benefits). 2. OUT-OF-NETWORK Only for specified services;member pays more for such out-of-network care. CARE COVERED?' 1. AREAS OF COLORADO Plan is available only in the following counties:Adams,Arapahoe,Boulder, WHERE PLAN IS Broomfield,Clear Creek,Denver,Douglas,El Paso,Elbert,Fremont,Gilpin, AVAILABLE 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. IN-NETWORK OUT-OF-NETWORK 4. ANNUAL DEDUCTIBLE No deductibles. a) Individual $500 b) Family $1,000 5. ENROLLEE OUT-OF-POCKET The out-of-pocket maximums exclude ANNUAL MAXIMUM= deductibles and copayments. a) Individual $2,500 $5,000(plus deductible). b) Family $5,000 $10,000(plus deductible). 6. LIFETIME OR BENEFIT No lifetime maximum. $1,000,000 MAXIMUM PAID BY THE PLAN FOR ALL CARE 7a. COVERED PROVIDERS 4,370 physicians and 39 hospitals in All providers licensed or certified to Colorado. See provider directory for provide covered benefits. complete list. 7b. With respect to network plans, Yes. Not applicable. are all the providers listed in 7a accessible to me through my primary care physician? S. ROUTINE MEDICAL OFFICE $15 copayment per visit with PCP; You pay 30%. 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). 2 Out-of-rocket 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. 40771.00 • IN-NETWORK OUT-OF-NETWORK 9. PREVENTIVE CARE a) Children's services $15 copayment per visit with PCP; Well-baby/Well-child care(up to age $30 copayment per visit with 13),you pay 30%. Specialist. b) Adults'services $15 copayment per visit with PCP; Not covered,except mammograms and $30 copayment per visit with prostate cancer screenings as required. Specialist. 10. MATERNITY a) Prenatal care $15 copayment per visit. You pay 30%. b) Delivery&inpatient well $400 copayment per admission. You pay 30%when preauthorization is baby care obtained,50%when not preauthorized. 11. PRESCRIPTION DRUGS Available as separate pharmacy plan Available as separate pharmacy plan Level of coverage and or as an optional benefit if purchased or as an optional benefit if purchased restrictions on prescriptions by your employer,see benefit by your employer,see benefit schedule schedule attached(if applicable). attached(if applicable). 12. INPATIENT HOSPITAL $400 copayment per admission. You pay 30%when preauthorization is obtained,50%when not preauthorized. 13. OUTPATIENT/AMBULATORY $100 copayment per visit You pay 30%when preauthorization is SURGERY obtained,50%when not preauthorized. 14. LABORATORY&X-RAY No copayment(100%covered); You pay 30%. MRI,CT,SPECT and PET Scan$75 copayment per procedure.The$75 copayment is in addition to other applicable copayments. 15. EMERGENCY CARE Emergency room setting inside and You pay 50%. 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 $50 copayment per episode. You pay 30%. 17. URGENT,NON-ROUTINE, $100 copayment in emergency room You pay 50%. AFTER HOURS CARE setting,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 Coverage is no less extensive than the MENTAL ILLNESS°CARE the coverage provided for any other coverage provided for any other physical physical illness. illness. 3"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. wm.m IN-NETWORK OUT-OF-NETWORK 19. OTHER MENTAL HEALTH CARE a) Inpatient care $50 copayment per day,$25 copayment You pay 50%(includes hospital and per partial day;coverage for maximum medical services);coverage for of 45 fill or 90 partial days per contract maximum of 45 full or 90 partial days year. per contract year. b) Outpatient care No copayment for visits 1-5,$30 You pay 30%,20 visit maximum per copayment thereafter. year. 20. ALCOHOL&SUBSTANCE Inpatient: $50 copayment per day, Inpatient and Detoxification:covered ABUSE coverage for maximum of 21 days. under the Mental Health benefit. Outpatient: no copayment for visits Outpatient: You pay 30%maximum 1-5,$30 copayment per visit of$500. Limited to one course of thereafter. Limited to one course of treatment per contract year,two treatment per contract year,two courses of treatment during the courses of treatment during the member's lifetime. member's lifetime. Services for detoxification: $400 copayment per admission 21. PHYSICAL,OCCUPATIONAL, Physical/Occupational Therapy: $15 You pay 30%up to$1,000 per type of &SPEECH THERAPY copayment per visit,coverage for therapy. maximum of 20 sessions per acute condition. Speech Therapy: $15 copayment per visit,coverage for maximum of 20 sessions for certain acute conditions.For children born 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 You pay 30%(maximum benefit EQUIPMENT member per contract year,including $1,000). 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;you pay 20%. 23. OXYGEN No copayment. Covered as durable Covered as durable medical equipment medical equipment(see#22). (see#22). 24. ORGAN TRANSPLANTS Bone marrow(for certain Cornea and kidney transplants,and conditions),cornea,liver(for skin grafts are covered based on children),and kidney transplants,and criteria. skin grafts,are covered based on criteria. Heart, lung,heart/lung (combined),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). You pay 30%for up to 60 visits per year. x)).00 IN-NETWORK OUT-OF-NETWORK 26. HOSPICE CARE No copayment(100%covered). Inpatient: you pay nothing up to 30 days. Outpatient: you pay 30%when preauthorization is obtained,50% when not preauthorized;up to 270 days(maximum benefit$55 per day). 27. SKILLED NURSING No copayment(100%covered). You pay 30%when preauthorized, FACILITY CARE Covered up to 120 days per contract 50%when not preauthorized;for up to year. 30 days. 28. DENTAL CARE Available as a separate dental care Not covered. plan or as an optional benefit. 29. VISION CARE $15 copayment per visit;one visit per Not covered. 12 months. 30. CHIROPRACTIC CARE Available as a separate chiropractic Chiropractic services included under care plan or as an optional benefit. Physical Therapy(see#21). 31. SIGNIFICANT ADDITIONAL Infertility treatment,50%copayment; None. COVERED SERVICES(list up allergy injections,$5 copayment; to 5) injectables for home use,$75 copayment;cardiac rehabilitation covered to$1000 within a 90-day period. PART C:LIMITATIONS AND EXCLUSIONS 32. PERIOD DURING WHICH PRE-EXISTING Six 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 "PRE-EXISTING CONDITION"? advice,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). It is important to review them to see if a service or treatment you may need is excluded from the policy. s Waiver of ore-existing condition exclusions. State law requires carriers to waive some or all of the pm-existing condition exclusion period based on other coverage you recently may have had. Ask your carrier or plan sponsor(e.g.,employer)for details. 4077100 PART D:USING THE PLAN IN-NETWORK OUT-OF-NETWORK 36. Does the enrollee have to obtain a referral and/or prior Yes. No. authorization for specialty care in most or all cases? 37. Is prior authorization required for surgical procedures Yes. Yes. and hospital care(except in an emergency)? 38. If the provider charges more for a covered service than No. Yes. 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?' 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 40773,Large Group Plus number of this policy;whether it is individual,small group,or large group;and if it is a short-term policy. PART E:COST 43. 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 at(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. 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. 4071.00 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 Not Covered: visual acuity exam under your medical plan are Fitting of contact lenses,vision therapy and/or available under this rider. These include refractions radial keratotomy, keratomilieusis and excimer for prescription lenses, are covered once every 12 laser surgery. months. Services must be obtained from a partici- This information contains only highlights of the eye paring VSP® provider. examination benefit and is not intended to contain Using VSP® is as easy as 1, 2, 3. First, locate a VSP® the complete provisions of these benefits. Please provider near you by checking your PacifiCare refer to your Combined Evidence of Coverage and Provider Directory,by visiting VSP's website at Disclosure Form for a complete description of this www.VSP.com or by calling VSP® at 1-888.426- benefit. 4877. Second, call your doctor and make an appointment. Third,keep your scheduled appoint- ment. A referral from your primary care physician (PCP) is not required for this benefit. 6455 South Yosemite Street Copyright©2000 PacifiCare of Colorado Greenwood Village, CO 80111 EM05000.04 10/2002 ATTACHMENT P - PLUS SCHEDULE OF BENEFITS ATTACHMENT TO THE COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE FORM WHEREAS,this PLUS AMENDMENT sets movement to the nearest hospital where forth the provisions applicable to the Health the Medically Necessary care may be Plan operated by PacifiCare; given WHEREAS, this PLUS AMENDMENT shall • When ordered by the Member's become an integral part of the Agreement; attending Physician, movement from the WHEREAS,unless otherwise indicated herein, hospital to another institution or to or all capitalized terms within this PLUS from the Member's home for emergency AMENDMENT shall have the same meaning situations attributed to such capitalized terms in the Not Covered: Agreement and references to section numbers in Ambulance service provided due to the this PLUS AMENDMENT are to the sections of absence of another medically appropriate the to sections of the Agreement; epro p form of transportation or for the Member's WHEREAS,unless otherwise indicated herein, convenience. all terms, conditions and provisions set forth the Emergency Medical Conditions Agreement shall remain in full force and effect. In the event of any of the provisions outlined An Emergency Medical Condition is any below conflict between the terms and conditions event which a Prudent Layperson reasonably of the Agreement, the provisions, terms and believes threatens his or her life or limb in conditions of this PLUS AMENDMENT shall such a manner that a need for immediate govern and control; medical care is created to prevent death or serious impairment of health. NOW, THEREFORE, as of the Group Coverage Effective Date as indicated on the Cover Sheet, Note: in consideration of the mutual promises, Treatment and transportation for Emergency covenants and provisions contained in this Medical Conditions are generally covered Agreement, it is hereby amended as follows: under the PacifiCare in-network coverage. 1. The following provisions are hereby added 2. The following provisions are hereby added to Section Three,Emergency and to Section Five,Your Medical Benefits: Urgently Needed Services: Your Out-of-Network Benefits Your Out-of-Network Emergency Benefits The following services are covered benefits when Medically Necessary, unless excluded Ambulance or Limited by under VI, Exclusions And Ambulance services are Limited to Limitations Of Benefits, in Section Five, as transportation to the nearest facility with the it appears in the Group Agreement and as expertise for treating your condition for any amended below, or listed as"not covered" of the following: in the benefits sections. PacifiCare may determine Medical Necessity by using • Movement from the place where the precert Member was injured in an accident or ifzcation programs as deemed became ill to the nearest hospital for appropriate by PacifiCare. Such programs and criteria are reviewed and updated from treatment time to time. See Section Eight, Overseeing • If Medically Necessary care is not Your Health Care,for further information. available at a hospital or Hospice, 1 20020268 11/02 IV. INPATIENT OUT-OF- processing costs are Limited to NETWORK BENEFITS blood collected for a scheduled 1. Alcohol,Drug, or Other procedure. Coverage includes wound healing products that Substance Abuse Detoxification -Detoxification meet criteria established by is the medical treatment of PacifiCare. withdrawal from alcohol, drug or 3. Foot Conditions—The other substance addiction. following services are covered Treatment in an acute care when provided by a licensed setting is covered for the acute Physician: stage of alcohol, drug or other • Treatment of weak, strained, substance abuse withdrawal flat, unstable, or imbalanced when medical complications feet,treatment for occur or are highly probable. metatarsalgia or bunion Detoxification is initially covered up to forty-eight(48)hours and • Cutting or removing one or extended when Medically more corns, calluses, toenails, Necessary. Rehabilitation for removal of part or all of one substance abuse or addiction is or more nail roots for covered. Inpatient services are treatment of a metabolic or those services provided to peripheral vascular disease Members who reside for the • Surgical or nonsurgical course of their treatment program treatment of subluxations of at the program site. Methadone the foot, subluxations of the treatment for detoxification is not foot are partial displacements covered. or dislocations of joint Not Covered: surfaces, tendons, ligaments, or muscles of the foot • Rapid anesthesia opiate detoxification Limit: • Services which are not A maximum of$500 per Medically Necessary for the Member per contract year. treatment of Substance Abuse Not Covered: disorders • Corrective or supportive • Services that are required by devices, appliances, or shoes a court order as a part of parole or probation, or • Routine foot care or routine instead of incarceration, hygiene care which are not Medically 4. Hospice Services - Hospice Necessary. services are covered for • Methadone maintenance or Members with a terminal illness, treatment. defined as a medical condition resulting in a prognosis of life of 2. Blood and Blood Products - six (6) months or less, if the Blood and Blood Products are disease follows its natural course, covered. Autologous (self who alone in conjunction with donated), donor-directed, and family or Members has donor-designated blood voluntarily requested admission. 2 20020268 11/02 Hospice services are provided Respite care is Limited to an pursuant to the plan of care occasional basis and to no more developed by the Member's than five(5)consecutive days at interdisciplinary team,which a time. includes,but is not Limited to, Limits: the Member,the Member's Primary Care Physician, a • Individual, family, and registered nurse, a social worker caregiver counseling, medical and a spiritual caregiver. The social services, and coverage of these services will bereavement support services not prevent PacifiCare from re- for the Member's family evaluating the Member's status following Member's death and subsequently redetermining are subject to a$500 the status of care. maximum per contract year, and are not subject to the Hospice services include skilled maximum Limit for home nursing services, certified home Hospice care or the health aid services and maximum daily benefit for homemaker services under the home Hospice care explained supervision of a qualified in Hospice Care Limits registered nurse;bereavement below: services; social services/counseling services; • Prior authorization required medical direction; volunteer by the interdisciplinary team services; pharmaceuticals, and PacifiCare(except for medical equipment and supplies Medical Emergencies). that are reasonable and necessary • Where both inpatient and for the palliation and outpatient care is provided, management of the terminal each day of care,regardless illness and related conditions; of whether inpatient or respiratory therapy and outpatient,will count toward inhalation services;physical and the maximum benefit period. occupational therapy and speech- language pathology services for • Medical supplies ordinarily purposes of symptom control, or furnished by the Hospice to enable the Member to agency, including maintain activities of daily living prescription drugs and and basic functional skills. biologicals are covered and are not subject to the Inpatient Hospice services are maximum Limit for home provided in an appropriately Hospice care or the licensed Hospice facility when maximum daily benefit for the Member's interdisciplinary home Hospice care explained team has determined that the in the Hospice Care Limits, Member's care cannot be below. managed at home because of acute complications or when it is • Inpatient respite care is a necessary to relieve the family short-term inpatient stay members or other persons caring which may be necessary for for the Member("respite care"). the patient in order to give 3 20020268 11/02 temporary relief to the person Certain covered benefits are who regularly assists the not subject to this maximum, patient with home care, and as noted above. its coverage is Limited each • The maximum daily benefit time to no more than five (5) for home Hospice care, days in a row. including respite care, is $55. Hospice Care Limits Certain covered benefits are • To qualify for Hospice care, not subject to this maximum, the Member's Physician must as noted above. certify that the Member is Not Covered: terminally ill. The Physician • Services and supplies related must submit a written plan of to the terminal condition that care. are not a part of Hospice care • The Member must choose to • Services of a caregiver other receive Hospice care instead than as provided by the of standard benefits for the Hospice agency as part of terminal illness. It is this benefit, including,but important for the Member to not Limited to, someone who realize that Hospice care is lives in the Member's home for terminal conditions and or someone who is a relative that the Hospice benefit of the Member structure is based upon the concept that those Members • Domestic or housekeeping receiving Hospice care services that are unrelated to choose not to avail the Member's care themselves of other health • Services that provide a care benefits for care related protective environment where to the terminal condition. no professional skill is While receiving Hospice required, such as care, in the Member's home companionship or sitter or in a Hospice facility, if a services Member requires treatment for a condition not related to • Services not directly related the terminal illness, to the medical care of the PacifiCare of PacifiCare Member including, but not continues to pay for all Limited to: Covered Services. • Estate planning, drafting • The coverage of these of will, or other legal services will not prevent services PacifiCare from re-evaluating • Funeral counseling or the Member's status and funeral arrangements or subsequently redetermining services the status of care. • Food services such as • The maximum benefit for Meals on Wheels home Hospice care, including respite care, is $5,000 per • Transportation services, Hospice benefit period. except covered benefits 4 20020268 11/02 for necessary professional alcohol-drug detoxification ambulance services and Rehabilitation Services. 5. Inpatient Alcohol-Drug 6. Inpatient Care in Other Rehabilitation Care -Alcohol- Institutions - Services of other drug inpatient Rehabilitation institutions are covered only on Services are covered when order of the attending Physician, Medically Necessary. Inpatient and only when significant, services are those services measurable improvement can be provided to Members who reside anticipated. Services include for a course of their treatment accommodations,meals, general program at the program site. A nursing care,medical supplies Medically Necessary course of and equipment ordinarily treatment may be either inpatient furnished by the facilities, and all or outpatient or a combination of prescribed drugs and biologicals. both if authorized by the Limits: PacifiCare participating program site. • Please refer to your Schedule Limits: of Benefits for Limits for under this benefit. • Please refer to the Out-of- • The Member's status also Network portion of your may be reevaluated and, if it Schedule of Benefits for the is determined that the status maximum amount payable of the care is no longer acute, for Physician visits the services may not be (including psychologist covered. visits)during a Member's confinement for alcohol-drug Not Covered: dependency or mental and • Expenses of chronic, nervous disorders. custodial, or maintenance • A maximum of forty-five care (45) inpatient days (or ninety • Chronic or maintenance care, [90] partial hospitalization private duty nursing, and days)per contract year, less respite care (except as may the number of days, if any, be provided under 4, devoted to inpatient "Hospice Services." detoxification during the contract year, or until the • Convalescent care Provider deems that the • Private duty nursing Member has satisfactorily • completed the inpatient Personal comfort or program, whichever is less. convenience items, such as Each day of confinement for television or telephone psychiatric care, and each • Private room, except when two(2)partial hospitalization Medically Necessary days of such care will reduce • Care provided to a Member by one (1)day the number of may be Custodial Care even days available for inpatient though all of the following apply: 5 20020268 11/02 • The Member is under a • All implants not specifically Physician's care or listed as covered supervision 8. Inpatient Physician Services- • Services are being Physician's services including prescribed to support and time for visits and examinations generally maintain the relating to an illness or injury, Member's condition, and medical consultation provide for the Member's services, including charges made comfort, or assure the by a Physician for a second manageability of the surgical opinion are covered. Member These services include • Services are being consultation and personal provided by a registered attendance with the inpatient in nurse or other licensed the Physician's office, or in a Provider hospital or other institution. Physician's visits to the 7. Inpatient Hospital Member's home are covered only Benefits/Acute Care— when Medically Necessary and Medically Necessary inpatient only if the Member is too ill or Hospital Services are covered, disabled to go to the Physician's including,but not Limited to: office. semi-private room, nursing and other licensed health Not Covered: professionals, intensive care, • Expenses for medical reports, operating room, recovery room, including preparation and laboratory, and professional presentation charges by the hospital • Expenses for examinations pathologist or radiologist and conducted for the purpose of other miscellaneous hospital medical research charges for Medically Necessary care and treatment. 