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Home My WebLink About740577.tiff RESOLUTION RE: AMENDMENT TO AGREEMENT BETWEEN WELD COUNTY AND PACIFIC MUTUAL LIFE INSURANCE COMPANY. WHEREAS, heretofore Weld County by resolution did enter into a contract with Pacific Mutual Life Insurance Company for group insur- ance covering Weld County employees under various policies including group policy No. GM-8864, including amendments thereto, and WHEREAS, now Pacific Mutual Life Insurance Company has submitted an additional amendment to group policy No. GM-8864, and WHEREAS, the Board of County Commissioners, Weld County, Colorado, believes it to be in the best interest of the County to accept the aforementioned amendment to group policy No. GM-8864 as proposed, covering its county employees, and to enter into such amendment to group policy No. GM-8864 on the bases recited therein, NOW, THEREFORE, BE IT RESOLVED, by the Board of County Commissioners, Weld County, Colorado, that the amendment submitted by Pacific Mutual Life Insurance Company amending the aforementioned group policy No. GM-8864, copy of which is attached hereto and made a part hereof by reference, be and it hereby is approved. BE IT FURTHER RESOLVED, that the Board be, and it hereby is authorized to execute the amendment to the aforementioned group policy No. GM-8864 as submitted and to make the same effective forthwith. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 14th day of August, A. D. , 1974. ' BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO ATTEST• ', ®sue/. Weld County Clerk and Recorder and Clerk to the Board By , r�.. ;< Lt ,1 a-J Deputy County Clerk APPROVED AS TO FORM;--- r� 1 t� 4€ l 1/4/.,3 IL County Attorney C' • 740577 t _ POLICYHOLDER'S COPY AMENDMENT NO, 2 /__ Attached to and part of Group Policy Na, GM-8864 lyiend between Pacific Mutual Life Insurance Company, 'and the Policyholder, WELD COUNTY COLORADO- _ The Policyholder and Pacific Mutual hereby agree that the policy is amended, u of the effective date stated on each amended page by deleting from the policy the page or pages thereof listed under Column I and inserting into the policy the attached page or pages listed under Column II, each marked by "Amendment No, 2 effective January 1, 1974", except that page 11E-1-c is deleted and inserted effective April 1, 1972. COLUMN I- PAGES DELETED COLUMN II- PAGES INSERTED 2-B 2-B 9A-1-f 9A-1-f l0A l0A 11C-1-c 11C-1-c 11E-1-c 11E-1-c 11F-1-a 11F-1-a 12 12 IN WITNESS WHEREOF, the parties hereto have, by their duly authorized representatives set their hands on the date set forth beneath their respective signatures. POLICYHOLDER PACIFIC MUTUAL LIFE INSURANCE COMPANY adae%244,,,, Signature of Officer � President TITLE Board of County Commissioners .� /. Weld County, uoiorado Secretary DATE August 14, 1974 ATTEST Registrar DATE GR-4827 • GENERAL PROVISIONS INDIVIDUALS' CERTIFICATES. The Insurance Company shall issue to the Policyholder, for delivery to each insured Individual, an individual certificate setting forth a summary of the essential features of the insurance coverage to which the Individual is entitled and stating to whom the benefits are payable. PREMIUM CALCULATIONS-EXPERIENCE RATING. This policy shall not be entitled to share in the surplus earnings of the Insurance Company. Each premium shall be calculated at the premium rate specified in the table below; TABLE OF PREMIUM RATES Monthly Rate per Individual Individual Insurance If not eligible for Medicare $20.84 If eligible for Medicare $ 6.00 Dependents Insurance If not eligible for Medicare $ *a .a4/ If eligible for Medicare $ 6.00 The Insurance Company shall have the right to make experience reductions or increases in premium rates on any premium-due date, and to reduce or increase premium rates whenever a class of Individuals is made eligible or eliminated from eligibility for insurance under this policy. No increase in premium rates,other than an increase when a class of Individuals is made eligible or eliminated from eligibility for insurance under this policy,shall become effective less than twelve months after the effective date of this policy or less than twelve months after the effective date of any previous increase in premium rates. Each reduction or increase in any premium rate shall be made by written notification to