unisys insured hmo...about this supplement this supplement describes the benefits provided through...

UNISYS

SELF-INSURED MANAGED-CARE OPTION

FOR UNISYS PARTICIPANTS

IN DESIGNATED GEOGRAPHIC LOCATIONS

January 2001

Supplement to the Summary Plan Description

for Medical Plans Sponsored by Unisys

ABOUT THIS SUPPLEMENT

This supplement describes the benefits provided through the self-insured managed-care medical options

made available in designated geographic locations to eligible Unisys employees, eligible former Unisys

employees and their eligible dependents. This supplement amends the Summary Plan Description (SPD)

booklet referenced below, that applies to you based on your employment status.

�� For active employees eligible to participate in the Unisys Flexible Benefits Program — SPD for health

and welfare benefits, including amendments as may be made from time to time.

�� For eligible retired or disabled former employees — SPD for the Unisys Post-Retirement and Extended

Disability Medical Plan (PRM Plan), including amendments as may be made from time to time.

Except where otherwise noted, this supplement modifies only the medical plan provisions for covered/non-

covered services and administrative procedures reflected in your SPD. Refer to your SPD for general

information on eligibility, enrollment, changing your medical elections, when coverage begins and ends, and

other important information, including the “additional information” section.

Throughout this supplement, “you” generally refers to covered employees, covered former employees and

covered dependents. The term “you” also is interchangeable, depending on the context of the sentence, with

an eligible employee, eligible former employee or an eligible dependent. “Retiree” generally refers to Unisys

retirees or disabled former Unisys employees and their covered dependents.

Keep this supplement handy as an ongoing reference. This supplement, your SPD, and any amendments

constitute your health plan documents. This supplement contains Plan provisions as of January 1, 2001,

unless otherwise noted.

FOR QUICK REFERENCE, KEEP THESE NUMBERS HANDY

Your primary care physician or clinic (PCP)

your first contact for all of your health-care needs

(does not apply to

SelectAdvantage for services

on or after July 1, 2001)

(Fill in the name and telephone number above)

Member Services �� general information

regarding the Plan �� help you identify network

providers

�� respond to inquiries on

claims

For Aetna, HealthPartners and Medica Self-Insured members,

also use these numbers to:

�� report treatment for a

medical emergency within

24 hours of treatment; also

contact your PCP/PCC �� precertify services

Aetna U.S. Healthcare® Members:

�� 1-800-238-3488

HealthPartners Members:

�� 952-883-5000 in the Minneapolis/St. Paul metro area

�� 1-800-883-2177

To report a medical emergency or urgent medical need after clinic daytime operating hours

�� 612-339-3663 in the Minneapolis/St. Paul metro area

�� 1-800-551-0859 outside the metro area

Medica Self-Insured Members:

�� 1-800-962-9497

�� 952-992-3190 or 1-800-841-6753 for TTY connections for the hearing impaired

To report a medical emergency or urgent medical need after clinic daytime operating hours

�� call your PCC after-hours telephone number

United Behavioral Health (UBH) for treatment of mental-health or substance abuse disorders

�� 1-800-848-8327

SelectAdvantage Members, through June 30, 2001:

�� 1-248-637-6777

�� 1-888-302-0767

For treatment of mental-health or substance abuse disorders

�� 1-800-888-9037

SelectAdvantage Members, on and after July 1, 2001:

�� 1-800-521-1321

Self-Insured HMO 2001 — i

CONTENTS

Introduction .................................................................................................................................................2

How the Plan Works....................................................................................................................................6

NETWORK PROVIDERS.............................................................................................................................6

Your Primary Care Physician (PCP) for Aetna U.S. Healthcare........................................................7

Your Primary Care Clinic (PCC) for HealthPartners and Medica Self-Insured.................................7

Your Primary Care Physician (PCP) for SelectAdvantage .................................................................7

Role of your PCP/PCC........................................................................................................................8

Selecting your PCP/PCC.....................................................................................................................8

Changing your PCP/PCC ** ..............................................................................................................9

Network Specialists ............................................................................................................................9