9. Inpatient Psychiatric Care - Medically Necessary inpatient Not Covered: psychiatric care is covered as • Take-home drugs described below. In the case of • Take-home supplies basic coverage benefits based upon either confinement as an Implants - Coverage under this inpatient or partial benefit also include devices that hospitalization in a hospital or are Medically Necessary and psychiatric hospital licensed by must be implanted by surgical the Department of Public Health means. The may include and Environment,the period of pacemakers,replacement joints, confinement for which benefits and permanent replacement are payable shall be at least forty- lenses following cataract surgery. five (45)days for inpatient care Not Covered: or ninety(90)days for partial hospitalization in any one twelve • Experimental/Investigational (12) month benefit period. or cosmetic implants "Partial hospitalization"under • Penile implants this benefit is defined as 6 20020268 11/02 treatment for at least three(3) 11. Mastectomy.Breast hours,but not more than twelve Reconstruction After (12) hours in a twenty-four(24) Mastectomy and Complications hour period. For purposes of From Mastectomy—Medically computing a period for which Necessary mastectomy and benefits are payable, each two(2) lymph node dissection are days of partial hospitalization covered, including prosthetic shall reduce by one day the forty- devices and/or reconstructive five(45)days available for surgery to restore and achieve inpatient care, and each day of symmetry for the Member inpatient care shall reduce by two incident to the mastectomy. The (2)days the ninety days available length of a hospital stay is for partial hospitalization care. determined by the attending Each day of confinement for Physician and surgeon in alcohol detoxification or consultation with the Member, rehabilitation explained in 5., consistent with sound clinical "Inpatient Alcohol-Drug principles and processes. Medical Rehabilitation,"will reduce by treatment for any complications one (1) day the number of days from a mastectomy, including available for inpatient psychiatric lymphedema, is covered. care and will reduce by two(2) Coverage of reconstructive breast days the number of partial surgery as described above shall hospitalization days available. include: 10. Inpatient Rehabilitation Care— • Reconstruction of the breast Rehabilitation Services that must on which the mastectomy be provided in an inpatient was performed rehabilitation facility are • Surgery and reconstruction of covered. Inpatient rehabilitation the unaffected breast to consists of the combined and produce a symmetrical coordinated use of medical, appearance social, educational and vocational measures for training • Surgically implanted breast or retraining individuals disabled prostheses by disease or injury. The goal of • Coverage of physical these services is for the disabled complications resulting from Member to obtain his or her the mastectomy, including highest level of functional lymphedemas ability. Rehabilitation Services include,but are not Limited to Coverage for the cost of surgical physical, occupational, and bras, including external speech therapy. Please refer to prostheses, in lieu of VI., "Exclusion and Limitations reconstructive breast surgery will of Out-of-Network Benefits," for be covered to the extent the applicable benefit preauthorized. Limitations. Limit: This benefit does not include $500 per Member per contract drug, alcohol, or other substance year. abuse rehabilitation. 7 20020268 11/02 12. Obstetrical Care- Obstetrical Preferred Transplant Network care for female Members in facility. Covered Services for connection with normal living donors are Limited to pregnancy and childbirth are Medically Necessary clinical covered. Treatment necessitated services once a donor is by complications of pregnancy identified. Transportation and are covered. other non-clinical expenses of the Not Covered: living donor are excluded, and are the responsibility of the • Home delivery Member, who is the recipient of • Any procedure intended the transplant. (See the solely for sex determination definition for"Regional Organ Procurement Agency.") • Birthing classes Coverage under this benefit is Note: Limited to the following: Under Federal law, group Health • Cornea transplants Plans may not restrict benefits • Kidney transplants for any hospital length of stay in connection with childbirth for the • Skin grafts (not to include mother or newborn child to less skin grafts performed for than forty-eight(48)hours cosmetic purposes) following a normal vaginal Transplant Criteria: delivery, or less than ninety-six • (96)hours following a cesarean All necessary services for section. However, Federal law covered transplants at generally does not prohibit the designated transplant mother's or newborn's attending facilities. Services are Provider, after consultation with covered to the extent the mother, from discharging the preauthorized based on mother or her newborn earlier medical criteria established than forty-eight(48)hours (or by PacifiCare and provided ninety-six [96] hours as only upon referral by the applicable). In any case,plan Member's Participating issuers may not,under Federal Provider. Covered Services law, require that a Provider include the directly related, obtain authorization from the reasonable medical and plan or the issuer for prescribing hospital expenses of the a length of stay not in excess of donor. forty-eight(48)hours(or ninety- • Referrals are subject to six [96] hours). determination by a 13 Organ Procurement Participating Provider that Transplant and Transplant the service referred Services—Non-Experimental represents the preferred and Non-Investigational organ method of treatment. transplants and transplant • Coverage will be restricted to services are covered when the transplant services provided recipient is a Member and the to the donor and recipient transplant is performed at a 8 20020268 11/02 only when the recipient is a • Lung PacifiCare Member. • Pancreas • Neither PacifiCare nor its • Multiple organs Participating Providers will be responsible to furnish a • Non-human donor or to assure the • Artificial organs and their availability or capacity of implantation designated facilities. • All other transplants not • If, after referral, the listed in this Group Participating Provider Agreement as covered determines that the Member benefits does not satisfy its criteria for the service involved, V. OUTPATIENT OUT-OF- PacifiCare's obligation is NETWORK BENEFITS Limited to paying for 1. Allergy Treatment—Outpatient Covered Services provided services for the treatment of prior to such determination. allergies and allergy treatment Transplant Guidelines- The materials are covered. following guidelines apply to 2. Blood and Blood Products - transplants: Blood and Blood Products are • Referrals are subject to covered. Autologous (self determination by PacifiCare donated), donor-directed, and that the service referred to donor-designated blood represents the preferred processing costs are Limited to method of treatment. blood collected for a scheduled procedure. Coverage includes • If, after referral, the receiving wound healing products that Provider determines that the meet criteria established by Member does not satisfy its PacifiCare. criteria for the service involved, PacifiCare's 3 Chemotherapy - Outpatient obligation is Limited to injectable chemotherapy, when paying for eligible charges oral administration of prescribed incurred prior to such medication is not medically determination, plus eligible appropriate is covered. Included charges subsequently in this benefit are Medically incurred that are covered in Necessary services and materials. whole or in part under Not Covered: Medicare. • Chemotherapy requiring a The following transplants are not bone marrow transplant for covered: breast cancer and other solid • Bone marrow tumors • Heart • Chemotherapy given orally instead of intravenously, • Heart-lung unless the Member has the • Liver optional prescription drug coverage 9 20020268 11/02 Note: covered benefits relating to Also see VI., "Exclusions and screening by low-dose Limitations of Out-of-Network mammography as described Benefits." above. ' 4. Breast Cancer Screening and 5. Dental Treatment Anesthesia— Diagnosis - Services are covered See 15., Oral Surgery and Dental for routine and certain diagnostic Services: Dental Treatment • Anesthesia for Dependent screening by low-dose mammography for the presence Children. of breast cancer. Screening and 6. Diabetic and Dietary diagnosis will be covered Management and Treatment - consistent with generally Coverage includes dietary accepted medical practice and counseling,medication scientific evidence as determined management, and self- by a Physician. Mammography management skills instruction for for screening or diagnostic Members diagnosed with purposes is covered as authorized diabetes or those with special by a Physician. management needs. The diabetes Coverage shall be the lesser of outpatient self-management eighty-four dollars ($84)per training and education covered mammography screening, or the under this benefit will be actual charge for such screening. provided by appropriately Coverage is provided according licensed or registered health care professionals. These services to the following guidelines: must be provided under the • Provision of a single baseline direction of and prescribed by a mammogram for women Participating Provider. The thirty-five (35)years of age dietary counseling covered under and under forty (40)years of this benefit consists of one(1) age; dietary counseling session when • Screening not less than once regulation of the diet is a every two years for women significant part of the treatment forty(40)years of age,but at program for a pathological state least once each such year, as or illness. specified in the policy or Limit: contract, for a woman with risk factors to breast cancer One (1)visit per contract year as determined by her Not Covered: Physician. Dietary counseling for obesity, • Annual screening as specified including weight reduction in the policy or contract for programs women who are fifty(50) to 7. Dialysis - Acute hemodialysis sixty-five(65)years of age. services for chronic renal disease Not Covered: and for kidney transplants, Preventive diagnostic screening including training and of all kinds, except for the expendable medical supplies are covered. For chronic 10 20020268 11/02 hemodialysis, application for authorized period of coverage, Medicare Part A and Part B continuation is subject to written coverage must be made. Chronic reauthorization in advance for dialysis (peritoneal or another specified period. Durable hemodialysis) must be authorized Medical Equipment is covered by PacifiCare, and provided only based on criteria established by at hemodialysis facilities that are PacifiCare. The criteria may approved for participation in the include that the equipment must Medicare program. enable a patient who otherwise • Referrals are subject to would have to be treated in an determination by PacifiCare acute care or rehabilitative that the service referred to facility to be cared for outside represents the preferred such an institution. method of treatment. Replacements,repairs and • If, after referral, the receiving adjustments to Durable Medical Provider determines that the Equipment are Limited to normal Member does not satisfy its wear and tear or because of a criteria for the service significant change in the Member's involved, PacifiCare's physical condition. PacifiCare has obligation is Limited to the option to repair or replace paying for eligible chargesDurable Medical Equipment items. incurred prior to such The following equipment and determination, plus eligible accessories are not covered: charges subsequently • Non-Medically Necessary incurred that are covered in optional attachments and whole or in part under modifications to Durable Medicare. Medical Equipment for the 8. Durable Medical Equipment comfort or convenience of the (Rental, Purchase or Repair)- Member, Durable Medical Equipment, • Accessories for portability or including oxygen and insulin travel, pumps, is covered when it is designed to assist in the • A second piece of equipment treatment of an injury or illness with or without additional of the Member, and the accessories that is for the same equipment is primarily for use in or similar medical purpose as the home. Durable Medical existing equipment, and home Equipment is medical equipment and car remodeling. that can exist for a reasonable • Penile Prosthesis or Prostheses period of time without significant for cosmetic purposes deterioration. Durable Medical Equipment, including oxygen, Limits: must be authorized for a Please refer to your Schedule of specified period of time in Benefits for the applicable annual advance in writing by PacifiCare. dollar maximum for this benefit. The authorization will specify whether purchase or rental is Coverage for orthopedic braces,to approved. After the initial include the fitting and adjustment of 11 20020268 11/02 covered braces and repair or • Surgical procedures causing replacement of covered braces permanent sterilization, unless necessitated by misuse. including vasectomies and PacifiCare may replace or repair a tubal ligations. brace at its discretion. Orthopedic • Costs related to an elective braces are covered when prescribed abortion, with a Limit of two by a participating Physician and (2) elective abortions per obtained through a designated Member per lifetime. Provider and that meet all of the following criteria: Not Covered: a) are required to support or • Drug therapy for Infertility correct a defect of form or and related costs function or a permanently • Expenses related to donor non-functioning or sperm and/or donor ova malfunctioning body part, (collection, preparation, and; storage, etc) b) are medically approved and • Fitting of diaphragms and in general use for the specific cervical caps and the cost of condition, and; diaphragms and cervical caps c) are primarily and customarily • Gamete Intrafallopian used either as an alternative Transfer(G.I.F.T.)procedure to surgery or to speed and related costs recovery of a patient who has had surgery, and; • In vitro fertilization (test tube babies) d) can withstand repeated use, and; • In vivo fertilization e) are not generally useful to a • Infertility services, including patient in the absence of an testing, artificial injury or illness. insemination, related medical advice and instruction Limit: • Insertion and removal of $250 per Member per contract intrauterine devices and/or year. Coverage under this implantable contraceptive benefit applies against the devices and drugs and the Durable Medical Equipment cost of such devices and Maximum as outlined in your drugs Schedule of Benefits. • Other ovum transplant Not Covered: procedures and related costs Dental braces, orthotic devices • Pergonal therapy for for podiatric use and arch Infertility support,braces used as aids in sports and activities, corsets and • Procedures deemed to be other non-rigid appliances. Experimental 9. Family Planning—Coverage for • Reversal of voluntary voluntary family planning to sterilization and related include: procedures 12 20020268 11/02 • Surrogate parentage and the patient's condition, related costs progress, and level of care • Pregnancy test kits and needs. ovulation kits • Home health aide services 10. Home Health Care under the supervision of a registered nurse or licensed Designated Home Health Plan occupational, physical, or Before home health care services speech therapist. can qualify as a covered benefit, • Respiratory and inhalation the Member's Physician must therapy. establish a specific, time- • segmented home health plan in Physical, occupational, collaboration with a home health and/or speech therapy and care agency. The services must audiology. be provided by the home health • One-time training for a agency. family member, household Limits: resident, or nonprofessional person employed by the • Services are covered only patient or family. This when necessary as training covers the services alternatives to hospitalization necessary to the custodial or or in place of hospitalization. maintenance levels of care. • Covered benefits are Limited • Medical supplies as specified to sixty(60)visits by a home in the home health plan. health care agency per • Member per contract year. Prescription drugs and Each visit of four(4)hours or medicines, and insulin. less from a home health care Limits: agency team is considered a • Physical, occupational, and single visit. speech therapy are covered as • After the period of time part of home health care only specified in the home health if the patient is homebound. care plan, continuation of this The number of visits are care depends on re- subject applicable Limits as determination of status. outlined under 17., Services for Home Health Care "Outpatient Medical include the following: Rehabilitation Therapy" in V. "Outpatient Out-of-Network • Medical social services. Benefits," and in the • Nutritional counseling by a Schedule of Benefits. nutritionist or dietitian. Not Covered: • Intermittent,part-time Skilled • Custodial and maintenance Nursing Care. care and private duty nursing. • Periodic assessment visits by On-going home care may be either a Physician or a necessary for these levels of licensed nurse to determine care,but this care is not 13 20020268 11/02 covered under this Group services/counseling services; Agreement. medical direction; volunteer • Homemaker services services; pharmaceuticals, medical equipment and supplies • Supplies for personal comfort that are reasonable and necessary or convenience for the palliation and Note: management of the terminal illness and related conditions; The determination of level of respiratory therapy and care(such as Custodial Care, inhalation services; physical and maintenance care, or private duty occupational therapy and speech- nursing) in no way implies that language pathology services for the care being provided is not purposes of symptom control, or required by the Member; it to enable the Member to means only that it is the kind of maintain activities of daily living care that is not a covered benefit, and basic functional skills. even if it is Medically Necessary. Covered Hospice services are 11. Hospice Services- Hospice available in the home on a services are covered for twenty-four(24) hour basis when Members with a terminal illness, Medically Necessary, during defined as a medical condition periods of crisis, when a Member resulting in a prognosis of life of requires continuous care to six(6) months or less, if the achieve palliation or disease follows its natural course, management of acute medical who alone in conjunction with symptoms. family or Members has voluntarily requested admission. Limits: Hospice services are provided • Physical, occupational and pursuant to the plan of care speech therapy are subject to developed by the Member's the applicable Limits as interdisciplinary team,which outlined under 17., includes,but is not Limited to, "Outpatient Medical the Member, the Member's Rehabilitation Therapy"in V. Primary Care Physician, a "Outpatient Out-of-Network registered nurse, a social worker Benefits,"and in the and a spiritual caregiver. The Schedule of Benefits. coverage of these services will • not prevent PacifiCare from re- Individual, family, and evaluating the Member's status caregiver counseling, and subsequently redetermining medical social services, and the status of care. bereavement support services for the Member's family Hospice services include skilled following Member's death nursing services, certified home are subject to a$500 health aid services and maximum per contract year, homemaker services under the and are not subject to the supervision of a qualified maximum Limit for home registered nurse;bereavement Hospice care or the services; social maximum daily benefit for 14 20020268 11/02 home Hospice care explained • To qualify for Hospice care, in Hospice Care Limits the Member's Physician must below: certify that the Member is • Continuous Home Care or terminally ill. The Physician short-term inpatient care must submit a written plan of provided in a Hospice care. inpatient unit,hospital, or • The Member must choose to Skilled Nursing Facility as receive Hospice care instead required for pain or symptom of standard benefits for the management is subject to the terminal illness. It is Limits as described in 11., important for the Member to "Hospice Services" and in the realize that Hospice care is Schedule of Benefits. for terminal conditions and • Prior authorization required that the Hospice benefit by the interdisciplinary team structure is based upon the and PacifiCare(except for concept that those Members Medical Emergencies). receiving Hospice care choose not to avail • Where both inpatient and themselves of other health outpatient care is provided, care benefits for care related each day of care,regardless to the terminal condition. of whether inpatient or While receiving Hospice outpatient,will count toward care, in the Member's home the maximum benefit period. or in a Hospice facility, if a • Medical supplies ordinarily Member requires treatment furnished by the Hospice for a condition not related to agency, including the terminal illness, prescription drugs and PacifiCare of PacifiCare biologicals are covered and continues to pay for all are not subject to the Covered Services. maximum Limit for home • The coverage of these Hospice care or the services will not prevent maximum daily benefit for PacifiCare from re-evaluating home Hospice care explained the Member's status and in the Hospice Care Limits, subsequently redetermining below. the status of care. • Inpatient respite care is a • The maximum benefit for short-term inpatient stay home Hospice care, including which may be necessary for respite care, is $5,000 per the patient in order to give Hospice benefit period. temporary relief to the person Certain covered benefits are who regularly assists the not subject to this maximum, patient with home care, and as noted above. its coverage is Limited each •time to no more than five (5) The maximum daily benefit days in a row. for home Hospice care, including respite care, is $55. Hospice Care Limits Certain covered benefits are 15 20020268 11/02 not subject to this maximum, office (except insulin) are as noted above. covered when a part of the Not Covered: medical office visit. Self injectable medications (except • Services and supplies related insulin) are covered and subject to the terminal condition that to the applicable Copayment are not a part of Hospice care when the Member is trained in • Services of a caregiver other the administration of the than as provided by the medication, and the medication Hospice agency as part of has been prescribed by a this benefit, including,but Participating Provider, and not Limited to, someone who obtained at a designated lives in the Member's home PacifiCare Participating or someone who is a relative Pharmacy as authorized by of the Member PacifiCare. A Copayment will be collected for up to a thirty • Domestic or housekeeping (30) day supply of medication, services that are unrelated to course of therapy or treatment of the Member's care an acute episode,whichever is • Services that provide a shorter. No more than a thirty protective environment where (30) day supply will be dispensed no professional skill is at one time. A Copayment will required, such as also be collected when a self- companionship or sitter administered injectable is services administered in the Physician Services related office. Outpatient injectable • Stheervic es s not tinjectables, must be obtained directly care of the medications, including self- to tlember including, but not through a Participating Provider Limited to: and may require pre- • Estate planning, drafting authorization. Insulin is covered of will, or other legal as a pharmacy benefit if you are services covered by an Outpatient Prescription Drug supplemental • Funeral counseling or funeral benefit. The outpatient arrangements or prescription drug benefit is services covered only if it has been • Food services such as selected by your employer as part Meals on Wheels of the subscribing group's plan. • Transportation services, 13. Foot Conditions—The except covered benefits following services are covered for necessary professional when administered from a ambulance services licensed Provider: 12. Injectable Drugs (Outpatient • Treatment of weak, strained, Iniectable Medications and Self flat,unstable, or imbalanced Iniectable Medications)- feet, treatment for Outpatient injectable medications metatarsalgia or bunion administered in the Physician's 16 20020268 11/02 • Cutting or removing one or • Tooth extraction prior to a more corns, calluses, toenails, major organ transplant or removal of part or all of one radiation therapy to the head or more nail roots for or neck; treatment of a metabolic or • Surgical services in the peripheral vascular disease hospital, Physician's office, • surgical or nonsurgical or in a licensed outpatient