the Policyholder by the Insurance Company. Except as may be otherwise provided, any insurance becoming effective shall be charged for from the first day of the policy month coinciding with or next following the date the insurance takes effect. Premium charges for any insurance terminated shall cease as of the last day of the policy month coinciding with or next following the date the insurance terminates. If premiums are payable quar- terly, semi-annually, or annually,premium charges or credits for a fraction of a premium-paying period required by the foregoing terms of this paragraph shall be made on a pro-rata basis for the number of policy months between the date premium charges com- mence or cease and the end of the premium-paying period. Premium adjustments involving the return of unearned premiums shall be limited to the period of twelve months immediately pre- ceding the date of receipt by the Insurance Company of evidence that such adjustments should be made. Instead of the method of calculation of premiums above provided,premiums may be calculated by any method which produces approx- imately the same total amount of premiums and is mutually agreeable to the Insurance Company and the Policyholder. At the end of each policy year of not less than twelve months' duration throughout which this policy shall have been continuously in effect, the Insurance Company may allow to the Policyholder an experience credit in such amount, if any, as shall be determined by an experience rating plan which the Insurance Company then has in effect. The amount of each such experience credit shall be paid in cash to the Policyholder, or upon request by the Policyholder, shall be applied against the payment of any premium or premiums. If at any rime the aggregate of any Individual contributions theretofore made under this policy shall exceed the aggregate of premiums theretofore paid under this policy (after giving effect to any experience credits), such excess shall be applied by the Policyholder for the sole benefit of Individuals, but the Insurance Company shall not be obliged to see to the application of any such excess. GRACE PERIOD-DISCONTINUANCE OF POLICY. A grace period of thirty-one days following the due date shall be allowed the Policyholder for the payment of each premium after the first. If any premium with respect to the insured Individuals in any class is not paid before the expiration of the grace period, this policy shall automatically discontinue with respect to all Individuals in such class at the expiration of the grace period, except that if the Policyholder shall have given the Insurance Company written notice in advance of discontinuance at the commencement of or during the grace period, this policy shall discontinue with respect to all Indi- viduals in such class as of such earlier date. As to each class, the Policyholder shall be liable to the Insurance Company for all unpaid premiums with respect to the insured Individuals in such class for the period (including a pro-ran premium for the grace period or fraction thereof) dg which this policy was in force with respect to such insured Individuals. The Insurance Company riserves the right to discontinue this policy on any premium-due date (a) with respect to all classes of Individuals, when fewer than 25 Individuals are insured under this policy; or (b) with respect to any class of Individuals, when less than one hundred per cent of the eligible Individuals in such class are insured hereunder; provided that the Insurance Company shall give the Policyholder at least thirty-one days' notice of its intent to discontinue. GR-231 (8864) AMENDMENT NO. 2 EFFECTIVE JANUARY 1, 1974 PAGE 2-8 In.1-19 COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS CASH DEDUCTIBLE. The cash deductible applicable to a covered person for each calendar year shall consist of eligible charges incurred in connection with an illness, in an amount determined as hereinafter provided, incurred during a period of twelve consecutive months, or less, in such calendar year in connection with the illnesses of such person; provided, however, that(1) the cash deductible shall apply only with respect to hospital charges incurred on an in-patient basis, and to charges for nursing, physiotherapy and appliances, and(2) no cash deductible shall apply with respect