IF YOUR PHYSICIAN OR CLINIC LEAVES THE NETWORK.......................................................................10

WHAT TO DO FOR A MEDICAL EMERGENCY OR AN URGENT MEDICAL NEED......................................10

WHAT TO DO IF YOU OR YOUR DEPENDENT IS OUTSIDE THE SERVICE AREA WHEN MEDICAL CARE IS

OBTAINED..............................................................................................................................................11

Aetna U.S. Healthcare Cost-Sharing Table ...............................................................................................16

HealthPartners Cost-Sharing Table............................................................................................................23

Medica Self-Insured Cost-Sharing Table...................................................................................................30

SelectAdvantage Cost-Sharing Table ........................................................................................................40

Definitions .................................................................................................................................................50

Precertification...........................................................................................................................................62

EMERGENCY SERVICES .........................................................................................................................62

NON-EMERGENCY SERVICES.................................................................................................................62

Covered Expenses/Services .......................................................................................................................66

Exclusions .................................................................................................................................................84

Special Programs .......................................................................................................................................96

How to File a Claim...................................................................................................................................98

INFORMATION NEEDED FOR A CLAIM ....................................................................................................98

ADDRESS FOR CLAIMS SUBMISSIONS.....................................................................................................98

SOME EXPENSES ARE NOT REIMBURSABLE ...........................................................................................98

FILING LIMITATIONS ..............................................................................................................................99

PAYEES ..................................................................................................................................................99

DELAYED PAYMENTS.............................................................................................................................99

RIGHT TO RECOVER EXCESS PAYMENTS................................................................................................99

Complaint and Appeals Procedure ............................................................................................................99

REGISTERING A COMPLAINT OR DISAGREEMENT WITH A DETERMINATION .........................................99

APPEALS OF PRECERTIFICATION DETERMINATIONS ...........................................................................101

Additional Information About the Plan ...................................................................................................104

FUNDING..............................................................................................................................................104

RIGHT TO RECEIVE AND RELEASE NEEDED INFORMATION.................................................................104

RIGHT TO DEVELOP GUIDELINES .........................................................................................................104

ACCESS TO RECORDS AND CONFIDENTIALITY .....................................................................................105

AMENDMENTS TO THIS SUPPLEMENT..................................................................................................105

CASE REVIEW ......................................................................................................................................105

EXTENSION OF BENEFITS .....................................................................................................................105

Index........................................................................................................................................................108

INTRODUCTION

Self-Insured HMO 2001 –– 1

INTRODUCTION

INTRODUCTION

2 — Self-Insured Managed-Care Option 2001

INTRODUCTION

Unisys offers this self-insured managed-care option in designated geographic locations to eligible Unisys

employees, former employees, and their dependents.

Under a fully-insured plan, Unisys pays fixed monthly premiums set by the plan. The plans bear the risk

that expenses will not exceed the premiums collected. The premiums include projected benefit payments,

state insurance taxes, administrative costs, and a profit margin. The benefits provided under the plan are

subject to mandates specific to the states in which they operate.

Under a self-insured plan, Unisys makes benefit payments as services occur, including a fee for the use of

the third-party administrator’s network and the third-party administrator’s services noted below. Costs are

variable rather than fixed because Unisys, not the plans, bears the risk of volatility of expenses. State

insurance taxes and state mandates do not apply. Instead, the plan is subject to the federal Employee

Retirement Income Security Act.

Unisys has contracted with the following third-party administrators (TPAs) for claims processing,

precertification, utilization review, member services, grievance resolution, and a provider network under

the Plan. Use the group number noted below when asking questions about benefits under the Plan.

Third-party administrators

(TPAs)

Group ID Number

active employees and their

covered dependents

Group ID number

retired or disabled former employees and

their covered dependents or survivors

Aetna U.S. Healthcare® #00176C #00176C NOT eligible for Medicare

HealthPartners

Administrators, Inc.

(owner: HealthPartners, Inc.)