treatment of subluxations of surgical facility. This the foot, subluxations of the includes the services of a foot are partial displacements surgical assistant and or dislocations of joint anesthesiologist with surgical surfaces, tendons, ligaments, services when Medically or muscles of the foot Necessary. Limit: Cleft lip, cleft palate, or any A maximum of$500 per condition or illness that is related to or developed as a result of the Member per contract year. cleft lip or cleft palate will be Not Covered: considered to be compensable for • Corrective or supportive coverage under the provisions of devices, appliances, or shoes Colorado law for newborn children born with cleft lip or • Routine foot care or routine cleft palate or both. The hygiene care following care and treatment is 14. Oral Surgery and Dental covered to the extent Medically Services - Coverage for Oral Necessary and when ordered by a surgery and certain medical participating Physician: service charges associated with • Oral and facial surgery, dental services only as follows: surgical management, and • Emergency treatment follow-up care by plastic received within twenty-four surgeons and oral surgeons (24)hours of the occurrence • Prosthetic treatment such as of accidental injury to the jaw obturators, speech appliances, or mouth; and feeding appliances • Treatment of congenital • Medically Necessary conditions of the jaw that orthodontic treatment may be demonstrated to cause actual significant • Medically Necessary deterioration in the Member's prosthodontics treatment physical condition because of • Habilitative speech therapy inadequate nutrition or • Otolaryngology treatment respiration; • Biopsy and excision of cysts • Audiological assessments and or tumors of the jaw and treatment treatment of malignant Note: neoplastic disease; If a dental insurance policy is in effect at the time of the birth, or 17 20020268 11/02 is purchased after the birth of a • The child has sustained child with cleft lip or cleft palate extensive orofacial and dental or both,no benefit under this trauma Group Agreement will be The Member's dentist must provided for any orthodontics or obtain pre-authorization from the dental care needed as a result of PacifiCare before the dental the cleft lip or cleft palate or procedure is provided. both. Not Covered: Dental anesthesia in a dental office or dental clinic is not Dental Services beyond covered. Professional fees of the emergency treatment to stabilize dentist are not covered except for an acute injury—including,but services covered by PacifiCare not Limited to, follow-up dental under V., "Outpatient Out-of- restoration procedures, crowns, Network Benefits," 14., Oral fillings, dental implants, caps, Surgery and Dental Services. dentures,braces, dental 16. Outpatient Alcohol-Drug appliances and orthodontic Rehabilitation Care. Outpatient procedures. alcohol-drug Rehabilitation 15. Oral Surgery and Dental Services provided to Members Services: Dental Treatment who are maintain their place of Anesthesia for Dependent residence at home and receiving Children -Anesthesia and services at the program site on associated facility charges for ambulatory basis are covered. dental procedures provided in a Limit: hospital, outpatient surgery center, or other licensed facility Please refer to the Out-of- pursuant to Colorado law are Network portion of your covered when: Schedule of Benefits for maximum benefit amount • The child is defined as a Dependent as defined in payable per contract year. This Colorado law; maximum amount payable, or until the Provider has deemed • The child has a physical,mental, or medically satisfactory completion of the outpatient program, will be the compromising condition or; maximum benefit per contract • The child has dental needs year, whichever is less for which local anesthesia is ineffective because of acute 17. Outpatient Medical infection, anatomic Rehabilitation Therapy - variations, or allergy or; Services provided by a registered • The child is extremely physical, speech or occupational uncooperative, therapist for the treatment of an unmanageable, anxious, or illness, disease or injury are uncommunicative child or covered. adolescent with dental needs Cardiac deemed sufficiently important that dental care Short-term cardiac rehabilitation cannot be deferred; or is covered based on criteria 18 20020268 11/02 established by PacifiCare at an improvement of a Member's approved facility for the short- condition within two (2) months. term follow-up of acute care Limits: episode. This benefit is an extension of the treatment for an • Please refer to your Schedule inpatient acute care episode and of Benefits for applicable must begin within two (2) Limits under this benefit. months of discharge. None of these benefit Limits Limit apply to therapy provided during an Member's A maximum of$1,000 within a confinement in a hospital. ninety(90)day period • The Member's status may be Occupational/Physical/Speech reevaluated and, if it is Short-term, outpatient determined that the condition occupational and physical is no longer acute, it may not therapy by licensed therapists. be covered. This therapy includes evaluation, Physical, Occupational and treatment, or therapy to correct or Speech therapy for the care and adjust any structural imbalance, treatment of congenital defect distortion, subluxation, or and birth abnormalities for misplaced body tissue of any children up to age five(5) are kind. This short-term, outpatient covered, without regard to physical therapy is for the whether the condition is acute or treatment of acute conditions that chronic and without regard to are subject to significant whether the purpose of the improvement within two (2) therapy is to maintain or to months of when treatment improve functional capacity. begins. Benefits paid for a Limits: procedure billed as a "manipulation" or other form of Not to exceed twenty(20) physical therapy will be applied sessions for Physical, toward the benefit Limit for Occupational, and Speech physical therapy. therapy per acute condition. Services of licensed speech Not Covered: therapists who are Participating Speech therapy related to a Providers or approved by developmental or communication PacifiCare are covered. This delay is not covered. therapy is a benefit only for the short-term rehabilitation required Note: immediately following these Also see VI., "Exclusions and acute episodes: stroke, accidental Limitations of Out-of-Network brain injury (not occurring during Benefits." birth), and injury or surgery directly affecting the larynx 18. Outpatient Psychiatric Care— and/or vocal cords or for Services for Medically Necessary treatment of vocal cord nodules outpatient psychiatric care for adults and children, are covered. in lieu of surgery. The goal of this therapy is a significant The coverage under this benefit, 19 20020268 11/02 and any coverage of services licensed outpatient surgery necessary to fulfill the designated facilities are covered when treatment program in addition to provided as a substitute for those services listed here, are inpatient care. This includes the based on Medical Necessity and services of a surgical assistant are subject applicable Limits as and anesthesiologist with outlined in the Schedule of surgical services when Medically Benefits. Necessary. Care for schizophrenia, 21. Phenylketonuria (PKU) and schizoaffective disorder, bipolar Inherited Enzymatic Disorders affective disorder,major Testing and Treatment - depressive disorder, specific Testing for Phenylketonuria obsessive-compulsive disorder, (PKU) is covered to prevent the and panic disorder shall be development of serious physical covered as any other physical or mental disabilities or to illness and will not be subject to promote normal development or the Limitations of Mental Health function as a consequence of Services as described above. PKU enzyme deficiency. 19. Outpatient Physician Services- Medical Foods, for the purpose Physician's services including of this benefit, refer exclusively time for visits and examinations to prescription metabolic relating to an illness or injury, formulas and their modular and medical consultation counterparts, obtained through a services, including charges made pharmacy. Medical Foods are by a Physician for a second specifically designated and surgical opinion are covered. manufactured for the treatment of These services include Inherited Enzymatic Disorders consultation and personal caused by Single Gene Defects. attendance with the inpatient in Coverage for Inherited the Physician's office, or in a Enzymatic Disorders caused by hospital or other institution. Single Gene Defects shall Physician's visits to the include, but not be Limited to the Member's home are covered only following diagnosed conditions: when Medically Necessary and Phenylketonuria,Maternal only if the Member is too ill or Phenylketonuria, Maple Syrup disabled to go to the Physician's Urine Disease, Tyrosinemia, office. Homocystinuria, Histidinemia, Not Covered: Urea Cycle Disorders, Hyperlysinemia, Glutaric • Expenses for medical reports, Acidemias, Methylmalonic including preparation and Acidemia, and Propionic presentation Acidemia. Covered care and • Expenses for examinations treatment of such conditions shall conducted for the purpose of include, to the extent Medically medical research Necessary, medical foods for home use for which a 20. Outpatient Surgery- Short stay, participating Physician has same day or other similar 20 20020268 11/02 issued a written, oral, or Alternatives," in VI., "Exclusions electronic prescription. and Limitations of Out-of- The maximum age to receive this Network Benefits,"up to the benefit for Phenylketonuria is Durable Medical Equipment twenty-one (21)years of age; benefit maximum as described in except that the maximum age to the Schedule of Benefits. receive this benefit for Not Covered: Phenylketonuria for women who Penile prostheses or prostheses are child-bearing age is thirty- for cosmetic purposes five(35)years of age. 24. Radiation Therapy(Standard Limit: and Complex): Medical Foods will be subject to • Standard photon beam a fifty(50)percent Copayment. radiation therapy 22. Prostate Screening - Coverage is covered. for annual screening for the early • Complex radiation therapy is detection of prostate cancer in covered. This therapy men over the age of fifty (50) requires specialized years and in men over the age of forty(40)years who are in high- trained or certified equipment, as well as risk categories. Coverage shall be personnel to perform the the lesser ofsixty-five (65) therapy. Examples include, screeni ng per or the but are not Limited to: actual charge for such screening. but are not py(radioactive Prostate Screening benefits are not subject to a deductible. The implants), conformal photon beam radiation. Gamma screening shall consist, at a minimum, of the following tests: knife procedures and stereotactic procedures done • A prostate-specific antigen on an outpatient basis are ("PSA")blood test; covered as outpatient • Digital rectal examination. surgeries for purpose of determining Copayments. • At least one screening per (Please refer to your Schedule year shall be covered for any of Benefits for additional man fifty(50)years of age or information.) older. Note: • At least one screening per year shall be covered for any Also see VI., "Exclusions and man from forty(40)to fifty Limitations of Out-of-Network (50) years of age who is at Benefits." increased risk of developing 25. Radiology Services-Standard prostate cancer. X-ray films (with or without oral, 23. Prosthetics and Corrective rectal, injected or infused Appliances. Coverage is Limited contrast medium) for the to external extremity prosthetics, diagnosis of an illness or injury and will be considered under the are covered. Standard X-ray provisions of 55., "Treatment services are X-ray(s) of an 21 20020268 11/02 extremity, abdomen, head, chest, • To repair an injury sustained back, mammograms, nuclear while the Member is a studies,barium studies, and bone Member of PacifiCare and density studies. Specialized repair is initiated within one Scanning and Imaging (1)year following the injury. Procedures, such as CT, SPECT, • The correction of a PET and MRI (with or without congenital defect that contrast media), are covered. substantially impairs major Therapeutic radiological organ function, or leads to a services, including radiation therapy and radioactive isotope progressive deterioration of the health of a covered child. therapy. Not Not Covered: Covered: • Reconstructive nasal surgery, Preventive diagnostic screening of all kinds, except for the including rhinoplasty. covered benefits relating to • Revisions of a procedure screening by low-dose performed for cosmetic mammography as described in 4., purposes, including but not "Breast Cancer Screening and Limited to breast Diagnosis." augmentation. 26. Reconstructive Sur&ery— • Surgical treatment for Plastic,reconstructive or obesity, except for cases that cosmetic surgery, including skin meet the standards of lesions that are removed for Medically Necessary care as cosmetic purposes are not accepted by PacifiCare for covered. Exceptions for cases of morbid obesity and reconstructive surgery must be that are then preauthorized in approved in writing by writing by PacifiCare's PacifiCare and will be considered medical director. only when performed primarily • Reconstructive surgery that to improve the physical health does not correct or materially and function of the patient. Any improve a physiological non-Covered Services received function. prior to written approval will not be reimbursed by PacifiCare and 27. Well-Babv/Well Child Care— will be the financial Immunizations in a Physician's responsibility of the Member. office for Members up to age thirteen(13), according to the Limits: Immunization Schedule as The expenses of plastic, required by law. Please refer to reconstructive or cosmetic the schedule under 22., surgery will be covered if the "Immunizations,"under the surgery is performed as soon as "Outpatient Benefits,"in Section medically feasible and it is Five,Your Medical Benefits. Medically Necessary for either of Coverage of well-baby and/or the following reasons: well-child care is not subject to a deductible. 22 20020268 11/02 VI. EXCLUSIONS AND unexpected, life-threatening LIMITATIONS OF OUT-OF- complications of cosmetic NETWORK BENEFITS surgery. Unless described as a Covered OTHER EXCLUSIONS AND Service in an attached supplement, LIMITATIONS FOR OUT-OF all services and benefits described NETWORK BENEFITS below are excluded from coverage 1. Acupuncture and Acupressure or Limited under this Health Plan. -Acupuncture and Acupressure Any supplement must be an are not covered. attachment to this Combined Evidence of Coverage and 2. Air Conditioners, Air Purifiers Disclosure Form. (Note:Additional or Other Environmental exclusions and Limitations may be Equipment - Air Conditioners, included with the explanation of air purifiers and other your benefits.) environmental equipment are not GENERAL EXCLUSIONS covered. Services that are not Medically 3. Alcoholism,Drug Addiction and Other Substance Abuse Necessary, as defined in the Rehabilitation - One (1)course Definitions section of this Combined of treatment per contract year. Evidence of Coverage and Two(2) courses of inpatient or Disclosure Form, are not covered. outpatient treatment for each Services not specifically included in Member during his/her lifetime. this Combined Evidence of Coverage For inpatient rehabilitation, and Disclosure Form, or any services related to the treatment supplement purchased by your of alcoholism are covered at the employer, are not covered. designated facility and will be 1. Services rendered prior to the subject to the Limits as described Member's effective date of in your Schedule of Benefits. For enrollment or after the effective services not related to the date of disenrolhnent are not treatment of alcoholism, services covered. are covered up the Limits as described in your Schedule of 2. PacifiCare does not cover the Benefits or until the Participating cost of services that result from a Provider has determined treatment plan for a non-Covered satisfactory completion of the Service and that are the sole, inpatient program,whichever is direct and predictable less. For outpatient consequence of a non-Covered rehabilitation, refer to your Service (as recognized by the Schedule of Benefits for organized medical community in applicable Limitations under this the State of Colorado). However, benefit. PacifiCare will cover Medically 4. Behavior Modification and Necessary services required to treat an illness or injury that may Non Crisis Mental Health be a consequence of non- Counseling and Treatment— Covered Services but are not Behavior modification and non- predictable in advance, such as crisis mental health counseling and treatment are not covered 23 20020268 11/02 unless provided as part of a incurred when scheduled services treatment program in an inpatient are canceled by the Member, setting. Examples include, but telephone consultations,personal are not Limited to, art therapy, comfort items, or the completion music therapy and play therapy. of claim forms. 5. Biofeedback- Biofeedback 10. Class Action/Settlements- services are not covered except Services that the Member is as covered under pain clinics or entitled to as a result of class as related to acute pelvic muscle action or special group rehabilitation. settlements, for example, Agent 6. Blood and Blood Products— Orange treatment programs and Special blood handling fees and asbestosis indemnification funds. the storage of cord blood are not If specific treatment facilities are covered. not stipulated by the responsible agency or group, this Group 7. Bloodless Surgery Services- Agreement will pay for eligible Bloodless surgery services are charges contingent on either only covered to the extent coordination of benefits or available from a Provider. subrogation rights. 8. Bone Marrow and Stem Cell 11. Clinics: The following clinics, Transplants -Autologous or services, or programs are not allogeneic bone marrow or stem covered: cell transplants are not covered • when they are Experimental or Special service clinics, Investigational Autologous bone centers, or programs on an marrow or stem cell transplants inpatient or outpatient basis. and chemotherapy requiring a This includes but is not bone marrow or stem cell Limited to clinics, centers or transplant for stage I and stage programs for: IV breast cancer, ovarian cancer • Lactation and other solid tumors. Repeat • Senior services bone marrow or stem cell transplants(allogeneic, • Headaches autologous or any combination) • Eating disorders for the same disease, except for Members with multiple • Smoking cessation myeloma,regardless of whether • Personal goal- or not the original transplant was fulfillment therapy covered under this Group • Agreement. Unrelated Donor Premenstrual Searches must be performed at a syndrome (PMS) PacifiCare approved transplant • Stress management center. (See"Preferred • Transplant Network"in Section Inpatient or outpatient Ten,Definitions.) services of facilities, clinics, or centers that 9. Cancellation Charges - specialize in, or Expenses for missed advertise their appointments and/or charges 24 20020268 11/02 services for, the but not Limited to breast treatment of pain. augmentation is not covered. 12. Communication Devices— • Surgical treatment for Computers, personal digital obesity, except for cases that assistants and any speech- meet the standards of generating devices are not Medically Necessary care as covered. accepted by PacifiCare for • 13. Complementary and cases of morbid obesity and Alternative Medicine - that are then preauthorized in Complementary and Alternative writing by PacifiCare's Medicine are not covered unless medical director, is not purchased by your employer as a covered. supplemental benefit. (See the • Reconstructive surgery, definition for Complementary which does not correct or and Alternative Medicine in materially improve a Section Ten,Definitions.) physiological function is not 14. Cosmetic Services and Surgery covered. —Plastic,reconstructive or However, the expenses of plastic, cosmetic surgery are not covered, reconstructive or cosmetic including skin lesions that are surgery will be covered if the removed for cosmetic purposes. surgery is performed as soon as Exceptions for reconstructive medically feasible and it is surgery must be approved in Medically Necessary for either of writing by PacifiCare and will be the following reasons: considered only when performed • To repair an injury sustained primarily to improve the physical while the Member is a health and function of the patient. Member of PacifiCare and Any non-Covered Services repair is initiated within one received prior to written approval (1)year following the injury will not be reimbursed by PacifiCare and will be the • The correction of a financial responsibility of the congenital defect that Member. substantially impairs major organ function, or leads to a Not Covered: progressive deterioration of • Reconstructive nasal surgery, health of a covered child. including rhinoplasty is not 15. Custodial Care-Custodial Care covered. is not covered. Custodial Care is • Cosmetic procedures and defined as any skilled or non- services performed due the skilled health services, or treatment of hairloss. Wigs, personal comfort or convenience hair implants, and similar related services,which provide supplies and procedures are general maintenance, supportive, not covered. preventive and/or protective care. • Revision of a previous Custodial Care: procedure performed for • Does not seek a cure. cosmetic purposes including, 25 20020268 11/02 • Can be provided in any means all services required for setting. prevention and treatment of • May be provided between diseases and disorders of the periods of acute or teeth, including,but not Limited intercurrent health care to: oral exams, X-rays,routine needs. fluoride treatment; plaque removal, tooth decay, routine • Is care provided to an tooth extraction, dental individual whose health embryonal tissue disorders, services requirements are periodontal disease, crowns, stabilized and whose current fillings, dental implants, caps, medical condition is not dentures, braces, and orthodontic expected to significantly and procedures. (Coverage for dental objectively improve or care may be available if progress over a specified purchased by the Subscriber's period of time. employer as a supplemental Custodial Care may include the benefit.) supervision or participation of a 17. Dental Treatment Anesthesia- Physician, licensed nurse, or Dental treatment anesthesia registered therapist as necessary provided or administered in a or desirable services. The mere dentist's office is not covered, participation of these except as provided for children professionals does not preclude as defined above in V., the services as being custodial in "Outpatient Out-of-Network nature. If the nature of the Benefits," 14., "Oral Surgery and services can be safely and Dental Services:"Dental effectively performed by a Treatment Anesthesia for trained non-medical person, the Dependent Children. Charges for services are custodial. Further, the dental procedure(s) itself, Custodial Care and the nature of including but not Limited to those services are not altered by professional fees of the dentist or the availability of the non- oral surgeon,X-ray and medical person. Custodial Care laboratory fees or related dental may also be referred to as supplies provided in connection chronic, maintenance, with the care, treatment, filling, domiciliary,respite, and/or removal or replacement of teeth convalescent care. or structures directly supporting 16. Dental Care,Dental Appliances the teeth are not covered except and Orthodontics—Except as for services covered by otherwise provided under V., PacifiCare under V., "Outpatient "Outpatient Out-of-Network Out-of-Network Benefits," 14., Benefits," 14., "Oral Surgery and "Oral Surgery and Dental Dental Services,"dental care, Services." dental appliances and 18. Diabetic and Dietary orthodontics, and care provided Management and Treatment- under newborn care concerning Dietary counseling for obesity, coverage of cleft palate and cleft including weight reduction lip, are not covered. Dental Care programs are not covered. 