to any eligible charges incurred for treatment of bodily injuries sustained in an accident. Only eligible charges which are subject to the cash deductible may he applied toward satisfaction of the cash deductible. The cash deductible applicable to a covered person for a calendar year shall be $100. The cash deductible applicable to a covered person for a calendar year shall, subject to the provisions of the second paragraph of this section,be satisfied at the time as of which eligible charges, in an amount at least equal to the cash deductible applica- ble to such person for the calendar year, have been incurred during a period of twelve consecutive months, or less, in such cal- endar year in connection with the illnesses of such person. The cash deductible applies separately to the amount of eligible charges incurred during each calendar year by each covered person: provided, however, that if three "covered family members" incur eligible charges in excess of their cash deductible during a calendar year, then, during such calendar year, on or after the date the third "covered family member" incurs eligible charges in excess of the applicable cash deductible, no additional cash deductible will be applied to eligible charges in- curred by any "covered family member". The term "covered family member" means an Individual and each of his qualified dependents insured under the policy. CARRY-OVER OF DEDUCTIBLE. If the cash deductible applicable to a covered person is satisfied by the application of eligible charges wholly incurred during the last three months of a calendar year, then(a) the cash deductible applicable to such person for the next ensuing calendar year shall also be considered as having been satisfied as of January 1 of such ensuing calendar year, provided that the eligible charges so applied in the previous calendar year are equal to the cash deductible applicable to such person for such ensuing calendar year. otherwise(b) the cash deductible applicable to such person for such ensuing calendar year shall be reduced as of January 1 of such year by the amount of eligible charges so applied in the previous calendar year. Further- more, if the cash deductible is not satisfied for a calendar year but eligible charges are incurred during the last three months of such calendar year, or if the cash deductible is satisfied for a calendar year partially by the application of eligible charges incur- red during the last three months of such calendar year, then the cash deductible for the next ensuing calendar year may be satis- fied in part by eligible charges incurred during the last three months of the prior calendar year with respect to which no benefits were payable during such year. MAXIMUM AMOUNT. Not more than $80,000 of benefits in the aggregate(herein called the Maximum Amount) shall be payable by the Insurance Company under the provisions of this policy with respect to the entire duration of coverage of any one person, whether or not such coverage was interrupted by a previous termination of the person's insurance hereunder for any reason, except as provided by the section entitled "Maximum Amount Reapplied". In the event that benefits to the extent of the Max- imum Amount become payable, the insurance under this policy as to the Individual or qualified dependent with respect to whom the maximum becomes operative shall automatically terminate as provided by the section entitled "Termination of Insurance". MAXIMUM AMOUNT REAPPLIED. If benefits to the extent of$1,000.00 or more became payable with respect to illnesses of the Individual or a qualified dependent, the Maximum Amount may be reapplied to such person by the Individual furnishing, without expense to the Insurance Company, evidence satisfactory to the Insurance Company of the insurability of the person with respect to whom the Maximum Amount is being reapplied. If such evidence is furnished, the Maximum Amount shall be reapplied to such person, effective on the date the Insurance Company determines the evidence to be satisfactory except that in the event such per- son is an employee who is not then actively at work on full time, the reapplication shall be deferred until his return to active work on full time. If the conditions to have the Maximum Amount reapplied to such person are satisfied, the Maximum Amount