#3493 #3493

Medica Self-Insured (MSI) �� #45935 non-bargaining

�� #45936 bargaining

�� #45936 bargaining to age 65

�� #45937 non-bargaining NOT eligible for

Medicare

�� #45938 non-bargaining eligible for Medicare

SelectCare Systems

Corporation through 6/30/01

(product: SelectAdvantage)

Select Advantage on and

after 7/01/01

�� PPOM networks

�� ABS third-party

administrator

�� #095625-0001

�� #095625-0002 COBRA

�� #095625-0004 NOT eligible for Medicare

�� #095625-0003 eligible for Medicare

Each third-party administrator:

�� Has a network of physicians, hospitals and health-care centers that are available as part of the Plan;

�� Follows a credentialing process before a provider is admitted to their network; and

�� Monitors the performance of their network providers.

Neither Unisys nor any of the TPAs engage in the performance or delivery of medical, hospital services, or

other types of health-care services. The TPAs have contractual agreements with their network providers to

furnish covered services within the scope of their licenses to plan members. Neither Unisys nor any of the

TPAs guarantee the professional services of the providers. The selection of a provider and the decision to

receive or decline health-care services is solely your decision and responsibility.

This Supplement to your Summary Plan Description (SPD) booklet includes: a description of how the Plan

works, a description of benefits available under the Plan; procedures for submitting requests for

reimbursement, and procedures for appealing a denied request for benefits. Refer to the appropriate SPD

INTRODUCTION

Self-Insured Managed-Care Option 2001 — 3

referenced inside the front cover under “About This Supplement” for:

�� General information on eligibility;

�� Covered dependents;

�� Coordination of benefits with other group plans;

�� When coverage begins and ends;

�� Your continuation options (if any) when coverage ends; and

�� General additional Plan information, such as your rights under the Employee Retirement Income

Security Act (ERISA) of 1974, as amended, and third-party liabilities.

Read this supplement and your SPD. Many provisions are interrelated; reading just one or two provisions

may give you a misleading impression. Some terms in this supplement have a particular meaning under the

Plan and are defined, beginning on page 49.

Unisys maintains this Plan for the exclusive benefit of covered employees, covered former employees, and

their covered dependents. Each covered person's rights under the Plan are legally enforceable.


HOW THE PLAN WORKS

HOW THE PLAN WORKS


HOW THE PLAN WORKS

To understand how the Plan works, it is important to know how to use the “Network” providers and

benefits. In order to use this Plan, you will need to know about the most important network provider of

them all — your PCP, your “primary care physician” (for HealthPartners or Medica Self-Insured, your

PCC, your “primary care clinic”).

Network Providers

Network providers are doctors, hospitals, and other health-care providers who belong to the third-party

administrator’s network of contracted providers.

A directory of Network physicians and providers who have agreed to provide covered services to Plan

members is available to you before you enroll. This directory is updated regularly. You also can access the

websites as noted below for the most up-to-date information:

Third-party administrator

(TPA) Website Feature for provider directory

Aetna U.S. Healthcare www.aetnaushc.com Click on DocFind®; then search under

�� Type of provider

�� HMO, if an active employee

�� HMO, if a retiree not eligible for

Medicare

�� Medicare Golden Plan, if a retiree

eligible for Medicare

HealthPartners www.healthpartners.com �� Click on Consumer Choice

�� Choose HealthPartners Primary Clinic

�� Choose from providers, care networks,

clinics, and hospitals

Medica Self-Insured www.allina.com Click on the Medica.com tab

�� Visitors Center

�� Provider Directory

�� Continue

�� Medica Premier

�� Continue

�� Search Options

SelectCare – for

SelectAdvantage through

6/30/01

www.selectcare.com Physicians, hospitals and other services

�� SelectCare Physician Search for non-

hospital providers

�� HMO/HMO Plus/

SelectAdvantage POS for network

hospitals

SelectAdvantage – on and

after 7/01/01

www.abs-tpa.com �� Click on Members button

�� Choose the Unisys button for providers

and other search options

HOW THE PLAN WORKS


Your Primary Care Physician (PCP)

for Aetna U.S. Healthcare

At the core of the Plan is your PCP. The Plan promotes the PCP as your personal medical-care coordinator.

When you enroll in the Plan, you choose a PCP for yourself and for each covered family member. You

choose from the licensed network physicians who practice in one of the following areas of medicine:

�� Family/General Practice: Family/general practitioners have special medical training in prevention,

diagnosis, and management of the medical needs of adults and children. Many family/general

practitioners perform minor surgery, obstetrics and gynecology services.