26 20020268 11/02 Limit: Equipment is covered based on One visit per contract year criteria established by PacifiCare. The criteria may include that the 19. Dialysis—Services for Chronic equipment must enable a patient dialysis (peritoneal or who otherwise would have to be hemodialysis),provided at treated in an acute care or hemodialysis facilities not rehabilitative facility to be cared approved for participation in the for outside such an institution. Medicare program, and without Replacements,repairs and prior authorization by PacifiCare, adjustments to Durable Medical are not covered. Equipment are Limited to normal 20. Disabilities Connected to wear and tear or because of a Military Services -Treatment in significant change in the a government facility for a Member's physical condition. disability connected to military Replacement of lost or stolen service that the Member is Durable Medical Equipment is legally entitled to receive through not covered. The following a federal governmental agency, equipment and accessories are and to which Member has not covered: Non-Medically reasonable access, is not covered. Necessary optional attachments and modifications to Durable 21. Drugs and Prescription Medical Equipment for the Medication(Outpatient)— comfort or convenience of the Outpatient drugs and prescription Member, accessories for medications are not covered; portability or travel, a second however, coverage for piece of equipment with or prescription medications may be without additional accessories available as a supplemental that is for the same or similar benefit. If your Health Plan medical purpose as existing includes a supplemental benefit, equipment, and home and car a brochure will be enclosed with remodeling. Penile Prosthesis or your materials. Infusion drugs Prostheses for cosmetic purposes and infusion therapy are not are not covered. considered outpatient drugs for the purposes of this exclusion. 23. Elective Enhancements— Refer to V., "Outpatient Out-of- Procedures, services and supplies Network Benefits," 11., for elective, non-Medically "Injectable Drugs (Outpatient Necessary enhancements (items, Injectable Medications and Self devices or services to improve Injectable Medications)."Pen appearance or performance) are devices for the delivery of not covered. This includes but is medication are not covered. not Limited to, elective enhancements related to hair 22. Durable Medical Equipment— growth, athletic performance, Coverage is Limited to cosmetic changes, and anti- equipment that can assist in the aging. treatment of an injury or illness of the Member, and the 24. Education Programs - Expenses equipment is primarily for use in of health education,patient the home. Durable Medical education, wellness promotion, 27 20020268 11/02 or any similar program or Drug Administration(FDA) service. or other governmental agency 25. Educational Services for and such approval has not Developmental Delays and been granted at the time of its Learnin¢Disabilities— use or proposed use, Educational services to treat or developmental delays or learning • it is the subject of a current disabilities are not covered. A Investigational new drug or learning disability is a condition new device application on where there is a meaningful file with the FDA, difference between a child's current academic level of or function and the level that would • it is being administered for be expected for a child of that non FDA-approved age. Educational services include indications, but are not Limited to language and speech training, reading, or psychological and visual • it is being provided pursuant integration training as defined by to a Phase I or Phase II the American Academy of clinical trial or as the Pediatrics. Policy Statement- Experimental or research arm Learning Disabilities, Dyslexia of a Phase III clinical trial, and Vision:A Subject Review. or 26. Exercise Equipment and • Services- Exercise equipment or it is being provided pursuant any charges for activities, to a written protocol which instructions or facilities normally describes among its intended or used for developing objectives, determinations of or maintaining physical fitness safety, toxicity, effectiveness are not covered. This includes, or effectiveness in but is not Limited to, charges for comparison to conventional physical fitness instructors, alternatives, health clubs or gyms, or home or exercise equipment or swimming • pools, even if ordered by a health it is being delivered or should be delivered subject to the care professional. approval and supervision of 27. Experimental and/or an Institutional Review Investigational Procedures, Board(IRB) as required and Items and Treatments— defined by federal Treatments,procedures, devices regulations,particularly those and/or drugs shall be deemed of the FDA or the excluded as Experimental, Department of Health and Investigational, unproven, Human Services(HHS), unusual, or not customary if: or • it cannot be lawfully marketed without the • the predominant opinion approval of the Food and among experts as expressed in the published authoritative 28 20020268 11/02 literature is that usage should Necessary,but for being be substantially confined to provided in conjunction with research settings, the provision of a treatment, or procedure, device or drug which is Experimental, • if the predominant opinion Investigational,unproven, among experts as expressed unusual or not customary. in the published authoritative literature is that further Determinations under this research is necessary in order heading will be based on the to define safety, toxicity, following: effectiveness or effectiveness • the Member's medical compared with conventional records, alternatives, • the protocol(s)pursuant to or which the treatment is to be • it is not a covered benefit delivered, under Medicare as • any informed consent determined by the Centers for documents the Member is Medicare and Medicaid required to read and/or Services(CMS) of HHS, execute, as a condition of or receiving the treatment, • it is Experimental, • the published authoritative Investigational,unproven, medical or scientific unusual or not customary or literature regarding the is not a generally acceptable procedure at issue as applied medical practice in the to the Member's medical predominant opinion of condition, independent experts, • regulations,bulletins, letter or rulings or other official actions and publications • a majority of a representative issued by the FDA, HHS, sample of not less than three CMS,the National Institutes health insurance or benefit for Health (NIH), the Providers or administrators National Cancer Institute consider the requested (NCI) or other applicable treatment,procedure, device regulatory agencies, or drugs to be Experimental, • Investigational,unproven, the opinions of independent unusual or not customary experts, based upon criteria and • materials prepared by, for or standards regularly applied on behalf of other health by the industry, insurance or benefit or Providers and administrators concerning the requested • it is not Experimental or treatment,procedure, device Investigational in itself or drug, and/or pursuant to the above, and would not be Medically 29 20020268 11/02 • recognized technology categories are those assessments or evaluations by prescribed for: private or federal entities • Use in dosage forms not (e.g. Blue Cross &Blue commercially available Shield Association,American Medical Association, Office • Use by routes of of Technology Assessment) administration not approved by the FDA • other materials that, in the exercise of PacifiCare's • Non-FDA approved discretion, are relevant. indications No treatment,procedure, device • Naturopathic services and/or drug excluded by this • Megavitamin therapy subsection on the inception date of this Group Agreement shall be PacifiCare shall have the covered because it subsequently discretionary authority to ceases to meet the criteria of this interpret this plan and determine section during the remaining all questions arising in the contract year,unless PacifiCare administration, interpretation, issues a written amendment and application of the plan expressly making it a covered including determining what benefit. procedures, devices or drugs are Experimental, investigation, Treatments,procedures, devices unusual, not customary, or and/or drugs considered to be unproven. All such Experimental, Investigational, determinations shall be final, unproven, unusual, or not conclusive, and binding. customary include, but are not Limited to: 28. Eve Wear and Corrective Refractive Procedures - • Orthomolecular medicine Corrective lenses and frames, • Holistic medicine contact lenses, contact lens fitting and measurements are not • Environmental medicine covered. Surgical and laser • Chelation therapy, unless procedures to correct or improve Medically Necessary for the refractive error are not covered. treatment of metal poisoning 29. Family Planning -Family • Cytotoxin testing planning benefits, other than • Hair analysis those specifically listed in 8., "Family Planning"under V., • Colonies "Outpatient Out-of-Network • Gene manipulation therapy Benefits,"are not covered. Elective Abortions are Limited to • Medications that are two (2) elective abortions per Experimental, investigative, Member per lifetime. or used in ways not approved by the Food and Drug 30. Foot Care—Except for Administration(FDA). Medically Necessary foot care Medications included in these for conditions as described above in IV. "Inpatient Out-of-Network 30 20020268 11/02 Benefits," 3., "Foot Conditions" 33. Government Services and and V., "Outpatient Out-of- Treatment- Any services Network Benefits," 13., "Foot provided by a local, state or Conditions,"routine foot care, federal government agency are including,but not Limited to, not covered, except when removal or reduction of corns coverage under this Health Plan and calluses, clipping of toenails, is expressly required by federal is not covered. Corrective or or state law, and an expense must supportive devices, appliances, be paid by the Member in the or shoes or are not covered. absence of this insurance. This Limit: exclusion is not applicable to Colorado-supported institutions A maximum of$500 per treating mental illness, mental Member per contract year. retardation, or both and nervous 31. Foot Orthotics/Footwear- disorders if such charges for Orthotic devices for podiatric use treatment are customarily and arch support,braces used as charged to nonindigent patients aids in sports and activities, by such state institutions. corsets and other non-rigid 34. Growth hormones. appliances are not a covered benefit. 35. Health Care Expenses Incurred Due to Liable Third 32. Genetic Testing and Party-Except as set forth in the Counseling- Genetic testing of Combined Evidence of Coverage non-Members is not covered. and Disclosure Form in Section Genetic testing solely to Six,Payment Responsibility, determine the gender of a fetus is "PacifiCare's right to the not covered. Genetic testing and repayment of a debt as a charge counseling are not covered when against recoveries from third done for non-medical reasons, or parties liable for a Member's when a Member has no medical health care expenses," coverage indication or family history of a for any health care expenses genetic abnormality. General incurred as the result of a liable testing and counseling are not third party are not covered. covered to screen newborns, children or adolescents to 36. Hearing Aids and Hearing determine their carrier status for Devices -Hearing aids and non- inheritable disorders when there implantable hearing devices are would be no immediate medical not covered. Audiology services benefit or when the test results (other than screening for hearing would not be used to initiate acuity) are not covered. Hearing medical interventions during aid supplies are not covered. childhood. Genetic testing and Implantable hearing devices are counseling are not covered not covered. except when determined by 37. Incarceration -Expenses PacifiCare's medical director or resulting from committing, designee to be Medically attempting, or taking part in a Necessary to treat the Member felony, or expenses incurred for an inheritable disease. while the Member is incarcerated 31 20020268 11/02 or serving a term of ovum transplant procedures, imprisonment or involuntary surrogate parentage, drug confinement. therapy for Infertility, and 38. Immunizations-Immunizations related costs of each are not for children and adults, including covered. those required for work, are not • The cost related to donor covered except as explained in sperm and donor ova 27., "Well-Baby/Well-Child (collection,preparation, Care,"in V., "Outpatient Out-of- storage, etc.) Network Benefits." • Procedures considered to be 39. Infertility Reversal- Expenses Experimental/Investigational of procedures, therapies, • Reversal of a sterilization services, medications, and procedure(s) is not a covered supplies related to sex benefit. transformation,reversal of sex transformation, and sexual • Surrogate parentage and any dysfunctions or inadequacies, related costs including penile implants or any • Pregnancy test kits and prosthesis for impotency. ovulation kits. 40. Infertility Services—The 41. In-Network Services— Infertility services, including Expenses of In-Network Services testing, artificial insemination, arranged provided, arranged, or and related medical advice and paid by PacifiCare. instruction are not covered. 42. Institutional Services and Not Covered: Supplies—Except for Skilled • Fitting of diaphragms and Nursing Services provided in a cervical caps and the costs of Skilled Nursing Facility, any diaphragms and cervical services or supplies furnished by caps. a facility that is primarily a place of rest, a place for the aged, a • Insertion and removal of intrauterine devices and/or nursing home, or any similar institution,regardless of implantable contraceptive devices and drugs and the affiliation or denomination, are not covered. (Skilled Nursing cost of such devices and Services are covered as described drugs in this Combined Evidence of • Pergonal therapy for Coverage and Disclosure Form Infertility under IV., "Inpatient Out-of- • In vitro fertilization(test tube Network Benefits" and V., babies) the Gamete "Outpatient Out-of-Network Intrafallopian Transfer Benefits.") (G.I.F.T.)procedure, the 43. Jurisdiction-Expenses for Zygote Intrafallopian which payment is not lawful in Transfer(Z.I.F.T.)procedure, the jurisdiction where the Artificial Reproductive Member is living when the Technology(A.R.T.), other expenses are incurred. Expenses 32 20020268 11/02 for services that are not within Statistical Manual of Mental the scope of the Provider's Disorders-IV (DSM-IV). license in the jurisdiction where the • Counseling for adoption, services are provided. custody, family planning or 44. Medical reports. Medical report pregnancy in the absence of a expenses, including preparation DSM-IV diagnosis. and presentation. • Counseling associated with 45. Medicare Benefits for or in preparation for a sex Medicare Eligible Members - change operation. The amount payable by Medicare • Sexual therapy programs, for Medicare Covered Services is including therapy for sexual not covered by PacifiCare for Medicare Eligible Members, addiction, the use of sexual surrogates, and sexual whether or not a Medicare treatment. Eligible Member has enrolled in Medicare Part A and Medicare • Vocational,pastoral or Part B. spiritual counseling. 46. Mental Health • Dance, Poetry, music, or art Services/Psychiatric Care- The therapy, except as part of a following mental health services treatment program in an are not covered: inpatient setting. • Confinement, treatment, • Non-organic therapies service or supply that is not including,but not Limited to, authorized, except in the bioenergetics therapy, event of an emergency. confrontation therapy, crystal healing therapy, educational • Confinement,treatment, remediation, Eye Movement service or supply that is notDesens ordinarily provided for the guided image Reprocessing, specific treatment which was imagery,marathon authorized. therapy,primal therapy, rolfing, sensitivity training, • Confinement, treatment, training psychoanalysis, service or supply obtained transcendental meditation, through or required by a and Z therapy. governmental agency or • Organic therapies including, program. but not Limited to, aversion • Weight control programs and therapy, carbon dioxide treatment for addictions to therapy, environmental tobacco,nicotine or food. ecological treatment or • Treatment or psychological remedies,herbal therapies, testing for any reading or homodialysis for learning disorder,mental schizophrenia, vitamin or retardation, or other orthomolecular therapy, developmental disorders as narcotherapy with LSD, and defined by the Diagnostic and sedative action electrostimulation therapy. 33 20020268 11/02 • Surgery or acupuncture as a training, employment mental health benefit. investigations, fitness for • Laboratory fees as a mental duty evaluations, or career health benefit for outpatient counseling. treatment plans. 47. Military Service,War, Riot, or • Services which are not Insurrection -Expenses Medically Necessary for the resulting from military service treatment of mental health for any country or organization, disorders. including service with military forces as a civilian whose duties • Services that are required by do not include combat. Expenses a court order as a part of resulting from war or any act of parole or probation, or war,whether or not declared, or instead of incarceration, from any riot or insurrection. which are not Medically Necessary. 48. Non-recommended services- Expenses for services that were • Long-term insight-oriented not recommended by a psychotherapies that regress Physician, or not accompanied the Member emotionally or by a diagnosis of an injury or behaviorally. illness from the Physician who • Personal enhancement, self- ordered the service for which the actualization therapy or other expenses were incurred. similar treatment plans. 49. Nurse Midwife Services—Nurse • Services provided by a non- midwife services are covered licensed Provider. only when provided through an OB/GYN Provider. Home • Neurological services and deliveries are not covered. tests, including,but not Limited to, EEGs, Pet scans, 50. Nursing,Private Duty-Private beam scans, MRIs, skull x- duty nursing is not covered. rays and lumbar punctures. 51. Nutritional Supplements or These services must be pre- Formulas - Formulas, food, authorized by the Primary vitamins,herbs and dietary Care Physician. supplements, and any procedures • Treatments which do not for determining vitamin or meet the national standards mineral deficiencies are not for mental health professional covered, (except as described practice. under V., "Outpatient Out-of- Network Benefits,"21., • Medical treatment for eating "Phenylketonuria(PKU)and disorders. Inherited Enzymatic Disorders • Treatment sessions by Testing and Treatment"). telephone or computer 52. Off Label Drug Use - Off label Internet services (except as drug use,which means the use of provided by Colorado law). a drug for a purpose that is • Evaluation or treatment for different from the use for which education, professional the drug has been approved for 34 20020268 11/02 by the FDA, including off label mechanisms as a means for self-injectable drugs, is not appropriately managing the covered except as follows: If the utilization of a drug that is self-injectable drug is prescribed prescribed for a use that is for off label use, the drug and its different from the use for which administration is covered only that drug has been approved for when the following criteria are marketing by the FDA. met: 53. Oral Surgery and Dental • The drug is approved by the Services - Dental Services -- FDA; including, but not Limited to, • The drug is prescribed by a crowns, fillings, dental implants, Provider for the treatment of caps, dentures,braces and a life-threatening condition or orthodontic procedures- are not for a chronic and seriously covered. Other services not debilitating condition; covered include but are not Limited to: • The drug is Medically Necessary to treat the • General dental services and condition; dental x-rays, including treatment on or to the teeth or • The drug has been recognized gums for treatment of the life- • threatening or chronic and Any services customarily seriously debilitating provided by a general dentist, condition by one of the an oral surgeon, or any other following: The American dental specialist Medical Association Drug • Any procedure involving Evaluations, The American osteotomy of the jaw Hospital Formulary Service • Periodontal treatment and/or Drug Information, The United States Pharmacopoeia surgery Dispensing Information, • Treatment or care for Volume 1, or in two articles overbite or underbite from major peer-reviewed • Treatment or care for medical journals that present maxillary and mandibular data supporting the proposed osteotomies, and jaw or off label drug use or uses as orthognathic conditions generally safe and effective; • Dental prosthetics, • The drug is covered under the orinjectable drug benefit metallic e bone h cylinder and described in the outpatient on screws) benefits of this Combined implants (bone screws) Evidence of Coverage and • Hospital costs for dental Disclosure Form. surgery or other dental reasons Nothing shall prohibit PacifiCare from the use of a formulary, • Expenses for dental care in Copayment, technology the treatment for assessment panel, or similar misalignment or similar malfunction of the jaw joint, 35 20020268 11/02 commonly known as Preferred Transplant Network temporomandibular joint facility greater than sixty(60) problems or TMJ syndrome, miles from the Member's including but not Limited to Primary Residence as splint therapy. Covered preauthorized by PacifiCare. Services related to the • Food and housing is not treatment of TMJ must be covered unless the Preferred preauthorized and are Transplant Network center is Limited to $500 per Member located more than sixty(60) per contract year. miles from the Member's 54. Oral Surgery and Dental Primary Residence, in which Services: Dental Treatment case food and housing is Anesthesia—Dental anesthesia Limited to $125 dollars a day in a dental office or dental clinic to cover both the Member is not covered, except as and escort, if any (excludes provided in. V., "Outpatient Out- liquor and tobacco). Food of-Network Benefits," 14., "Oral and housing expenses are not Surgery and Dental Services:" covered for any day a Professional fees of the dentist Member is not receiving are not covered. (Please see VI., Medically Necessary "Exclusions and Limitations of transplant services. Out-of-Network Benefits," 16., 57. Phenvlketonuria (PKU1 and "Dental Care, Dental Appliances Inherited Enzymatic Disorders and Orthodontics and 17., Testing and Treatment—Food "Dental Treatment Anesthesia.") products naturally low in protein 55. Organ Donor Services- are not covered, except as Medical and Hospital Services, provided under V., "Outpatient as well as other costs of a donor Out-of-Network Benefits,"21., or prospective donor, are only "Phenylketonuria(PKU)and covered when the recipient is a Inherited Enzymatic Disorders Member. The testing of blood Testing and Treatment." relatives to determine 58. Physical or Psychological compatibility for donating organs Examinations -Physical or is Limited to sisters,brothers, parents, examinations for and natural children. employment, insurance, Donor Searches are only covered when performed by a Provider licensing, camp exams, flight included in the Preferred physicals, court hearings,travel, premarital, pre-adoption or other Transplant Network facility. non-preventive health reasons are 56. Organ Transplants—All organ not covered. Health appraisals transplants must be preauthorized and check-ups for children over by PacifiCare and performed in a the age of thirteen(13) and adults PacifiCare Preferred Transplant are not covered. Network facility. 