shall be applied to such person as though no benefits became payable under this policy with respect to illnesses of such person prior to the date such reapplication is effected. If any benefits became payable with respect to the illnesses of the Individual or a qualified dependent and the Maximum Amount applicable to such person has not been fully reapplied to such person at the end of any calendar year, a portion of the Maximum Amount equal to the lesser of 21,000.00 and the entire portion of the Maximum Amount which has not been reapplied shall auto- matically be reapplied to such person on the first day of the next ensuing calendar year. WHEN CHARGES DEEMED INCURRED. For the purposes of this policy, a charge shall be deemed to be incurred as of the date of the service, treatment or purchase of the supply giving rise to the charge. GR-231 (8864) PAGE 9A-1-f (CARRY-OVER DED.) AMENDMENT NO. 2 EFFECTIVE JANUARY 1, 1974 • EXCEPTIONS. For the purposes of this policy, anything herein to the contrary notwithstanding, eligible charges shall in no event include: (1) charges incurred in connection with a bodily injury arising out of, or in the course of, any employment for wage or profit or disease covered by a workmen's compensation act or similar legislation or the maritime doctrine of main- tenance, wages and cure; (ii) charges for or in connection with any eye examinations, glasses, hearing aids, or the fitting of any thereof; (iii) charges incurred for cosmetic surgery unless necessary for repair or alleviation of damage resulting from an accident occurring while a covered person; (iv) charges incurred for any dental services and supplies for treatment of(a) teeth, (b) the gums other than for tumors, and(c) other associated structures primarily in connection with the treatment or replacement of teeth, unless the charges are necessary for repair or alleviation of damage to sound natural teeth resulting from an accident occurring while a covered person; (v) charges incurred for callus or corn paring, toenail trimming, or foot massage; (vi) charges for or in connection with travel or transportation, whether by ambulance or otherwise, except that charges for professional ambulance service used to transport the covered person directly to and from a hospital where treat- ment is given for an illness will not be excluded by this exception; (vii) charges with respect to confinement in an hospital owned or operated by the United States Government, or with respect to any surgical, medical, or other treatment received in such a hospital, or with respect to a hospital confinement or any surgical, or other treatment for which no charge is made that the Individual or qualified dependent is required to pay; (viii) charges incurred during confinement in a hospital owned or operated by a State, Province or political subdivision unless there is an unconditional requirement to pay such charges without regard to any rights against others, con- tractual or otherwise; (ix) charges for medical examinations of any covered person for "check-up" purposes when not incident and necessary to the treatment of an illness, except that this item(ix) shall not apply with respect to(a) the first $90 of such charges incurred, other than for routine immunizations, during each calendar year on behalf of a qualified dependent who is less than two years of age, and(b) an additional amount consisting of the first $35 of such charges incurred for routine immunizations of a qualified dependent who is less than two years of age; (x) charges for or in connection with any illness caused by any act of war, whether declared or undeclared, or by any atomic explosion or other release of nuclear energy(except only when being used soley for medical treatment of an illness of a covered person); (xi) charges incurred for treatment of mental infirmity(a) while confined to an institution which is primarily for treat- ment of the mentally ill, or(b) all other such charges incurred while not confined to a hospital, which(1) exceed 80% of the amount determined by multiplying the applicable number of Relative Value Units specified in the "Psychiatric Services" section of t. •e r. ve Value Schedule of Medical Services by the Dollar Unit Value specified in the Schedule of Benefits on pare 1ID f. all treatment of mental infirmity during each of