�� Internal Medicine: Internists have specialized training in the prevention, diagnosis, and management

of illness in adults. Many internists also have specialized areas of interest, called subspecialties, in

which they have further training. These include endocrinology, cardiology, gastro-enterology, and so

on.

�� Pediatrics: Pediatricians have specialized training in the medical management of children from birth

through late teen years. Besides treating illnesses, these physicians are interested in seeing that their

patients undergo normal growth and development.

Women age 16 or older have the option of choosing an OB/GYN in addition to their medical PCP. If you

choose to do so, you can see that OB/GYN for routine obstetrical and gynecological care without a referral

from your PCP. More complicated situations and surgeries will be coordinated by both your network

OB/GYN and your PCP.

Your Primary Care Clinic (PCC)

for HealthPartners and Medica Self-Insured

At the core of the Plan is your PCC. The Plan promotes the PCC as your personal medical care

coordinator. When you enroll in the Plan, you choose a PCC for yourself and for each covered family

member. You choose from the primary care clinics listed in the Provider Directory. Refer to page 6 to learn

how to obtain the list of primary care clinics.

The PCCs are either:

�� Owned, operated, and staffed by the third-party administrators, or

�� Contracted with the third-party administrators to provide primary care services and ambulatory medical

care.

Within the clinics are licensed network physicians who practice in one of the primary care areas of

medicine defined above as Family/General Practice, Internal Medicine, or Pediatrics.

Your Primary Care Physician (PCP)

for SelectAdvantage

For services on or before June 30, 2001, SelectAdvantage requirements for PCP selection and referrals are

the same as those noted above for Aetna U.S. Healthcare.

On and after July1, 2001, SelectAdvantage does not require the selection of a PCP. You may seek services

from any PPOM network provider without referrals, including network specialists. Traditionally this type

of network-based plan is considered an open-access HMO.

HOW THE PLAN WORKS


Role of your PCP/PCC

You become a partner with your PCP/PCC in preventive medicine. Helping you maintain good health

through preventive care is one of the goals of the Plan. Periodic evaluations, examinations, x-rays and lab

work all contribute to keeping you in good health and are provided when your PCP/PCC so advises. These

services also help your PCP/PCC detect potential problems early, preventing complications later.

Consult your PCP/PCC whenever you have questions about your health. Your PCP/PCC is your guide

through today’s complex medical-care system.

When medically necessary, your PCP/PCC refers you to other doctors or facilities for treatment. To receive

coverage, you must have a prior written or electronic referral from your PCP/PCC for all non-emergency

services and any necessary follow-up. The referral is important because:

�� It is how your PCP arranges for you to receive the necessary, appropriate care and follow-up treatment.

�� It guarantees payment to network specialists and hospitals for referred covered services, so you will

only be responsible for applicable copayments. (Note: not all services are covered under the Plan.

When you receive a referral, check with Member Services to be sure that the services requested by the

referral are covered under the Plan.)

�� It is required for services to be considered for payment.

Even when your PCP/PCC refers you to a specialist or hospital, it is important that your PCP/PCC

continues to monitor your progress.

Note for Medica Self-Insured

Medica Self-Insured allows you to refer yourself to network providers without referral from your PCC.

This is called “self-referral.” Tier II benefits apply for all covered services directly from the self-referral

provider, as well as all covered services ordered or coordinated by the self-referral provider. Copayments

and coinsurance are higher under Tier II than when you obtain a referral from your PCC (Tier I).

Note for SelectAdvantage on and after July 1, 2001

SelectAdvantage allows you to refer yourself to network providers without referral for services on and after

July 1, 2001. This is called “self-referral.”

Selecting your PCP/PCC

When you enroll for coverage, you must select a network PCP/PCC to manage the care of each family

member. You may select a different PCP/PCC for yourself and for each of your covered dependents.

For more information about a specific doctor or clinic you can access the information through the websites

noted on page 6 or call Member Services at the telephone number listed inside the front cover of this

Supplement. It also may be helpful to schedule a meeting with your prospective PCP/PCC to ask questions

and determine your personal comfort level with the provider.