59. Post-mortem testing. • Transportation is Limited to 60. Prior Expenses-Expenses for the transportation of the medical and/or Hospital Services Member and one escort to a incurred prior to the Effective 36 20020268 11/02 Date of Coverage for the cosmetic surgery, including skin Member or after termination of lesions that are removed for coverage under this Group cosmetic purposes are not Agreement. covered. Exceptions for 61. Private Rooms and Comfort reconstructive surgery must be Items - Personal or comfort approved in writing by items, and non-Medically PacifiCare and will be considered Necessary private rooms during only when performed primarily inpatient hospitalization, are not to improve the physical health covered. and function of the patient. Any non-Covered Services received 62. Prosthetics—Replacement of prior to written approval will not lost prosthetics is not covered. be reimbursed by PacifiCare and Prosthetics that require surgical will be the financial connection to nerves,muscles or responsibility of the Member. other tissues (bionic)are not covered. Prosthetics that have Reconstructive nasal surgery, electric motors to enhance including rhinoplasty are not motion(myoelectronic) are not covered. covered. Revisions of a procedure performed for cosmetic purposes, 63. Public Facility Care-When state or local law requires but not Limited to breast treatment in a public facility, care augmentation, is not covered. is not covered; however, Surgical treatment for obesity is PacifiCare will reimburse a not covered, except for cases that Member for out-of-pocket meet the standards of Medically expenses incurred for any Necessary care as accepted by Covered Service delivered at a Colorado for cases of morbid public facility that meets the obesity and that are then defmition of Emergency or preauthorized in writing by Urgently Needed Services. PacifiCare's medical director. Injuries or illnesses sustained Reconstructive surgery that does while incarcerated in a State or not correct or materially improve Federal prison, in legal custody, a physiological function is not on a legal hold, or in legal covered. detention are not covered. Only Emergency and Urgently Needed The expenses of plastic, Services are covered until the reconstructive or cosmetic Member is stabilized and placed surgery will be covered if the on a police hold. Nothing in this surgery is performed as soon as provision will restrict the liability medically feasible and it is of PacifiCare with respect to Medically Necessary for either of Covered Services solely because the following reasons: such services were provided • To repair an injury sustained while the Member was in a state while the Member is a hospital. Member of PacifiCare and 64. Reconstructive Surgery— repair is initiated within one Plastic, reconstructive or (1)year following the surgery 37 20020268 11/02 • The correction of a acute, it may not be congenital defect that covered. substantially impairs major • Physical, Occupational organ function, or leads to a and Speech therapy for progressive deterioration of a the care and treatment of covered child. congenital defect and Pre-authorizations for proposed birth abnormalities for reconstructive surgeries will be children up to age five (5) reviewed by Physicians are covered, without specializing in such regard to whether the reconstructive surgery who are condition is acute or competent to evaluate the chronic and without specific clinical issues involved regard to whether the in the care requested. purpose of the therapy is 65. Recreational, Lifestyle, to maintain or to improve Educational or Hypnotic functional capacity. Therapy—Recreational, • Limits: lifestyle, educational or hypnotic therapy, and any related • Not to exceed twenty(20) sessions for Physical, diagnostic testing, is not covered except when provided as part of a Occupational, and Speech therapy per acute covered inpatient hospitalization. condition. 66. Rehabilitation Services and • Not Covered: Therapy-Rehabilitation Services and therapy are either Speech therapy related to Limited or not covered, as a developmental or follows: communication delay is not covered. • Cardiac Coverage is Limited to a • Rehabilitation Services and Therapies Not Covered: maximum of$1,000 within a ninety(90) day period. • Behavior disorders • Occupational/Physical/Speec • Communication delay h • Learning disability • Please refer to your • Mental retardation and Schedule of Benefits for related conditions applicable Limits under this benefit. None of • Motor dysfunction these benefit Limits apply • Multiple handicaps to therapy provided during an Member's • Perceptual disorders confinement in a hospital. • Personal Goal Fulfillment • The Member's status may • Post-traumatic stress be reevaluated and, if it is determined that the • Pulmonary rehabilitation condition is no longer • Sensory deficit 38 20020268 11/02 • Sex addiction VI., "Outpatient Out-of- • Speech(except as Network Benefits," 11., covered in V., "Hospice Services." "Outpatient Out-of- • Sleep therapy Network Benefits," 17., • Vision therapy/orthoptics "Outpatient Medical Rehabilitation Therapy") • Vocational rehabilitation • Vision 67. Respite Care - Respite Care is not Special evaluation and therapies covered,unless part of an authorized Hospice plan as described above in including: V., "Inpatient Out-of-Network • Behavioral training Benefits,"4., "Hospice Services and • Bereavement support, VI., "Outpatient Out-of-Network Benefits," 11., "Hospice Services" except as part of Hospice Care as indicated in V., and is necessary to relieve the "Inpatient Out-of- primary caregiver in a Member's Network Benefits,"4., residence. Respite care is covered "Hospice Services and only on an occasional basis, not to VI., "Outpatient Out-of- exceed 5 consecutive days at a time. Network Benefits," 11., 68. Self-Inflicted Injury—As allowed "Hospice Services." by Colorado law, expenses resulting • Biofeedback(except as from any intentionally self-inflicted related to acute pelvic injury or illness. muscle rehabilitation) 69. Services in the Home-Expenses of • Cognitive therapy medical care or treatment given by any member of the Member's family, • Coma stimulation a relative, or anyone normally • Developmental and residing with the Member. Expenses neuroeducational testing that the Member is not legally or treatment obligated to pay(e.g., free clinics or services which the Member received • Educational studies as a professional courtesy) or • Hearing therapy charges that would not have been made had the Group Agreement not • Hypnotherapy been in force; expenses for services • Myofunctional therapy which were not actually provided. • Neuromuscular 70. Sex Transformations- Procedures, rehabilitation for Chronic services,medications and supplies Conditions related to sex transformations are not • Psychological testing covered. • Respiratory Therapy, 71. Skilled Nursing Facility except as part of Hospice Care/Subacute and Transitional Care as indicated in V., Care—Skilled Nursing Facility "Inpatient Out-of- room and board charges are excluded Network Benefits,"4., after the Limits as described in your "Hospice Services and Schedule of Benefits. Days spent out 39 20020268 11/02 of the Skilled Nursing Facility when • Personal comfort or convenience transferred to an acute hospital items, such as television or setting are not counted toward the telephone Limits as described in your Schedule • Private room, except when of Benefits when the Member is Medically Necessary transferred back to a Skilled Nursing Facility, but the count resumes upon • Care provided to a Member may the Member's return to a Skilled be Custodial Care even though Nursing Facility. Such days in an all of the following apply: acute hospital setting also do not • The Member is under a count toward renewing the Limits as Physician's care or described in your Schedule of supervision Benefits. In order to renew the room and board coverage in a Skilled • Services are being prescribed Nursing Facility a Member must to support and generally either be out of all Skilled Nursing maintain the Member's Facilities for sixty(60) consecutive condition,provide for the days or if the Member remains in a Member's comfort, or assure facility,then the Member may not the manageability of the have received Skilled Nursing Care Member or Skilled Rehabilitation Care for • Services are being provided sixty(60) days. by a registered nurse or other Limits: licensed Provider • Up to thirty(30) days of these 72. Supplies-Medical supplies prescribed services at other including without Limitation, on an institutions per contract year outpatient basis, enteral feeding substance and infant formula, • The Member's status also may be medical foods, hyperalimentation reevaluated and, if it is solution, total parenteral nutrition, determined that the status of the and infant formula on an outpatient care is no longer acute, the basis are not covered, except as services may not be covered. specified in V., "Outpatient Out-of- Not Covered: Network Benefits," 21., "Phenylketonuria(PKU)and • Expenses of chronic, custodial, Inherited Enzymatic Disorders or maintenance care Testing and Treatment." • Chronic or maintenance care, 73. Surrogacy- Infertility and maternity private duty nursing, and respite services for non-Members are not care (except as may be provided covered. PacifiCare may seek under Hospice Care as indicated recovery from a Member who is above in V., "Inpatient Out-of- receiving reimbursement for medical Network Benefits,"4., "Hospice expenses for maternity services Services and VI., "Outpatient Out-of-Network Benefits," 11., while acting as a surrogate. "Hospice Services.") 74. Transportation—Transportation is not a covered benefit except for • Convalescent care Ambulance transportation as defined • Private duty nursing in Emergency and Urgently Needed 40 20020268 11/02 Services of this Combined Evidence PacifiCare will provide a written of Coverage and Disclosure Form. response; only services specifically 75. Treatment Alternatives -Treatment authorized and received after the alternatives and Limited adaptations Member's receipt of the written to coverage under this Group response will be covered. PacifiCare Agreement are reserved to the sole shall have the sole discretionary discretion of PacifiCare. While this authority to interpret this plan and Group Agreement is the definitive determine all questions arising in the statement of PacifiCare's legal administration, interpretation, and obligation to provide benefits, application of the plan, and all such experience has shown that there may determinations shall be final, be unusual and extraordinary conclusive and binding. circumstances that are not 76. Veterans Administration Services contemplated by this Group —Except for Emergency or Urgently Agreement. Therefore, PacifiCare Needed Services, services provided specifically reserves the right, at its in a Veterans Administration facility sole discretion and based on prudent are not covered. business and medical judgment(with 77. Vision Care - See VI., "Exclusions the input of its Medical Director),toand Limitations of Out-of-Network adapt the coverage and benefits set Benefits,"28., "Eye Wear and forth in this Group Agreement. Corrective Refractive Procedures" The fact that PacifiCare makes an 78. Vision Training- Vision therapy adaptation to this Group Agreementrehabilitation and ocular training will not require or act as precedent programs (orthoptics) are not requiring that it make future covered. adaptations in similar or other situations, or otherwise be prevented 79. Weight Alteration Programs from administering this Group (Inpatient or Outpatient) -Weight Agreement in strict accordance with loss or weight gain programs are not its terms. • icovered. These programs include, In addition, PacifiCare may, at its but are not Limited to, dietary evaluations, counseling, exercise and sole discretion, reevaluate and behavioral modification. Also discontinue any adaptation granted under this provision if it determines excluded are surgery, laboratory that the original basis for granting tests, food and food supplements, vitamins and other nutritional the adaptation is no longer valid and supplements associated with weight supportive of the adaptation or is no loss or weight gain. longer likely to lead to measurable improvement in the health of the 80. Work-Related Injuries -Expenses Member. resulting from any injury arising out Any request for coverage of of, or in the course of, any work for treatment alternatives and/or Limited wage or profit(whether or not with adaptations to this Group Agreement the employer). Expenses resulting must be made in writing,by a from any illness or injury for which Physician or a Member,to the Member is eligible for or entitled to benefits under workers' PacifiCare. The coverage decision compensation statutes or any similar will be made by PacifiCare. laws. 41 20020268 11/02 81. Cumulative Benefits -Any service Primary Care Physician. Having a Primary provided to a Subscriber or Care Physician is essential to using the Dependent during a Contract Year is advantages of your PacifiCare in-network Limited cumulatively to the benefits coverage. Please review Section Five, covered in this Group Agreement. Your Medical Benefits,Your Out-of- The following changes in a Network-Benefits (as amended below), and Member's status may not increase your Schedule of Benefits included with this any restriction or Limitation on the document for the out-of-network benefits number of services or benefits a that are covered under your plan. Member can receive in a contract With your PacifiCare in-network coverage, year: your Primary Care Physician manages your • From Subscriber to Dependent health care and makes all referrals for • From Dependent to Subscriber specialty care. With out-of-network benefits, the decision to use any specialty • From group coverage to care services, such as obstetrics, cardiology, Continuation Coverage, or orthopedics is up to you. individual plan coverage, or You can choose either option at the time you conversion coverage select care. • From Employer Group contract to another Employer Group The PacifiCare Plus plan was developed contract primarily to serve you within the PacifiCare HMO Service Area. If you obtain services 3. The following provisions are hereby added (except emergency care) outside of this area, to the end of Section Six, Payment you should understand that your PacifiCare Responsibility, as follows: in-network coverage will not apply, and the Using PacifiCare Out-of-Network Coverage out-of-network benefits may be the only benefits available to you. See Section You Have the Option Seven, Member Eligibility in this With PacifiCare Plus you have coverage in Combined Evidence of Coverage and addition to your PacifiCare in-network Disclosure Form for details about the benefits. The principle feature that PacifiCare HMO Service Area. PacifiCare Plus adds to the in-network With PacifiCare out-of-network benefits, benefits is your ability to choose a licensed you can select Providers who do not practitioner outside of PacifiCare's participate with PacifiCare. When selecting participating contract Provider network. these Providers, you will need to obtain You can use the regular PacifiCare in- preauthorization for all non-emergency network benefits and services (with hospital admissions. Also, in some cases, predetermined and fixed Copayments)that you will need a second surgical opinion to are provided or arranged for by your get authorization for selected surgical Primary Care Physician. Or you can use a procedures. If you do not obtain Provider who is not contracted with authorization as required, PacifiCare Plus PacifiCare. In this case,using your out-of- will only pay (in most cases) a lesser network benefits,you are covered for(in percentage of eligible charges. Again, please most cases) a percentage of eligible charges review Section Five,Your Medical after your deductible has been met. In order Benefits,Your Out-of-Network-Benefits to obtain in-network coverage, covered (as amended below), and your Schedule of medical services, except true emergency Benefits included with this document for the care, must be provided or referred by your 42 20020268 11/02 out-of-network benefits that are covered PacifiCare knows that you may be faced under your plan. with making some difficult choices about medical care. That is why your PacifiCare We have created preadmission authorizations to help ensure that you out-of-network plan covers second surgical receive the appropriate level of care that we opinions. We want to help make sure, believe all PacifiCare Members need and before you obtain any non-emergency deserve. surgical procedures that you have considered all the available options open to Non-Emergency Hospital/Ambulatory you. Surgical Center Admissions To receive the maximum reimbursement 1. To obtain preauthorization for non- from your PacifiCare out-of-network plan emergency surgical or medical hospital you must do the following: and ambulatory surgical center admissions, you must contact PacifiCare 1. Notify PacifiCare of the surgical at least forty-eight(48)hours prior to procedure prescribed by your Physician. admission. The number is: The number is: (800)255-1189 (800)255-1189 2. Once the approval process is complete, 2. Your Physician will be called for you and your Physician will receive final clarification of procedure criteria. confirmation notification or an 3. We will notify you as to whether a explanation of denial from PacifiCare. second opinion is required once the 3. If you do not receive this letter before information from your Physician and your medical history has been evaluated. your scheduled admission,please call PacifiCare for further information. 4. If a second opinion is necessary, Emergency or Urgent Care Admissions PacifiCare will supply you with the name of a Physician or Physicians and Medical emergencies are generally covered will pay 100% of eligible charges for under PacifiCare in-network coverage, in second surgical opinions. cases where a Prudent Layperson, acting 5. If the need for surgery is confirmed, the reasonably,believes that an Emergency second opinion specialist will notify Medical Condition exists. If the medical emergency does not qualify under PacifiCare. PacifiCare in-network coverage for some 6. We will notify you; you and your reason,then your PacifiCare out-of-network Physician can then set your surgical benefits apply. PacifiCare Plus out-of- schedule and receive the maximum network benefits are paid at a percentage of reimbursement allowed under your plan. eligible charges, subject to deductibles. See The second opinion specialist is not the Schedule of Benefits included with this allowed to perform the surgery. document for the percentage that would be Remember,to maximize your PacifiCare covered under your plan. out-of-network benefits, all non-emergency For emergency or urgent care admissions, surgery must be Medically Necessary and you should notify Customer Service within approved in advance. forty-eight(48)hours, or as soon as Covered Charges practical, after a hospital admission. The percentages and dollar amounts given in Second Surgical Opinions the below may vary according to your plan. Please refer to Section Five,Your Medical 43 20020268 11/02 Benefits,Your Out-of-Network-Benefits • The percentage by which claims are (as amended below), and your Schedule of reduced when non-emergency surgical Benefits included with this document for the procedures are obtained without pre- percentages that apply to you. authorization The coverage on PacifiCare out-of-network • Claims for benefits with a maximum, benefits will be paid at a percentage of such as physical, occupational, and eligible charges after deductible, on most speech therapy, cardiac rehabilitation or covered benefits that have been properly psychiatric care authorized. If a benefit needing • Charges payable in-network, including authorization has not been authorized, Copayments PacifiCare will pay a reduced percentage of all eligible charges for benefits that are Deductibles determined to be Medically Necessary. The deductibles, as shown on the Schedule Please refer to Section Five,Your Medical of Benefits included with this document, are Benefits,Your Out-of-Network-Benefits waived for second and third surgical (as amended below), and your Schedule of opinions required by PacifiCare. Benefits included with this document for the percentage that would be covered under When two or more members in one family your plan. are injured in the same accident, only one deductible for that contract year will be Eligible charge means the fee PacifiCare applied to all the eligible charges from that will pay a Provider. For example, if your accident. bill for a specific procedure after deductible is $100, and the eligible charge for that Coinsurance procedure is $90, PacifiCare will pay a Whenever a Member fails to obtain pre- percentage of the eligible charge of$90. admission authorization, as explained below For example, if the percentage PacifiCare in"Preadmission Authorization pays is 70%, PacifiCare will pay $63. You Requirements for Confinement,"the are responsible for the rest. In this case, if coinsurance will be increased. The Member your deductible has been met, you will pay a will be required to pay an additional 20% of total of$37. the eligible charges for the hospital or other Deductibles are shown Schedule of Benefits institution and of all eligible charges for inserted in this Group Agreement. related professional services. Out-of-Pocket Maximum Whenever a Member fails to obtain a mandatory second surgical opinion, the Your PacifiCare Plus out-of-network coinsurance will be increased. The Member coverage has a maximum out-of-pocket will be required to pay an additional 20% expense per year provision. After you meet plan of the eligible charges for surgical your deductible and once you have paid the services and of all eligible charges for out-of-pocket maximum,your plan provides related institutional or professional health 100% of all eligible charges on covered care. benefits. Your maximum expenditures (after the deductible) in a year are shown on Managed Care Requirements for Out-of- the Schedule of Benefits included with this Network Benefits document. The provisions below are specific to out-of- The following do not apply to the out-of- network care, and do not otherwise preclude pocket maximum: the provisions set forth under In-Network care as outlined in the Combined Evidence of Coverage and Disclosure Form. 44 20020268 11/02 Preadmission Authorization Requirements • Attending Physician's telephone number for Confinement • Name of hospital, alcohol treatment Preadmission authorization for Confinement center, or other institution is required when both of the following are • Address of hospital, alcohol treatment true: center, or other institution • A Member is to be confined in a • Scheduled date of admission hospital, alcohol treatment center, Skilled Nursing Facility, rehabilitation • Reason for admission facility, or other institution as a Note: PacifiCare has the right to ask the registered