the first 10 calendar days of such treatment in a calendar ' ar, or(2) exceed 50"/0 of such amount for all such treatments during each of the next 16 calendar days of such treatment in such calendar year, or(3) are incurred during the portion of a calendar year which follows the 26th(reduced in the first year a person is insured hereunder by multiplying 26 by the ratio of 12 to the number of months between the date he became insured hereunder and the end of such calendar year) calendar day in which such charges are incurred during such calendar year; (xii) charges incurred for or in connection with the treatment of alcoholism or narcotism; (xiii) charges for any services or supplies other than those which are certified by a physician who is attending the Individual or qualified dependent as being required for the treatment of the illness, except that this item(xiii) shall not apply with respect to charges for circumcision or dilation and curettage, or any of the charges specified in parts(a) and(b) of item(ix) above; (xiv) charges incurred for any services rendered for pregnancy or for resulting childbirth or for prenatal or postnatal care, except that in the case of Caesarean section, abortion, miscarriage, dilation and curettage, or medical or surgical complications of a pregnancy, no charges shall be excluded if they otherwise qualify as eligible charges; GR-231 (8864) AMENDMENT NO. 2 EFFECTIVE JANUARY 1, 1974 Page l0A • COMPREIIENSIVE MAJOR MEDICAI. EXPENSE id:NEFII'S (Continued) slim:ICAi EXPENSE BENEFITS. For the purposes of this section, eligible charges shall he the charges which arc used in determining benefits under this section, except to the extent modified under this section and the section entitled "Exceptions". if an Individual or a qualified dependent, while a covered person, undergoes a surgical or radiotherapy procedure enumerated in the Relative Value Schedule of Surgical and Radiotherapy Procedures far the treatment of an illness, the Insurance Company shall. subject to the terns of this policy, pay a benefit in an amount equal to one hunted percent of the eligible charges actually made to the Individual or qualified dependent for; (a) the surgical procedure, if such procedure is performed by a physician; and (b) services rendered by a physician assisting with such surgical procedure; and (c) anesthesia services rendered by a physician or professional anesthetist for the administration of an anesthetic in comection with such surgical procedure; and (d) the radiotherapy procedure, if such procedure is performed by a physician or professional radio-therapist; but not exceeding an amount equal to one hundred percent of the applicable Dollar Unit Value for Surgical Expense Bene- fits shown in the Schedule of Benefits multiplied by the Relative Value specified for such procedure a services, as the case may be. in the Relative Value Schedule of surgical and Radiotherapy Procedures, less, in the event the cash deductible applicable to such covered person for the then current calendar year has not been satisfied, an amount equal to the part(or all) of such cash deductible that has not been satisfied. If two or more surgical or radiotherapy procedures are performed, payment shall be made for each procedure in accordance with the terms of the foregoing paragraph, provided that; (1) if multiple or bilateral surgical procedures, which add significant time or complexity to patient care, are performed at the same operative session, the total Relative Value for such procedures shall not, unless otherwise specified in the Relative Value Schedule of Surgical and Radiotherapy Procedures, exceed the Relative Value of the major procedure plus 307. of the Relative Value of each of the lesser procedures as specified in said Relative Value Schedule; and (2) if an incidental surgical procedure(such as incidental appendectomy, lysis of adhesions, excision of previous scar, puncture of ovarian cyst, etc.) is performed through the same incision, payment shall be made only for that one pro- cedure for which the largest Relative Value is specified in said Relatve Value Schedule. SCHEDULE OF BENEFITS Classifications of individuals One class applicable to all Surgical Expense Benefits Dollar Unit Value for Surgical Expense Benefit The eligible charges used in determining benefits under this