After you enroll, you and each family member will receive a medical ID card.

Newborns or new adoptions: To enroll a newborn or newly adopted child for coverage, you must notify

the Unisys Benefits Service Center of the addition of the child by calling 1-800-600-4015 within 30 days

of the date of birth or adoption. Then indicate your child’s PCP/PCC by calling Member Services at the

telephone number listed inside the front cover of this supplement. An ID card for the child is then sent to

you.

Note for SelectAdvantage on and after July 1, 2001: No PCP selection is required for any covered family

member. After you enroll in the Plan, you receive a medical ID card for yourself and one to share with

other covered family members. If you need additional ID cards, call Member Services

HOW THE PLAN WORKS


Changing your PCP/PCC* **

You may change your PCP/PCC by calling Member Services at the telephone number listed inside the

front cover of this Supplement. Some third-party administrators allow you to change your PCP/PCC over

the Internet by accessing their websites (see page 6).

If you use Member Services to change your PCP/PCC, give the Member Services representative the new

PCP/PCC office ID number (this is available in the paper directory, the online directory, or by calling the

provider’s office). Ask your current PCP/PCC to transfer your medical records to your new PCP/PCC.

If you need to see the new PCP/PCC immediately, tell Member Services so verification of the new

designation can be coordinated with the PCP/PCC’s office before you make your appointment.

Referrals from your prior PCP do not carry forward. You need to obtain new referrals from your new PCP.

Network Specialists ** ***

Your PCP/PCC provides most of your care. However, if your PCP/PCC determines that you need specialty

care, your PCP/PCC will issue a written or electronic referral to one of the specialists who belong to the

Plan’s Network. As long as you remain a Plan participant, referrals are valid for:

�� The services specified on the referral

�� The provider noted on the referral

�� The time frame noted on the referral; in most cases, this will not exceed 90 days from the date the

referral is issued

When your PCP/PCC refers you to a network specialist for covered services, the Plan provides full

coverage, after applicable copayments, up to the benefit limits shown in the cost-sharing chart for the

appropriate plan. The charts begin on the following pages:

�� Aetna U.S. Healthcare, see page 15

�� HealthPartners, see page 21

�� Medica Self-Insured, see page 29

�� SelectAdvantage, see page 39

To avoid personal responsibility for the full charge for costly and unnecessary specialist bills:

1. Always consult your PCP/PCC first when you need medical care. If it is medically necessary, your

PCP/PCC will provide a written or electronic referral to provider.

2. Take a moment to review the referral with your PCP/PCC. Understand what specialist services are

being recommended and why.

3. Present the written referral to the specialist. In the case of an electronic referral, reference the referral

date and your PCP/PCC’s name. The referral is necessary to have the noted services approved for

payment. Without the referral, you are responsible for payment for these services.

4. If the referral provider suggests any treatments or tests not listed in the referral, another written or

electronic referral from your PCP/PCC is required in order for the services to be covered.

* Note for HealthPartners and Medica Self-Insured: Changes in your primary care clinic made by the 20th of the

month are effective the 1st of the following month. Changes made after the 20th are effective the 1st of the next

following month. For example, a change requested May 15th is effective June 1st. A change requested May 22nd is

effective July 1st. You cannot access your new primary care clinic for services before the effective date of the

change.

** Note for Medica Self-Insured: Medica allows you to refer yourself to network providers without referral from

your PCC. This is called “self-referral.” Tier II benefits apply for all covered services directly from the self-referral

provider, as well as all covered services ordered or coordinated by the self-referral provider. Copayments and

coinsurance are higher under Tier II than when you obtain a referral from your PCC (Tier I).

*** Note for SelectAdvantage on and after July 1, 2001: You are not required to notify anyone for care by network

providers.

HOW THE PLAN WORKS


Note: If your condition does not meet the definition of emergency (see page 52) or urgent medical need

(see page 59), and you go directly to any doctor or facility without a written or electronic referral from your

PCP/PCC* **, you must pay the entire bill yourself.