bed patient for treatment of an Member's Physician for facts relating to illness or injury, including but not medical necessity. Limited to alcohol dependency and mental or nervous disorder. PacifiCare will provide written notification to the Member, the Member's Physician, • PacifiCare has primary responsibility for and the hospital, alcoholism treatment the Member's claims as described under center, Skilled Nursing Facility, "Coordinating Benefits With Another rehabilitation facility, or other institution of Plan", under Section Six,Payment any period of confinement that is authorized Responsibility. as Medically Necessary, or that confinement Preadmission Notification Requirements is not authorized. for Confinement Postadmission Notification Requirements The Member must notify PacifiCare, The Member or the attending Physician directly or through the attending Physician, must notify the PacifiCare by telephone if he/she is advised by a Physician to enter a within forty-eight(48)hours or by the next hospital, alcohol treatment center, Skilled business day after admission, if a Member Nursing Facility, rehabilitation facility, or enters a hospital, alcohol treatment center, other institution as a registered bed patient. Skilled Nursing Facility, rehabilitation The notice must be given to the PacifiCare facility, or other institution as a resident bed by telephone at least forty-eight(48) hours patient for one or more of the following: before the scheduled date of admission. The Member will be held responsible for any • Normal childbirth failure to give notice, even if resulting from • An urgent hospital admission the Physician's error or oversight. • A medical emergency This notification is not required if the reason for the confinement is one of the following: Before the authorized period of confinement ends, PacifiCare will contact the Member's • Normal childbirth Physician by telephone to determine • An urgent hospital admission whether the Physician believes that the Member needs further confinement. • A medical emergency PacifiCare will notify in writing the If notice is given by telephone, the Member Member, the Member's Physician, and the or the Physician's office staff must provide hospital, alcoholism treatment center, or the following information: other institution of any additional days of • Member's name confinement that are authorized as Member's ID number Medically Necessary, or that no additional • confinement is authorized. • Attending Physician's name and address Benefits for Confinement 45 20020268 11/02 If expenses are incurred for a confinement Member will be held responsible for any that has been preauthorized as Medically failure to give notice, even if resulting from Necessary, then the usual coinsurance as the Physician's error or oversight. shown in Schedule of Benefits included with Notice by the Member or the Physician's this document will apply. office staff must include the following The increased coinsurance shown in the information: Schedule of Benefits included with this • Member's name document for unauthorized confinements applies in the following situations: • Member's ID number • Expenses are incurred in connection • Attending Physician's name and address with a confinement in a hospital, alcohol • Attending Physician's telephone number treatment center, Skilled Nursing Facility, rehabilitation facility, or other • Name of hospital or ambulatory surgery institution, and center • The confinement was not preauthorized • Address of hospital or ambulatory by the PacifiCare, or surgical center • The confinement was as described in the • Scheduled date of surgical services "Coinsurance"above, and notification • Nature of surgical services was not given as explained above. Note: PacifiCare has the right to ask the Eligible charges subject to the increased Member's Physician for facts relating to coinsurance for an unauthorized medical necessity. confinement or subject to total disallowance as not Medically Necessary, include: PacifiCare may determine that a second surgical opinion is required. • Eligible charges of the hospital, alcohol treatment center, Skilled Nursing Benefits for Elective Surgery Facility,rehabilitation facility, or other Eligible charges subject to the increased institution coinsurance for failure to obtain • All eligible charges for professional preauthorization are subject to total services related to the confinement disallowance as not Medically Necessary and include: Whether or not admission was •preauthorized, if PacifiCare determines that Eligible charges of the hospital or the confinement lasted longer than was ambulatory surgical center Medically Necessary,no benefits will be • Eligible charges for professional services paid for the part of the confinement not related to the confinement considered Medically Necessary. If PacifiCare determines that the surgical Notification for Elective Surgery services were not Medically Necessary, then The Member must notify PacifiCare directly no benefits will be paid for the services or or through the attending Physician, if he/she related institutional or professional services. is advised by a Physician to undergo an Redetermination of Status elective surgical procedure in a hospital or PacifiCare may at any time make a ambulatory surgery center. Redetermination of Status in consultation The notice must be given to PacifiCare by with a Member's Physician. Each telephone at least forty-eight(48)hours Redetermination of Status will supersede before the scheduled date of admission. The 46 20020268 11/02 earlier determinations and may result in the • Prior approval by PacifiCare's Medical following: Director of services related to a covered • Payment of benefits at a different rate or transplant. on a different basis • Prior approval by PacifiCare's Medical • Termination of benefits for a particular Director of surgical services in cases of illness or injury morbid obesity. Claims for services or supplies determined • Prior approval by PacifiCare's Medical to be not Medically Necessary may be Director for services related to the denied before or after payment. treatment for misalignment or similar malfunction of the jaw joint, commonly When it is determined to be medically known as temporomandibular joint appropriate by PacifiCare, PacifiCare may problems or TMJ syndrome. recommend that an alternative level of care or location of care be substituted for the • The Member must notify PacifiCare if level or location at which a Member is he/she is advised to obtain home health receiving treatment. For example, home or Hospice care. health care services or Hospice care might Note: When in doubt, call PacifiCare. be recommended as a substitute for Your Primary Care Physician or specialty hospitalization. care Physician is the authority on the If the Member and the attending Physician management of your health. PacifiCare is decide to continue the existing level of care the best source of information about your and location of care,benefits will be payable health care plan Group Agreement, so long as that level and location remain including the determination of in-network Medically Necessary. However, if the and out-of-network benefits. Member's level or location of care remains Maximum Out-of-Pocket Expense unchanged after PacifiCare has notified the There is a maximum amount of coinsurance Member that it is no longer Medically that a Member must pay in any one contract Necessary, no further benefits will be paid year before PacifiCare will pay 100% of for the remaining course of treatment at that eligible charges. See the Schedule of level and location. Benefits included with this document to PacifiCare evaluates medical necessity determine your plans out-of-pocket solely for the purpose of determining maximum. whether expenses are covered benefits. The following amounts will not apply PacifiCare neither gives nor purports to give toward the maximum out-of-pocket expense: medical advice. • Approvals for Out-of-Network Care are Deductibles Important! • Amount of any reduction in payment for As explained above, PacifiCare's duty to eligible charges due to the Member's provide coverage for various services is failure to obtain preadmission conditional on the Member complying with authorization or a mandatory second certain other managed care requirements. surgical opinion Other approval requirements include, but are • Expenses incurred for care where the not Limited to: benefit Limit has been reached • Prior approval by PacifiCare's Medical • Expenses incurred by the Member to the Director of referrals for the treatment of extent that the billed amount exceeds chronic renal disease. eligible charges 47 20020268 11/02 • Expenses incurred by the Member that are not covered benefits or are subject to an exclusion • Coinsurance obligations incurred by the Member for alcohol detoxification and rehabilitation or the treatment of mental and nervous disorders • Expenses incurred for care that has additional Limits (e.g.,physical therapy, speech therapy, occupational therapy). Note: Copayments made for your out-of-network benefits do not apply to your in-network out-of-pocket maximum. Additionally, charges payable under the in-network coverage, including Copayments, will not be coordinated with the out-of-network coverage under this Group Agreement. 48 20020268 11/02 PacifiCare° ATTACHMENT R - OUTPATIENT PRESCRIPTION DRUG BENEFIT • TO COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE FORM • OUTPATIENT PRESCRIPTION DRUG BENEFIT HMO PLUS PLAN R— THREE-TIER OPTION WITH PREAUTHORIZATION We want our Members to get the most from their Outpatient Prescription Drug Benefit. Please read this Attachment R - Outpatient Prescription Drug What Is the Preferred Drug List Benefit to the Combined Evidence of Coverage and (Formulary)? Disclosure Form carefully. so you understand the The preferred drug list is a list of outpatient terms that explain your coverage. Understanding prescription drugs that are covered by PacifiCare these terms is essential to understanding your benefit. when prescribed by a PacifiCare participating Note: PacifiCare does not coordinate benefits for physician, an authorized non-plan physician or a licensed dentist and filled at a PacifiCare outpatient prescription drugs. participating pharmacy. The preferred drug list was created and is regularly updated by a Pharmacy and IN-NETWORK BENEFIT Therapeutics committee. which consists of practicing physicians and pharmacists. This committee decides How to Use the Program which prescription drugs provide quality treatment Your Outpatient Prescription Drug Benefit helps for the best value. Your physician has a copy of the cover the costs of medications prescribed by a preferred drug list and will use it as a reference when PacifiCare participating physician, an authorized prescribing medications. non-plan physician. or a licensed dentist and filled at a PacifiCare participating pharmacy. Members can access the preferred drug list via the interne' on the PacifiCare web site. Using your benefit is simple: www.PacifiCare.com or request a written copy from • Present your PacifiCare ID card at any our Customer Service Department at 1-800-877-9777 PacifiCare participating pharmacy. or 1-800-659-2656(TDD). • Pay your applicable Copayment for each prescription unit of covered medication or the Are Medications Not Listed on the retail cost of the prescription, whichever is less. Preferred Drug List (Formulary) Covered? What is Covered? Your employer has selected a pharmacy plan with a The following medications are covered when three-tier Copayment structure. Medications not prescribed by a PacifiCare participating physician. an listed on the preferred drug list are known as non- authorized non-plan physician, or a licensed dentist formulary medications. You can obtain a non- and filled at a PacifiCare participating pharmacy, formulary medication at the higher Copayment listed unless otherwise listed as not covered in this on page 1 of this Attachment R — Outpatient Attachment R - Outpatient Prescription Drug Benefit Prescription Drug Benefit. or in your Combined Evidence of Coverage and Disclosure Form. Medications from some drug classes require preauthorization and are covered when requested by a • Drugs that can only be dispensed upon the PacifiCare participating physician. an authorized written prescription of a physician or other non-plan physician or licensed dentist and prescriber who is authorized to prescribe that preauthorized by PacifiCare, based on criteria drug under applicable State law. established by PacifiCare. • Compounded medication(s) that are made up of If PacifiCare denies a preauthorization request from at least one prescription drug. (All compounded your physician, you will receive a letter explaining medications require preauthorization) the reason(s)the request was denied. In most cases,a • Diabetic supplies, insulin, insulin syringes, request is denied because there is a PacifiCare glucagon kits and glucose testing strips. preferred medication available or the requested • Immunosuppressants to prevent organ rejection. medication is an exclusion to your Outpatient • Oral birth control medications, diaphragms, and Prescription Drug Benefit. If you would like cervical caps that require a physician's PacifiCare to reconsider the denial, you may submit prescription by law. an appeal using the process described in the denial letter. 20020243 9/02 If you choose to use a medication not covered by changes. PacifiCare, you will be responsible for the full retail price of the medication. What does"Generic" Mean? Preauthorization for Selected Drugs A generic drug is a medication that has met the PacifiCare reserves the right to require standards set by the Food and Drug Administration preauthorization of a medication or to limit the (FDA) to assure its bioequivalency to the original quantity of a prescription to ensure that the following patented brand-name medication. When the FDA coverage criteria are met: approves a generic drug as bioequivalent, it assures that the generic drug's level of safety, purity, strength • There is no suitable PacifiCare preferred and effectiveness meets the same standards as the medication and the medication is essential for brand-name product. When the FDA approves new patient care. generic drugs and PacifiCare adds them to the • The patient failed an adequate therapeutic trial preferred drug list (formulary), the brand-name drug with the appropriate PacifiCare preferred then becomes a non-formulary drug. By using medication(s). generic drugs. you can maintain quality while • The use of the PacifiCare preferred medications realizing substantial savings. If you choose a brand- are contraindicated in the patient. name medication when an equivalent generic is • The prescription drug is prescribed according to available and listed on the preferre:'. drug list, you established, documented and approved will pay your non-formulary Copayment for the indications which are supported by the weight of brand-name medication. scientific evidence. • The prescription drug is for the treatment of a How Much Medication Can I Obtain for covered medical condition. a Copayment? Covered medications are dispensed in a Preauthorization means that PacifiCare must approve predetermined amount called a prescription unit. For the medication before you receive it. Your physician most oral medications a prescription unit represents a works with PacifiCare to complete the thirty (30) day supply of medication. A prescription preauthorization process. You will be responsible for unit may be set at a smaller quantity for the your applicable Copayment when PacifiCare Member's protection or safety, as determined by the authorizes a drug. manufacturer's recommendations. Medications which are normally dispensed in prepackaged units PacifiCare will cover a one time only emergency after (eye drops,creams,oral & nasal inhalers,etc.)will be hours prescription without preauthorization in the assessed one (1) Copayment per prepackaged unit, following situations: regardless of days supply. • Medication is prescribed in conjunction with a Insulin is limited to two (2) vials of the same kind of hospital discharge. emergency room, or urgent insulin per applicable Copayment at a participating care facility visit; limited to a seven (7) day pharmacy. supply, except for antibiotics which may be dispensed in up to a fourteen (14)day supply. Glucose and Ketone test strips and lancets are • Medication is used for acute treatment and dispensed in prepackaged units and are subject to the immediate use is required. applicable Copayment per prepackaged unit. After hours preauthorization will not be approved for See section titled "What is the Mail Service any of the following situations: Pharmacy Program" for information on potential cost savings when using our Mail Service Pharmacy • Continuation of a restricted medication based Program. solely on a previous authorization or previous use. • A change to an existing preauthorization to extend the days supply. • A change to an existing preauthorization to correct erroneous information. • Early refills of maintenance medications. • Early refills, for signature changes or dosage 20020243 9/02 How Much Medication Can I Obtain at To order your maintenance medications by mail,just • One Time? follow the steps below. A maximum of a thirty (30) day supply of any covered medication can be obtained at one time. The 1. Have your physician write a prescription for a only exceptions are: ninety (90) day supply of your maintenance medication with up to three (3) additional refills. • Quantity limitations for medications may be set (Note: Prescription Solutions must have a new as deemed appropriate by PacifiCare. prescription to process any new mail service • Medications obtained through the Mail Service request). Pharmacy Program. 2. Complete the confidential patient profile in the mail service brochure (A mail service brochure • Coverage of glucose and ketone test strips is should have been included with your benefit limited to 200 strips per thirty(30)days. materials). You may request a mail service • Coverage of lancets is limited to 200 units per brochure from our Customer Service Department thirty(30)days. at 1-800-877-9777 or 1-800-659-2656 (TDD). You may also find the form at the web site See section titled "What is the Mail Service address www.rxsolutions.com. Pharmacy Program" for information on potential 3. Send your prescription(s), completed patient cost savings when using our Mail Service Pharmacy profile and check or credit card information for Program. the appropriate Copayment in the envelope provided. Please make your check payable to What is the Mail Service Pharmacy Prescription Solutions. No cash please. Program? 4. You will receive your medication via U.S. Mail PacifiCare offers a Mail Service Pharmacy Program within 14 days of the date Prescription Solutions through Prescription Solutions®. The Mail Service receives your order. Pharmacy Program provides convenient service and savings on medications that you may take on a Note: Medications such as Schedule II substances regular basis by allowing you to receive certain drugs (e.g., Morphine, Ritalin and Dexedrine), antibiotics, by mail. drugs used for short-term or acute illnesses, and Some of the benefits of using our Mail Service drugs that require special packaging are not Pharmacy Program are: available through our Mail Service Pharmacy • A ninety (90) day supply of oral maintenance Program. medication can be obtained for two (2) applicable Copayments. Medications which are IMPORTANT TIPS: If you are starting a new normally dispensed in prepackaged units (eye maintenance medication, please request two (2) drops,creams, oral & nasal inhalers. etc.) will be prescriptions from your participating physician. assessed one (1) applicable Copayment per two Have one filled immediately at a participating (2) prepackaged units, not to exceed a ninety pharmacy while mailing the second prescription to (90)day supply. Prescription Solutions. Once you receive your • Insulin vials will be assessed one (1)Copayment medication from Prescription Solutions, you should for up to three (3) vials of the same kind of stop filling the prescription at the participating insulin, not to exceed a ninety(90)day supply. pharmacy. For more information about the Mail • Shipping and Handling is FREE. Service Pharmacy Program please contact • When you receive your prescription, you'll get Prescription Solutions Customer Services at 1-800- detailed instructions that tell you how to take it, 562-6223 or 1-800-735-2922(TDD). possible side effects and any other important information. If you have any questions, registered pharmacists are available to help you. • Prescriptions are mailed directly to your home, or address of your choice within the United States, in a discreetly labeled envelope to ensure privacy and safety. 20020243 9/02 Prescriptions Filled in Emergencies The above information should be sent to the Whenever possible,fill your prescriptions at a following address; • PacifiCare participating pharmacy. If you need to fill Prescription Solutions® a prescription while outside of Colorado,but within Mail Stop LC07-290 the United States, you can use PacifiCare's National ATTN:Claims Department Pharmacy Network. For assistance with locating a P.O.Box 6037 participating pharmacy in our National Pharmacy Cypress,CA 90630-0037 Network,call our Customer Service Department at 1-800-877-9777 or 1-800-659-2656(TDD)or search You are eligible for reimbursement under your In- by city and state at the web site address Network Benefit for prescriptions related to an www.rxsolutions.com. Emergency as defined by PacifiCare. If PacifiCare determines that your request is eligible for In- flow to fill a prescription at a pharmacy within our Network coverage, you will be refunded the cost of National Pharmacy Network: the prescription less any applicable In-Network • Always show your PacifiCare ID card to the Copayment that is due from you. pharmacist. • All provisions of your pharmacy benefit will Exclusions and Limitations to the apply. Outpatient Prescription Drug Benefit • The pharmacist will process your prescription The following are not covered benefits with the electronically for your Copayment. Note: optional Outpatient Prescription Drug Benefit: Maintenance medications (medications you take on an ongoing basis) filled outside of Colorado • Convenience Dosage Forms: Unit dose, will only be covered under your In-Network individual packets,etc. Benefit when processed electronically by a • Diabetic Supplies: All diabetic supplies such as National Network Pharmacy for your applicable insulin pens, penfills, pumps and associated In-Network Copayment. Maintenance supplies. except as specified in the "What is medications filled outside of Colorado for the Covered"section of this document. full retail price will be covered under your Out- • Dietary Products: Dietary or nutritional products of-Network benefit. and food supplements, whether prescription or • Pay your applicable Copayment. non-prescription. If you choose to fill a prescription at a non- • Drugs administered by a physician or physician's participating pharmacy, you must pay the full cost of staff. the prescription at the time it is filled. To be • Drugs administered while the Member is reimbursed you must submit the receipt(s) to the receiving skilled care as an inpatient in a Skilled address below. Nursing Facility or extended care facility. • Elective or voluntary enhancement procedures. To receive a refund you must send the following services, supplies and medications including but information to Prescription Solutions® along with a not limited to: weight loss, hair growth, sexual completed Direct Member Reimbursement Form. performance, athletic performance, cosmetic (Direct Member Reimbursement Forms are available purposes,anti-aging and mental performance. from our Customer Service Department at • Experimental or Investigational: Medications 1-800-877-9777 or 1-800-659-2656/TDDJ). that are experimental, investigational, or used in ways not approved by the Food and Drug • Copies of the prescription receipt(s), showing Administration (FDA). Medications included in prescription number, name of the medication, these categories are those prescribed for: date filled,pharmacy name, name of the Member • Non-FDA approved indications. for whom the prescription was written and proof • Use by routes of administration not of payment. approved by the FDA. • A statement describing why a PacifiCare • Use in dosage forms not commercially participating pharmacy was not available to you. available. • Fertility Drugs: Drug therapy for infertility except for Clomid when used during artificial insemination. To find out if this benefit applies to your plan refer to page 1 of this Attachment R —Outpatient Prescription Drug Benefit. 