section are not subject to the cash deductible described in the section entitled "Cash Deductible", If the procedure is performed in a hospital $6 70 except $7.50 for anesthesia services If the procedure is performed in a physician's office or in a clinic. . $7.70, except $8.50 for anesthesia services GR-231(8864) Page 11C-1 AMENDMENT NO. 2 EFFECTIVE JANUARY 1, 1974 COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS (Continued) DIAGNOSTIC LABORATORY AND X-RAY EXPENSE BENEFITS. For the purposes of this section, eligible charges shall be the charges which are used in determining benefits under this section, except to the extent modified under this section and the section entitled "Exceptions". If an Individual or qualified dependent. while a coveted person, incurs eligible charges for a necessary laboratory or x-ray procedure enumerated in the Schedule of Diagnostic Laboratory and X-Ray Procedures for diagnostic purposes in connection with the therapeutic treatment of an illness, and if such person is not entitled to other benefits of any kind under this policy by mason of such procedure. the Insurance Company shall, subject to the terms of this policy, pay a benefit in an amount equal to one hundred percent of the eligible charges actually made to the Individual or qualified dependent for such procedure consistent with the usual charges made for such procedure, but not exceeding an amount equal to one hundred percent of the Dollar Unit Value for Diagnostic Laboratory and X-Ray Expense Benefits shown in the Schedule of Benefits multiplied by the Relative Value specified for such procedure in the Schedule of Diagnostic Laboratory and X-Ray Procedures, lea, in the event the cash deductible applicable to such covered person for the then current calendar year has not been satisfied, an amount equal to the part (or all)of such cash deductible that has not been satisfied. SCHEDULE OF BENEFITS Classifications of Individuals One class applicable to all Diagnostic Laboratory and X-Ray Expense Benefits Dollar Unit Value for Diagnostic Laboratory and X-Ray Expense Benefits: $6.70 The eligible charges used in determining benefits under this section are not subject to the cash deductible described in the section entitled "Cash Deductible". GR-231. (8864) PAGE 11E-1-i AMENDMENT NO. 2 EFFECTIVE APRIL 1, 1972 • • COMPREHENSIVE MAJOR MEDICAL EXPENSE BENEFITS (Continued) PRESCRIPTION, APPLIANCE AND NURSING EXPENSE BENEFITS. If an Individual or qualified dependent, while a cov- ered person, incurs eligible charges, as defined below, for the therapeutic treatment of an illness, the Insurance Company shall, subject to the terms of this policy, pay benefits in an amount equal to eighty percent of the following: the total eligible charges, as defined in this section, incurred by such covered person, less, in the event the cash deductible applicable to such covered person for the then cur- rent calendar year has not been satisfied, an amount equal to the part (or all) of such cash deductible that has not been satisfied. For the purposes of this section, eligible charges shall be the following charges actually made to Individuals and qualified dependents on account of their illnesses, except to the extent modified under the section entitled "Exceptions": (1) charges made by a registered graduate nurse other than one who ordinarily resides in the Individual's (or the wife's or husband's) home or who is a member of the immediate family (comprising the Individual, the Individual's wife or husband, and the chil- dren, brothers, sisters, and parents of either the Individual or the Individual's wife or husband) for professional nursing services; and (2) charges made by a licensed physiotherapist other than one who ordinarily resides in the Individual's (or the wife's or husband's) home or who is a member of the immediate family (comprising the Individual, the Individual's wife or husband, and the children, brothers, sisters, and parents of either the Individual or the Individual's wife or husband) for professional physiotherapy; and (3) charges made for any of the following services and supplies to the extent such charges do not duplicate charges included under other sections of this policy: (a) drugs and medicines lawfully obtainable only upon the prescription of a physician; (b) rental of a wheel