20020243 9/02 • • Injectable Medications: All injectable • Other Exclusion and Limitations: All exclusions medications except insulin, glucagon and bee and limitations as listed in this Attachment R - sting kits. Outpatient Prescription Drug Benefit or in your • New procedures, services, supplies, and Combined Evidence of Coverage and Disclosure medications until they are reviewed for safety. Form efficacy, and cost effectiveness and approved by PacifiCare. OUT-OF-NETWORK BENEFIT • Non-Approved Drugs: Drugs determined by the PacifiCare of Colorado Pharmacy and The following is an optional covered benefit that may Therapeutics Committee to be ineffective. be selected by your employer, as part of the group duplicative or to have preferred therapeutic plan. Please refer to page 1 of this Attachment R — alternatives available. Outpatient Prescription Drug Benefit to find out if • Non-Covered Services: Any prescription drug this benefit applies to your plan. prescribed in connection with a service excluded under this agreement. If your In-Network benefit includes the optional • Non-Drug Supplies and Equipment: Non-drug pharmacy benefit, the benefit under this agreement supplies such as stockings, support garments and may not be as great as the benefit under the In- other therapeutic devices or appliances, even Network benefit, which provides pharmacy benefits though a prescription may be required, except as for services inside the PacifiCare HMO Service Area specifically listed as a covered benefit. using participating physicians and pharmacies, and • Over the Counter Medications: Medications for emergency-related services. See the In-Network (except insulin) which can be obtained without a Benefit section of this Attachment R - Outpatient prescription or have a nonprescription Prescription Drug Benefit for a description of the In- therapeutic equivalent, unless specified by the Network covered optional pharmacy benefits. Please PacifiCare preferred drug list. refer to your Combined Evidence of Coverage and • Progesterone and Estrogen Products: Specially Disclosure Form for an explanation of the PacifiCare compounded progesterone and estrogen products HMO Service Area. including progesterone suppositories. • Recreation or Travel — Medications when used Your Out-of-Network Benefit covers each prescribed for the purpose(s) of recreation and/or travel, medication and refill dispensed through pharmacies other than those medications recommended for not participating with the In-Network coverage travel by guidelines established by the Centers and/or medications prescribed by physicians not for Disease Control. participating with the In-Network coverage. The • Saline and medications for irrigation. amount you pay for prescriptions on your Plus Plan is • Sexual Dysfunction: Prescription medication for your applicable In-Network Copayment, plus a the treatment of sexual dysfunction, including percentage of the remaining cost of the prescription. erectile dysfunction, impotence and anorgasmy Refer to page 1 of this Attachment A — Outpatient or hyporgasmy. Prescription Drug Benefit to determine the applicable • Smoking Cessation: Smoking cessation drugs percentage of the remaining cost of the prescription. and/or aids. • Take-Home Use From a Facility: Drugs received PacifiCare, through its Pharmacy and Therapeutics from a hospital. Skilled Nursing Facility, Committee, has developed and maintains a preferred convalescent home or similar facility for take- drug list which is updated on an ongoing basis. home use. Benefits provided by the Outpatient Prescription • Immunizations,except oral typhoid. Drug Benefit Program are based on usage of the • Vitamins and Minerals: Vitamins and minerals. PacifiCare preferred drug list. To obtain a copy of except when requiring a prescription for a the preferred drug list, contact our Customer Service Department at 1-800-877-9777 or medically necessary vitamin or mineral. 1.800-659-2656(TDD). • Work-Related Medications: Medications recommended because of increased risk due to Note: PacifiCare may determine medical necessity type of employment. by using preauthorization programs as deemed • Lost or stolen medications. appropriate by PacifiCare. Coverage is based on PacifiCare criteria. 20020243 9/02 If you have any questions about the Copayment and/or coinsurance level applicable to your Plus Plan, please contact our Customer Service Department at 1-800-877-9777 or 1-800-659-2656(TDD). Note: All exceptions to the Outpatient Prescription Drug Benefit listed in this Attachment R - Outpatient Prescription Drug Benefit to Combined Evidence of Closure and Disclosure Form apply to the Out-of- Network Benefit. 20020243 9/02 Selected Benefit Descriptions Attachment R—Outpatient Prescription Drug Benefit Colorado Health Plan Description Form Addendum PacifiCare of Colorado Pharmacy Plan 418R3 BENEFIT BENEFIT LEVEL BENEFIT LEVEL In Network Out-of-Network 11.PRESCRIPTION DRUGS $15 formulary generic,$40 formulary You pay your applicable Level of coverage and brand-name,$60 non-formulary.PacifiCare copayment plus 30%of the restrictions on prescriptions does require prior authorization for specific remaining cost of the prescription drugs. prescription: • Formulary Generic+30% A 90-day supply of maintenance of remaining cost medications,or a three-cycle maximum of • Formulary Brand+30%of oral contraceptives,is available through the remaining cost mail-order prescription pharmacy for two • Non-Formulary+30%of applicable copayments. Prepackaged units remaining cost. 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 Non-Generic • Non-Formulary 1 neu.ro PACIFICARE OF COLORADO 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: 01/01/2003 through 12/31/2003 PLAN CODE: PLAN DESCRIPTION: 10663 Medical Plan 117R3 Pharmacy Plan E1143 Vision Plan HEALTH PLAN PREMIUMS: EE $246.67 EE + Sp $493.32 EE + Ch $473.60 EE + Fam $726.05 PREMIUMS DUE ON OR BEFORE (refer to Section 3.06): First of the month prior to the month in which premium applies ANNUAL OUT OF POCKET MAXIMUM PER INDIVIDUAL: $2,500 ANNUAL OUT OF POCKET MAXIMUM PER FAMILY: $5,000 CONTINUATION OF BENEFITS ELECTIONS: Standard 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): Waiting Period: First day of the month following first full pay period Full-Time Requirement: 20 hours per week 20020264 10/02 Termination of Coverage: Termination of coverage varies by date of termination. If termination occurs from the 151 through the 14th of the month, coverage terminates at the end of the current month. If • termination occurs on the 15th through the end of the month, coverage terminates at the end of the following month. 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) P- Plus Schedule of Benefits (If Purchased) R- Outpatient Prescription Drug Benefit(If Purchased) V- Vision Care(If Purchased) 20020264 10/02 PACIFICARE OF COLORADO MEDICAL AND HOSPITAL GROUP SUBSCRIBER AGREEMENT 20020264 10/02 MEDICAL AND HOSPITAL GROUP SUBSCRIBER AGREEMENT This Medical and Hospital Group Subscriber Agreement (the"Agreement") is entered into between PACIFICARE OF COLORADO, 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. 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 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 minimum of 24 hours per week, meets any applicable waiting period required by the Group, and is defined as an employee under State and Federal law; 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. 1.16 Member is any Subscriber or Dependent. 1.17 Open Enrollment Period is the period of not less than thirty(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. 2 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 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. 1.20 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 2.01.01Application 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. 2.01.02Time 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 thirty-one (31) days after becoming eligible. All applications for Enrollment which are not received by PacifiCare within the thirty-one(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 thirty-one (31) day period. Group shall provide notice to Members of the applicable Open Enrollment Periods. 3 2.01.03Notice 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 twelve (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. 2.01.04Late 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 sixty(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. 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. 4 3.02 Notices to PacifiCare. Group shall forward to PacifiCare all completed or amended Enrollment forms for each Member within thirty-one (31) days of the Member's initial eligibility. Group acknowledges that any Enrollment applications not forwarded to PacifiCare within such thirty-one (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 thirty-one (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. 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. 5 3.07 Modification of Rates and Benefits. 3.07.01Modification 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 thirty-one (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 thirty-one (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 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 thirty(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 and license fees, rounded to the nearest cent. 3.07.02Modification 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 thirty-one (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 thirty-one (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. 6 3.09 Continuation of Benefits and Conversion Coverage. 3.09.01Notice 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. 3.09.02Notice of Individual Conversion Rights. Within fifteen(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. 3.09.03Conversion 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. 3.09.04USERRA(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. 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 thirty(30) days of the termination, and to provide PacifiCare with eligibility information and data within thirty(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 (1) 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 (1)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, 8 '7. TERMINATION • 7.01 Termination by Group. Group may terminate this Agreement by giving a minimum of thirty(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. 7.02.01For 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 fifteen(15) days of the date of issuance of the notice, and that if payment of all unpaid Health Plan Premiums is received within the fifteen(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. 7.02.02Partial 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. 7.02.03Nonliability 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. 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. 9 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. 7.02.04Reinstatement Following Non-Payment of Premium. Requests for Reinstatement of this Agreement must be received by PacifiCare within fifteen (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 (5)percent of the monthly premium prorated on a thirty(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. 7.02.05Termination 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 thirty(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 thirty(30) days of receiving notice of the breach from PacifiCare, PacifiCare may terminate this Agreement at the end of the thirty(30) day notice period. 7.02.06For Providing Misleading or Fraudulent Information. PacifiCare may terminate this Agreement upon thirty(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. 10 7.02.07For Ceasing to Meet Group Eligibility Criteria. PacifiCare may terminate Group upon • thirty(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 seventy-five percent (75%); b. For Subscribers without Dependents, Group fails to maintain a Group Contribution equal to seventy-five percent (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. 7.02.08For Changing the Nature of Group's Business. PacifiCare may terminate Group upon thirty(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. 7.02.09For 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 thirty(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 thirty(30) days of the change. 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 thirty(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. 11 $. 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. 8.01.01Relationship 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. 8.01.02PacifiCare 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. 8.01.03Access 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. 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. 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 thirty(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 forty-eight(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 twenty-four(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. 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 thirty(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. 15 IN WITNESS WHEREOF, the parties hereto have executed this Agreement in Greeley , Colorado, on January 15 , 2003 GROUP: WELD COUNTY PACIFICARE OF COLORADO BY: b-c..J4 CC (k BY: 13 Xg — NAME: David E. Long NAME: Barbara Towle TITLE: Chair, Weld County Board of TITLE Manager, Account Services Commissioners DATE: 01/15/2003 DATE: December 23, 2002 Attest: ASj Clerk to the Boa 1861 • By: F�yynn Deputy Clerk to the 16 j.o/%y PacifiCare® Appendix A Attachment A—Schedule of Benefits Colorado Health Plan Description Form PacifiCare of Colorado Commercial HMO Copay Select (Split Copay)Plan 10663 PART A: TYPE OF COVERAGE 1. TYPE OF PLAN Health Maintenance Organization(HMO). 2. OUT-OF-NETWORK CARE COVERED?t 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. 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 b) Family $5,000 6. LIFETIME OR BENEFIT MAXIMUM No lifetime maximum. PAID BY THE PLAN FOR ALL CARE 7a. COVERED PROVIDERS 4,370 physicians and 39 hospitals in Colorado. See provider directory for complete list. 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 VISITS $15 copayment per visit with PCP; $30 copayment per visit with specialist. 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 per visit. b) Delivery&inpatient well baby care $300 copay per admission "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). 2 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. IOW 00 IN-NETWORK ONLY (out-of-network care is not covered except as noted) 11. PRESCRIPTION DRUGS Available as separate pharmacy plan or as an optional benefit if purchased Level of coverage and restrictions by your employer,see benefit schedule attached(if applicable). on prescriptions 12. INPATIENT HOSPITAL $300 copay per admission 13. OUTPATIENT/AMBULATORY $100 copayment per visit. SURGERY 14. LABORATORY&X-RAY No copayment(100%covered);MM,CT,SPECT and PET Scan$75 copayment per procedure.The$75 copayment is in addition to other applicable copayments. 15. EMERGENCY CARE 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 $50 copayment per episode inside and outside the service area. 17. URGENT,NON-ROUTINE, $100 copayment in emergency room setting inside and outside the service AFTER HOURS CARE 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 $50 copayment per day,$25 copayment per partial day;coverage for a) Inpatient care 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,coverage for maximum of21 days. ABUSE 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,& Physical/Occupational: $15 copayment per visit,coverage for maximum of 20 SPEECH THERAPY 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;you pay 20%. 23. OXYGEN No copayment. Covered as durable medical equipment.(see#22) 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 120 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. "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. 1066300 • IN-NETWORK ONLY (out-of-network care is not covered except as noted) 31. SIGNIFICANT ADDITIONAL Infertility treatment,50%copayment;allergy injections,$5 copayment; COVERED SERVICES(list up to 5) well-woman exam,$15 copayment; 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"PRE- A pre-existing condition is a condition for which medical advice, 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 IN-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 procedures Yes. 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 10663,Large Group number of this policy;whether it is individual,small group,or large group; and if it is a short-term policy. PART E:COST 43. 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. 5 Waiver of ore-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. 10663 00 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. 10663.00 Pacinucre® 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 Not Covered: visual acuity exam under your medical plan are Fitting of contact lenses,vision therapy and/or available under this rider. These include refractions radial keratotomy, keratomilieusis and excimer for prescription lenses, are covered once every 12 laser surgery. months. Services must be obtained from a partici- This information contains only highlights of the eye paring VSP® provides examination benefit and is not intended to contain Using VSP® is as easy as 1, 2, 3. First, locate a VSP® the complete provisions of these benefits. Please provider near you by checking your PacifiCare refer to your Combined Evidence of Coverage and Provider Directory, by visiting VSP's website at Disclosure Form for a complete description of this www.VSP.com or by calling VSP® at 1-888-426- benefit. 4877. Second, call your doctor and make an appointment. Third,keep your scheduled appoint- ment. A referral from your primary care physician (PCP) is not required for this benefit. 6455 South Yosemite Street Copyright©2000 PacifiCare of Colorado Greenwood Village, CO 80111 EM05000.0a 10/2002 Selected Benefit Descriptions Attachment R—Outpatient Prescription Drug Benefit Colorado Health Plan Description Form Addendum PacifiCare of Colorado Pharmacy Plan 117R3 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. PacifiCare does require prior authorization for specific prescription drugs. 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 1 II7RJ 00 PacifiCare e ATTACHMENT R -OUTPATIENT PRESCRIPTION DRUG BENEFIT TO COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE FORM OUTPATIENT PRESCRIPTION DRUG BENEFIT HMO PLAN R— THREE-TIER OPTION WITH PREAUTHORIZATION We want our Members to get the most from their Outpatient Prescription Drug Benefit. Please read What Is the Preferred Drug List this Attachment R - Outpatient Prescription Drug (Formulary)? Benefit to the Combined Evidence of Coverage and The preferred drug list is a list of outpatient Disclosure Form carefully, so you understand the prescription drugs that are covered by PacifiCare terms that explain your coverage. Understanding when prescribed by a PacifiCare participating these terms is essential to understanding your benefit. physician. an authorized non-plan physician or a licensed dentist and filled at a PacifiCare Note: PacifiCare does not coordinate benefits for participating pharmacy. The preferred drug list was outpatient prescription drugs. created and is regularly updated by a Pharmacy and Therapeutics committee, which consists of practicing How to Use the Program physicians and pharmacists. This committee decides Your Outpatient Prescription Drug Benefit helps which prescription drugs provide quality treatment cover the costs of medications prescribed by a for the best value. Your physician has a copy of the PacifiCare participating physician. an authorized preferred drug list and will use it as a reference when non-plan physician, or a licensed dentist and filled at prescribing medications. a PacifiCare participating pharmacy. Members can access the preferred drug list via the Using your benefit is simple: internet on the PacifiCare web site, • Present your PacifiCare ID card at any www.PacifiCare.com or request a written copy from PacifiCare participating pharmacy. our Customer Service Department at 1-800-877-9777 • Pay your applicable Copayment for each or 1-800-659-2656(TDD). prescription unit of covered medication or the retail cost of the prescription,whichever is less. Are Medications Not Listed on the Preferred Drug List (Formulary) What is Covered? Covered? The following medications are covered when Your employer has selected a pharmacy plan with a prescribed by a PacifiCare participating physician, an three-tier Copayment structure. Medications not authorized non-plan physician, or a licensed dentist listed on the preferred drug list are known as non-- and filled at a PacifiCare participating pharmacy, formulary medications. You can obtain a non-- unless otherwise listed as not covered in this formulary medication at the higher Copayment listed Attachment R - Outpatient Prescription Drug Benefit on page 1 of this Attachment R — Outpatient or in your Combined Evidence of Coverage and Prescription Drug Benefit. Disclosure Form. Medications from some drug classes require • Drugs that can only be dispensed upon the preauthorization and are covered when requested by a written prescription of a physician or other PacifiCare participating physician, an authorized prescriber who is authorized to prescribe that non-plan physician or licensed dentist and drug under applicable State law. preauthorized by PacifiCare, based on criteria • Compounded medication(s) that are made up of established by PacifiCare. at least one prescription drug. (All compounded If PacifiCare denies a preauthorization request from medications require preauthorization) your physician, you will receive a letter explaining • Diabetic supplies, insulin, insulin syringes, the reason(s)the request was denied. In most cases,a glucagon kits and glucose testing strips. request is denied because there is a PacifiCare • Immunosuppressants to prevent organ rejection. preferred medication available or the requested • Oral birth control medications, diaphragms, and medication is an exclusion to your Outpatient cervical caps that require a physician's Prescription Drug Benefit. If you would like prescription by law. PacifiCare to reconsider the denial, you may submit an appeal using the process described in the denial letter. 20020244 9/02 If you choose to use a medication not covered by changes. PacifiCare, you will be responsible for the full retail price of the medication. What does "Generic" Mean? Preauthorization for Selected Drugs A generic drug is a medication that has met the PacifiCare reserves the right to require standards set by the Food and Drug Administration preauthorization of a medication or to limit the (FDA) to assure its bioequivalency to the original quantity of a prescription to ensure that the following patented brand-name medication. When the FDA coverage criteria are met: approves a generic drug as bioequivalent, it assures that the generic drug's level of safety,purity, strength • There is no suitable PacifiCare preferred and effectiveness meets the same standards as the medication and the medication is essential for brand-name product. When the FDA approves new patient care. generic drugs and PacifiCare adds them to the • The patient failed an adequate therapeutic trial preferred drug list (formulary), the brand-name drug with the appropriate PacifiCare preferred then becomes a non--formulary drug. By using medication(s). generic drugs. you can maintain quality while • The use of the PacifiCare preferred medications realizing substantial savings. If you choose a brand- are contraindicated in the patient. name medication when an equivalent generic is • The prescription drug is prescribed according to available and listed on the preferred drug list, you established, documented and approved will pay your non--formulary Copayment for the indications which are supported by the weight of brand-name medication. scientific evidence. • The prescription drug is for the treatment of a How Much Medication Can I Obtain for covered medical condition. a Copayment? Covered medications are dispensed in a Preauthorization means that PacifiCare must approve the predetermined amount called a prescription unit. For medication before you receive it. Your physician most oral medications a prescription unit represents a works with PacifiCare to complete the thirty (30) day supply of medication. A prescription preauthorization process. You will be responsible for unit may be set at a smaller quantity for the your applicable Copayment when PacifiCare Member's protection or safety, as determined by the authorizes a drug. manufacturer's recommendations. Medications PacifiCare will cover a one time only emergency after which are normally dispensed in prepackaged units (eye drops,creams,oral & nasal inhalers,etc.) will be hours prescription without preauthorization in the assessed one (I) Copayment per prepackaged unit, following situations: regardless of days supply. • Medication is prescribed in conjunction with a Insulin is limited to two (2) vials of the same kind of hospital discharge, emergency room, or urgent insulin per applicable Copayment at a participating care facility visit; limited to a seven (7) day pharmacy. supply, except for antibiotics which may be dispensed in up to a fourteen(14)day supply. Glucose and Ketone test strips and lancets are • Medication is used for acute treatment and dispensed in prepackaged units and are subject to the immediate use is required. applicable Copayment per prepackaged unit. After hours preauthorization will not be approved for See section titled "What is the Mail Service any of the following situations: Pharmacy Program" for information on potential cost savings when using our Mail Service Pharmacy • Continuation of a restricted medication based Program. solely on a previous authorization or previous use. • A change to an existing preauthorization to extend the days supply. • A change to an existing preauthorization to correct erroneous information. • Early refills of maintenance medications. • Early refills, for signature changes or dosage 20020244 9/02 How Much Medication Can I Obtain at To order your maintenance medications by mail,just One Time? follow the steps below. A maximum of a thirty (30) day supply of any 1• Have your physician write a prescription for a covered medication can be obtained at one time. The ninety (90) day supply of your maintenance only exceptions are: medication with up to three (3) additional refills. (Note: Prescription Solutions must have a new • Quantity limitations for medications may be set prescription to process any new mail service as deemed appropriate by PacifiCare. request). • Medications obtained through the Mail Service Pharmacy Program. 2. Complete the confidential patient profile in the • Coverage a Pf and ketone test strips is mail service brochure (A mail service brochure limited to of glucose uips per thirty k (30)dent should have been included with your benefit ce • Coverage of lancets is limited to 200 units per bromachure hu e). You may Customer request ia mail Department g brochure from our Service Department thirty (30)days. at 1-800-877-9777 or 1-800-659-2656 (TDD). You may also find the form at the web site See section titled "What is the Mail Service address www.rxsolutions.com. Pharmacy Program" for information on potential 3. Send your prescription(s), completed patient cost savings when using our Mail Service Pharmacy profile and check or credit card information for Program. the appropriate Copayment in the envelope provided. Please make your check payable to What is the Mail Service Pharmacy Prescription Solutions. No cash please. Program? 4. You will receive your medication via U.S. Mail PacifiCare offers a Mail Service Pharmacy Program within fourteen (14)days of the date Prescription through Prescription Solutions®. The Mail Service Solutions receives your order. Pharmacy Program provides convenient service and savings on medications that you may take on a Note: Medications such as Schedule ll substances regular basis by allowing you to receive certain drugs (e.g., Morphine, Ritalin and Dexedrine), antibiotics, by mail. drugs used for short-term or acute illnesses, and Some of the benefits of using our Mail Service drugs that require special packaging are not available through our Mail Service Pharmacy Pharmacy Program are: • A ninety (90) day supply of oral maintenance Program. medication can be obtained for two (2) applicable Copayments. Medications which are IMPORTANT TIPS: If you are starting a new normally dispensed in prepackaged units (eye maintenance medication, please request two (2) drops, creams, oral & nasal inhalers,etc.) will be prescriptions from your participating physician. assessed one (1) applicable Copayment per two Have one filled immediately at a participating (2) prepackaged units, not to exceed a ninety pharmacy while mailing the second prescription to (90)day supply. Prescription Solutions. Once you receive your • Insulin vials will be assessed one (1)Copayment medication from Prescription Solutions, you should for up to three (3) vials of the same kind of stop filling the prescription at the participating insulin, not to exceed a ninety (90)day supply. pharmacy. For more information about the Mail • Shipping and Handling is FREE. Service Pharmacy Program please contact • When you receive your prescription, you'll get Prescription Solutions Customer Services at 1-800- detailed instructions that tell you how to take it, 562-6223 or 1-800-735-2922(TDD). possible side effects and any other important information. If you have any questions, Prescriptions Filled in Emergencies registered pharmacists are available to help you. Whenever possible,fill your prescriptions at a • Prescriptions are mailed directly to your home, PacifiCare participating pharmacy. If you need to fill or address of your choice within the United a prescription while outside of Colorado. but within States, in a discreetly labeled envelope to ensure the United States, you can use PacifiCare's National privacy and safety. Pharmacy Network. For assistance with locating a participating pharmacy in our National Pharmacy Network, call our Customer Service Department at 1- 20020244 9/02 • 800-877-9777 or 1-800-659-2656(TDD)or search Outpatient Prescription Drug Benefit by city and state at the web site address The following are not covered benefits with the www.rxsolutions.com. optional Outpatient Prescription Drug Benefit: How to fill a prescription at a pharmacy within our • Convenience Dosage Forms: Unit dose, National Pharmacy Network: individual packets,etc. • Always show your PacifiCare ID card to the • Diabetic Supplies: All diabetic supplies such as pharmacist. insulin pens, penfills, pumps and associated • All provisions of your pharmacy benefit will supplies, except as specified in the "What is apply. Covered" section of this document. • The pharmacist will process your prescription • Dietary Products: Dietary or nutritional products electronically for your Copayment. Note: and food supplements, whether prescription or Maintenance medications (medications you take non-prescription. on an ongoing basis) filled outside of Colorado • Drugs administered by a physician or physician's will only be covered when processed staff. electronically by a National Network Pharmacy • Drugs administered while the Member is for your applicable Copayment. receiving skilled care as an inpatient in a Skilled • Pay your applicable Copayment. Nursing Facility or extended care facility. • Elective or voluntary enhancement procedures, If you need to fill a prescription at a non-participating services, supplies and medications including but pharmacy in an urgent or emergency situation, you not limited to: weight loss, hair growth, sexual must pay the full cost of the prescription at the time it performance, athletic performance, cosmetic is filled. To be reimbursed you must submit the purposes, anti-aging and mental performance. receipt(s)to the address below. You are only eligible • Experimental or Investigational: Medications for reimbursement for prescriptions related to an that are experimental, investigational, or used in emergency as defined by PacifiCare. If PacifiCare ways not approved by the Food and Drug determines that your request is eligible for coverage, Administration (FDA). Medications included in you will be refunded the cost of the prescription less these categories are those prescribed for: any applicable Copayment that is due from you. • Non-FDA approved indications. • Use by routes of administration not To receive a refund you must send the following approved by the FDA. information to Prescription Solutions® along with a completed Direct Member Reimbursement Form. • Use in dosage forms not commercially available. (Direct Member Reimbursement Forms are available from our Customer Service Department at • Fertility Drugs: Drug therapy for infertility 1-800-877-9777 or 1-800-659-2656/TDD]). except for Clomid when used during artificial insemination. To find out if this benefit applies to your plan refer to page 1 of this Attachment R • Copies of the prescription receipt(s), showing Outpatient Prescription Drug Benefit. prescription number, name of the medication, date filled,pharmacy name,name of the Member • Injectable Medications: All injectable for whom the prescription was written and proof medications except insulin, glucagon and bee of payment. sting kits. • A statement describing why a PacifiCare • New procedures, services, supplies, and participating pharmacy was not available to you. medications until they are reviewed for safety, efficacy, and cost effectiveness and approved by The above information should be sent to the PacifiCare. following address: • Non-Approved Drugs: Drugs determined by the PacifiCare of Colorado Pharmacy and Prescription Solutions® Therapeutics Committee to be ineffective, Mail Stop LC07-290 duplicative or to have preferred therapeutic ATTN: Claims Department alternatives available. P.O.Box 6037 • Non-Covered Services: Any prescription drug Cypress,CA 90630-0037 prescribed in connection with a service excluded under this agreement. Exclusions and Limitations to the • Non-Drug Supplies and Equipment: Non-drug supplies such as stockings, support garments and 20020244 9/02 other therapeutic devices or appliances, even though a prescription may be required, except as specifically listed as a covered benefit. • Over the Counter Medications: Medications (except insulin) which can be obtained without a prescription or have a nonprescription therapeutic equivalent, unless specified by the PacifiCare preferred drug list. • Progesterone and Estrogen Products: Specially compounded progesterone and estrogen products including progesterone suppositories. • Recreation or Travel — Medications when used for the purpose(s) of recreation and/or travel, other than those medications recommended for travel by guidelines established by the Centers for Disease Control. • Saline and medications for irrigation. • Sexual Dysfunction: Prescription medication for the treatment of sexual dysfunction, including erectile dysfunction, impotence and anorgasmy or hyporgasmy. • Smoking Cessation: Smoking cessation drugs and/or aids. • Take-Home Use From a Facility: Drugs received from a hospital, Skilled Nursing Facility, convalescent home or similar facility for take- home use. • Immunizations,except oral typhoid. • Vitamins and Minerals: Vitamins and minerals, except when requiring a prescription for a medically necessary vitamin or mineral. • Work-Related Medications: Medications recommended because of increased risk due to type of employment. • Lost or stolen medications. • Other Exclusion and Limitations: All exclusions and limitations as listed in this Attachment R - Outpatient Prescription Drug Benefit or in your Combined Evidence of Coverage and Disclosure Form. 20020244 9/02 PACIFICARE LIFE ASSURANCE COMPANY ("The Company") 3100 WEST LAKE CENTER DRIVE SANTA ANA, CA 92704 GROUP HEALTH INSURANCE POLICY PacifiCare Life Assurance Company(the"Company") will provide the Policy benefits to each Covered Person in consideration and acceptance of the Group Policyholder's application and premium, and subject to all Policy provisions. The Policy becomes effective on the Policy Effective Date shown on the Policy Information Page and continues in force until the first anniversary of the Policy Effective Date, unless it terminates earlier as provided herein. Thereafter, the Policy remains in force for 12 months beginning on each following anniversary of the Policy Effective Date, subject to the Policy Termination section. The Policy is delivered in and governed by the laws of the State of Colorado. Signed for by PacifiCare Life Assurance Company at our Home Office in Santa Ana, California. PACIFICARE LIFE ASSURANCE COMPANY Ron Davis,President GHP 500.CO FACE PAGE TABLE OF CONTENTS SECTIONS Policy Provisions Page Number GHP 500- General Provisions 1, 2 Premium Provisions 3 Policy Termination 4 Policy Information Page 5 GHP 500.CO TOC GENERAL PROVISIONS CERTIFICATE. The Group Policyholder will receive individual Certificates for delivery to each Insured Person. These Certificates summarize the benefits provided by this Policy. If there is a conflict between the Policy and the Certificate, the Policy will control. CLERICAL ERROR. Clerical error does not invalidate insurance otherwise validly in force, nor continue insurance otherwise validly terminated. Neither the passage of time nor the payment of premiums for a person who is not eligible for insurance under the terms of the Policy makes the insurance valid for such person. In this event,the Company's only liability is the proper refund of unearned premiums. If a premium adjustment requires the refund of unearned premium,the maximum refund is the 12 month period preceding the date the Company receives proof of the adjustment. The Company can request such information while the Policy is in force and for 1 year after the Policy ends. CONFORMITY TO STATE AND FEDERAL LAW. The Company amends any provision of the Policy that conflicts with state or federal law on the Policy Effective Date to the minimum requirements of the law. CONSENT OF COVERED PERSON NOT REQUIRED. The Policy shall be subject to amendment, modification or termination per Policy Provisions without the consent of Covered Persons. DEFINITIONS. The Certificate provides the definitions of terms used in the Policy. ENTIRE CONTRACT. The Policy, the attached copy of the Group Policyholder's application, the attached copy of the Certificate, and the Insured Persons' enrollment cards, if any, constitute the entire contract between the parties. All statements made by the Group Policyholder and by Insured Persons are representations not warranties. A statement from the Insured Person will only support a contest of the coverage provided by the Policy when the Company provides a copy of the statement to the Insured Person. Only an officer of the Company may change the Policy or extend the time for payment of any premium. No change will be valid unless made in writing and signed by an officer of the Company. Any change so made will be binding on all Persons referred to in the Policy. No agent has the implied or expressed authority to determine insurability,make any contracts in the name of the Company,or cancel,alter or amend any provision of the Policy. EMPLOYER NOT OUR AGENT. The Employer is not an agent of the Company. LEGAL ACTIONS. Any person may not bring legal action for benefits against the Company: 1. Until at least 60 days after proof of loss is sent to the Company as required;or 2. More than 3 years after the time for submitting proof has ended. MISSTATEMENT OF AGE. Misstatement of the Covered Person's age will subject premiums to an equitable adjustment. If the amount of benefit is dependent upon age, the benefit will be that which would have been payable based upon the Covered Person's correct age. NON-PARTICIPATING. The Policy is non-participating and does not share in the Company's profits or surplus earnings. NOT IN LIEU OF WORKERS' COMPENSATION. The Policy is not instead of, and does not impact any requirement for coverage by Workers' Compensation Insurance. GHP 500.CO 1 GENERAL PROVISIONS (Continued) RECOVERY RIGHT DUE TO CLERICAL ERROR. When payments made under the Policy are due to clerical error,the Company has the right to recover any such payment it made in error. The Company has the right to recover from the person an amount equal to the amount paid by the Company. RIGHT TO RECEIVE INFORMATION. The Group Policyholder shall provide the Company with the information necessary to administer coverage under the Policy. Payroll and any other records of an Insured Person relating to coverage under the Policy shall be open for review by the Company at any reasonable time. The Company may request that information needed to compute the premium be furnished at least once each year. TIME EFFECTIVE. Whenever an effective date of coverage is specified by the Policy, such commencement of coverage will be effective as of 12:01AM of that date. TIME LIMIT ON CERTAIN DEFENSES. The validity of insurance shall not be contested because of any statement with respect to insurability made by any person, after the insurance has been in force for two years during the Insured Person's lifetime. WAIVER OF RIGHTS. The Company's failure to enforce any provision of the Policy does not affect the Company's right to enforce any provision at a later date, and does not affect the Company's right to enforce any other provision of the Policy. GIIP 500.Co 2 PREMIUM PROVISIONS PAYMENT OF PREMIUMS. The insurance provided by the Policy is not in effect until the Company accepts the first premium payment for such insurance. Each following premium payment is payable on or before the due date for insurance to remain in effect. The Group Policyholder is responsible for paying all premiums as they become due. Premiums are payable on or before the Premium Due Date, unless the Company agrees to some other mode of payment. Premiums are payable to the Company at its Home Office. PREMIUM RATE CHANGE. The Company may change any Premium Rate on any of the following dates: 1. any Policy Anniversary; 2. any Premium Due Date; 3. when the number of Insured Persons changes by 10%or more from the number of Insured Persons on the Policy Effective Date;or 4. the date any of the Policy's terms are changed, including any federal or state law or regulation affecting the Company's liability under the Policy. Unless the Company and the Group Policyholder agree otherwise, the Company will give at least 31 days advance written notice of any increase in Premium Rates. If the Group Policyholder fails to maintain minimum participation requirements, the Company, in its sole discretion, may elect to adjust the Premium instead of terminating the Policy. Misstatement of the age,family status or geographic location of an Insured Person and/or Dependent will subject premiums to an adjustment. GRACE PERIOD. After the first premium payment, the Company shall allow a Grace Period of 31 days following each Premium Due Date. During the Grace Period,coverage under the Policy will remain in effect provided the Company receives the premium before the end of the Grace Period. If any premium is unpaid at the end of the Grace Period, the Policy will terminate in accordance with the Policy Termination section of the Policy. PREMIUM AMOUNT. The amount of premium due is the sum of the products obtained by multiplying each rate shown on the Premium Rate Schedule by the number of Persons to which each such rate applies. GHP 500.CO 3 POLICY TERMINATION TERMINATION BY THE COMPANY. The Company may terminate the Policy on any Premium Due Date. To do so,the Company must give at least 31 days advance written notice of its intent to terminate the Policy to the Group Policyholder. The termination is not effective unless,on the date of termination,at least one of the following is true: 1. the Premium Rates then being charged have been in effect for at least twelve months; 2. the number of Insured Persons totals less than 10; 3. part of the premium is paid by Insured Persons and less than 75%of those eligible for coverage are insured; 4. all of the premium is paid by the Group Policyholder and less than 100% of those eligible for coverage are insured; 5. the Group Policyholder has not performed its obligations under the Policy in good faith;or 6. the Company has determined fraud or misrepresentation by the Group Policyholder. Notwithstanding the above, the Company may terminate the Policy on any Policy Anniversary Date. To do so,the Company must give at least 31 days advance written notice of its intent to terminate the Policy to the Group Policyholder. The Policy may terminate on an earlier date when both the Group Policyholder and the Company agree to such termination. TERMINATION BY GROUP POLICYHOLDER. The Group Policyholder may terminate the Policy at any time by giving notice to the Company. The Policy will terminate on the date the Company receives the notice or some later date on which the Group Policyholder and the Company have agreed. The Group Policyholder is responsible for premium payments through the date of termination. AUTOMATIC TERMINATION. The Policy will terminate, without any action on the part of the Company, on the day before the due date of any premium that remains unpaid at the end of the Grace Period. EMPLOYEE NOTIFICATION. In the event of Policy termination, the Group Policyholder is responsible for written notification to the Insured Persons of such termination. PROVIDING MISLEADING OR FRAUDULENT INFORMATION. At its discretion, the Company may terminate or rescind the Policy upon 31 days written notice to the Group Policyholder if the Group Policyholder knowingly provides materially misleading or fraudulent information to the Company on any application documents. GHP 500.CO 4 POLICY INFORMATION PAGE GROUP POLICYHOLDER: Weld County Government POLICY NUMBER: 00011069 POLICY EFFECTIVE DATE: January 1,2003 POLICY ANNIVERSARY: January 1,annually CONTRIBUTIONS: Insured Persons make contributions for the following: Personal Health Insurance Yes [X] Dependent Health Insurance Yes [X] WAITING PERIOD: First day of the month following first full pay period ELIGIBILITY: Employees who regularly work at least 20 hours per week OPEN ENROLLMENT PERIOD: November through December PREMIUM DUE DATE: First of the month PREMIUM IS PAYABLE: Monthly STANDARD PLAN: PPO Plan U04 OPTIONAL BENEFITS: Prescription Drug Benefit BUS MONTHLY PREMIUM RATE SCHEDULE: Monthly Rate per Employee Only $322.54 Monthly Rate per Employee plus One $645.08 Monthly Rate per Employee plus Child(ren) $619.28 Monthly Rate per Employee plus Family $949.39 Hello