chair, hospital bed, iron lung, and such other equipment as is necessary for the therapeutic treatment of the covered person; (c) artificial limbs and artificial eyes;and (d) casts,splints,and surgical dressings. The eligible charges used in determining benefits under this section are subject to the cash deductible described in the section entitled "Cash Deductible", unless the charges are for drugs or medicines or are incurred for treatment of bodily injuries sustained in an accident. oft-23, (8864) AMENDMENT NO. 2 EFFECTIVE JANUARY 1, 1974 PAGE 11F•1•a (OVERALL O{O.) /-.. • • RELATIVE VALUE SCHEDULE OF SURGICAL AND RADIOTHERAPY PROCEDURES Relative Value Follow-up Follow-0 Relative Value Prestos Days procedure DaYs No. Surgery Anesthesia Included No. Surgery Anesthesia Included ANI)OMI:N MIISCIi1.USKELE'lAl. SYSTEM +3261 Appendectomy 15.0 4.0+T 45 Amputations +3515 Call bladder, removal of 70.0 5.0+1' 45 +3114 Castrertomy, total 110.0 6.1)+'1' 90 +1705 Ann through humerus 40,0 :1.0+1' go +3571 Laparotomy. exploratory 15.0 4.0+'1 30 + 1736 Finger, one 15.0 3.0+'f 45 +3551 Pancreatectomy, local partial + 1767 Leg through tibia and fibula 50.0 3.0+I' 90 or subtotal 80.0 6.0+1' 90 + 1802 'foe, one 10.0 3.0+T 45 BREAST Fr + 457 Amputation - simple 30.0 3.0+T 45 Radius and ulna, simple + 470 radical 80.0 3.0+T 60closed reduction 444 Excision of cyst - unilateral . 15.0 3.0+T 30 820 under age 15 10.0 3.0+T 120 445 bilateral . . . 20.0 3.0+T 30 821 age IS or over 15.0 3.0+T 120 CHEST simple or compound + 825 'open reduction 50.0 3.0+T 150 2111 Bronchoscopy, diagnostic 15.0 4.0+T 30 Tibia and fibula, simple +2191 Lung, total removal of 100.0 11.0+T 90 closed reduction .2196 Pulmonary resection with 90 925a under age 15 20.0 3.0+T 90 concomitant thorocoplasty. . . 150.0 11.0+T 180 925 age 15 or over 25.0 3.0+T 180 +2301 Cardiotomy, exploratory 100.0 15.0+T 90 + 928 simple or compound +2350 Myocardial aneurysm 120.0 15.0+T 90 open reduction 60.0 3.0+T 180 ♦2317 Excision of cardiac tumor 100.0 15.0+T 90 851 Finger,simple,closed reduction 4.0 3.0+T 45 EAR, NOSE & THROAT 980 Toe,simple, closed reduction . . 3.0 3.0+'r 60 6000 Fenestration 100.0 4.0+T 90 Arthreplaaty 5972 Mastoidectomy, simple 50.0 4.0+T 180 (plastic or reconstructive operation) 5998 Stapes mobilization 70.0 4.0+T 90 + 1141 Shoulder 80.0 3.0+T 120 1991 Sphenoid ainosotomy 30.0 3.0+T 30 +1142 Elbow 80.0 3.0+T 120 Radical antrotomy (Caldwell-Luc) +1152 Ankle 75.0 3.0 aT 180 1988 unilateral 50.0 3.0+T 90 + 1151 Knee 100.0 3.0+T 270 1990 bilateral 65.0 3.0+T 90 Tonsillectomy with or without Repair of Tendons adenoidectomy- 2992 under age 15 15.0 3.0+T 30 ♦1573 Fasciectomy, for Dupuytrens 2993 age 15 or over 20.0 3.0+T 30 contracture 40.0 3.0+T 120 3044 Esophagectomy 100.0 12.0+T 90 +1585 Lengthening or shortening of Achilles tendon 35.0 3.0+T 90 EYE ♦1621 Transplatation of tendon 37.5 3.0+T 90 Cataract, operation for intro- RECTUM capsular, extracapsular, or +5611 linear, unilateral 70.0 8.0+T 90 Fissurectomy or ulceretomy +5421 Enucleation of eyeball 35.0 4.0+T 30 3371 with sphincterotomy 15.0 3.0+T 90 +5541 Excision of lesion of iris 50.0 4.0+T 45 llemorrhoidectomy, 3375 internal and external 32.0 3.0+T 90 GENITO-URINARY TRACT +4634 Cervix amputation 20.0 4.0+T 45 SKIPI.I. 3931a Cystoscopy, initial, office 6.0 3.0+T 7 Elevation of depressed skull hospital 8.0 3.0+T 7 +5018 fracture, simple 50.0 9.0+T 60 4650 Dilation and curettage of uterus Osteoplastic craniotomy for . (non-puerperal) 15.0 3.0+T 15 excision of brain tumor, a4617 Hysterectomy, total 70.0 4.0+T 45 +5130 abscess, or cyst supratentorial 125.0 9.0+T 90 +4621 subtotal 40.0 4.0+T 45 +5140 Craniotomy for pallidectomy . . . 100.0 9.0+T 90 +4627 radical for cancer 100.0 6.0+T 90 Osteoplastic craniotomy for +3835 Kidney - fixation of 35.0 5.0+T 90 +5136 obliteration of aneurysm 140.0 11.0+T 90 +3821 removal of 75.0 5.0+T 90 P re Burr holes with ventriculography Bladder tumor - g 3924 transurethral resection 50.0 5.0+T 90 +5152 not followed by surgery 30.0 7.0+T 30 Prostatectomy, perineal, +5153 followed by surgery 2(1.0 7.0+T 30 ♦4311 subtotal 75.0 6.0+T 90 4321 transorethral electroresection SPINE AND SPINAL CORD of prostate . 75.0 5.0+T 90 +4481 Cystocele - repair of 35.0 3.0+T 60 Lantinertomy for removal of inter- +4484 Rectocele - repair of 30.0 3.0+T 60 +5208 vertebral discs, cervical . . . . 90.0 8.0+T 90 +4485 Cystocele and rectocele- +5192 Cordotomy, cervico-dorsal. . . . 80.0 8.0+T 90 repair of 50.0 3.0+T 60 5214 Myelography 10.0 3.0+T 7 GOITRE ♦4917 Thyroidectomy. subtotal VEINS AND ARTERIES or partial 65.0 5.0+T 30 +2522 Ligation of carotid artery 40.0 4.0+T 30 ♦491t total or complete 80.0 5.0+T 30 ligation and division of +4911 Local excision of small cyst long saphenous vein at . or adenoma of thyroid 35.0 5.0+T 30 saphenofemoral junction HERNIA 2558 unilateral 20.0 3.0+T 30 ♦;1631 Inguinal. unilateral 2560 bilateral 28.0 3.0+T 10 g 35.0 3.0+T 45 Ligation and division and ♦3661 3en0u1, incisionul SS 0 3.0+T 45 complete stripping of - Umbilirrl long saphenous vein +:1W• under age 5 25.0 3.0+T 30 +2561n unilateral 30.0 3.0+T 3(L +3666 age 5 or over 35.0 3.0+T 30 +222562 bilateral 42.0 3.0+T 30 long and short saphenous veins MATERNITY +2563 unilateral 40.0 3.0+T 30 ♦4801 Classic Caesarean section. . . . 40.0 5.0+r 45 +2564 bilateral 5.5.0 3.0+T 30 +4811 Ectopic pregnancy, by Iaparotomy 50.0 5.0+T 60 GR-231(8864) (CONTINUED ON REVERSE SIDE) Page 12 (RVS-001.0) AMENDMENT NO. 2 EFFECTIVE JANUARY 1, 1974 RADIOTHERAPY Values for treatment include all technical expense, professional radiological service and professional admin- istrative services, where applicable, including professional nuclear physicist service. Procedure Relative No. Schedule Value 7628 Benign lesions, per treatment 2.0 7620 Malignant lesions, size 0-1 cm, per course 9.0 NUCLEAR MEDICINE Values for treatment include all technical expense including radioactive materials, professional physician services and professional administrative service, where applicable, including professional nuclear physicist service. Per Course Schedule Procedure No. 10710 Metastatic cancer to bone 18.0 10716 Hyperthyroidism 18.0 ASSISTANTS Where the procedure number is preceded by a cross (a ), a surgical assistant will be allowed. Assist at surgery, 20% of listed Relative Value of the surgical procedure — • minimum allowance.. 6.0 For surgical or radiotherapy procedures not shown on this Schedule, and which are not expressly excluded by the terms of this policy, the Insurance Company will determine the Relative Value for the procedure and for any anesthesia service in connection therewith. A procedure of equal gravity and severity will be used as a basis for such determination. The Relative Values for all surgical procedures include the surgery and the follow-up care for the period indi- cated in days in the column headed "Follow-up Days Included". When a surgical procedure or•procedures are carried out within the listed period of follow-up care for a previous surgery, the follow-up periods will continue concurrently to their normal terminations. Benefits shall not be payable for the attendance of two physicians on the same case at the same time except where it is warranted by the necessity of supplementary skills. ANESTHESIA I. The total values for anesthesia services include prc- and post-operative visits, administration of the anesthetic and the administration of fluids and/or blood incident to the anesthesia or surgery. 2. When hypothermia and/or a pump oxygenator are employed in conjunction with an anesthetic, the anesthetic "base" value will be 20 units. 3. In procedures where no value is listed, the basic portion of the calculated value will be the same as listed for a comparable procedure. 4. Where unusual detention with the patient is essential for the safety and welfare of such patient, the neces- sary time will be valued on the same basis as indicated below for anesthesia time. 5. No fee will be allowed for local infiltration anesthesia administered by the operating surgeon. Calculation of Total Anesthesia Values A BASIC VALUE: is listed for most procedures. This includes the value of all anesthetic services except the value of the actual time spent administering the anesthesia or in unusual detention with the patient. TIME UNITS are computed by allowing 1 unit for each 15 minutes of anesthesia time. Anesthesia time starts with the beginning of the administration of the anesthetic agents and ends when the anesthesiologist is no longer in personal attendance(when the patient may be safely placed under customary post-operative supervision). 'ic Value + Time Units = TOTAL ANES''5SIA VALUE Hello