If Your Physician or Clinic Leaves the Network

Doctors or clinics sometimes leave the network. They may leave because they are relocating, or because

they no longer meet the standards and requirements for network membership, or for other reasons. If your

PCP/PCC leaves the network, you will be notified and asked to select a new network PCP/PCC.

What to Do for a Medical Emergency or an Urgent Medical Need

Medical emergency is defined on page 52. Urgent medical need is defined on page 59. All emergency care

and urgent medical care is reviewed on a case-by-case basis. To avoid unforeseen problems, it is essential

that you understand what to do in case of a medical emergency or an urgent medical need.

If you have a medical emergency or an urgent medical need while outside the network service area, follow

these steps**:

1. Call your PCP/PCC for help. Explain the symptoms that are occurring and give your PCP/PCC any

other information necessary to help determine the appropriate action.

2. If directed by your PCP/PCC, if you cannot reach your PCP/PCC or a covering physician***, or if a

delay would endanger your health:

a. In a medical emergency — seek care at the nearest emergency treatment facility and have the

emergency room contact your PCP/PCC immediately, so your PCP/PCC can contribute to the

treatment you require

b. In an urgent medical situation — seek care at the nearest emergency treatment facility,

private practice physician, walk-in clinic, or surgicenter and have the provider contact your

PCP/PCC immediately, so your PCP/PCC can contribute to the treatment you require

3. If you are admitted to an inpatient facility, you, a family member, a treating physician, or the facility

should contact your PCP/PCC AND Member Services within 24 hours.

4. If you are not admitted to an inpatient facility, you or a family member must notify your PCP/PCC

within 24 hours after treatment is received.

Participating PCP/PCCs are required to provide coverage 24 hours a day, including weekends and

holidays. Chronic or less severe problems should be handled during routine office hours, but your

physician provides around-the-clock coverage to help deal with emergencies and urgent medical needs.

Care for a medical emergency is covered, no matter where, no matter when. If you have an urgent medical

need while inside the network service area, your PCP/PCC* ** must coordinate your care in order for

benefits to be payable. Urgently needed care may also be covered while out of the network service area, if

you follow the steps indicated above and your PCP/PCC refers you for immediate care.

The appropriate third-party administrator makes the initial coverage determination. If the third-party

administrator determines that the situation meets the Plan requirements for emergency care or urgent

* Note for Medica Self-Insured: Medica allows you to refer yourself to network providers without referral from




** Note for SelectAdvantage on and after July 1, 2001: You are not required to notify anyone for care by network

providers. If you obtain care from a non-network provider due to a medical emergency or urgent medical need

occurring outside the network service area, you must contact Member Services within one business day after services

are received.

*** Note for HealthPartners: After regular PCC hours, call the HealthPartners After Hours CareLine at the number

on your ID card. Or you may visit any of the plan-wide network urgent care clinics.

HOW THE PLAN WORKS


medical care, benefits are payable whether or not network providers are used. However, the Plan may limit

reimbursement to expenses incurred up to the time you are determined to be medically able to travel or to

be transported to a network provider.

Treatment in hospital emergency rooms is not covered for conditions that are determined not to be an

emergency or urgent medical need. If it is determined that your condition does not meet the requirements

to be classified as an emergency or urgent medical need by the Plan, you are not entitled to reimbursement.

Note: A number of situations in which emergency rooms have traditionally been used are not generally

considered a medical emergency or urgent medical need. If you are in doubt about whether your situation

constitutes a medical emergency or urgent medical need, call your PCP/PCC or call Member Services

at the telephone number listed inside the front cover of this supplement.

Follow-up care after emergency or urgently needed treatment (for example, suture removal, cast removal,

x-rays, clinic/office revisits, or emergency room revisits) is covered only when provided by your PCP/PCC

or when authorized by a written or electronic referral by your PCP/PCC*.

What to Do if You or Your Dependent Is Outside the Service Area

when Medical Care Is Obtained

Benefit payments for services you receive depend on a number of factors if:

��You are traveling outside the service area for some purpose other than:

�� The receipt of medical care,

OR

��Your primary residence is outside the service area;

��You or a covered dependent is a student residing outside the service area while away at school.

Benefits are available only in the following situations:

�� If the treatment is for a medical emergency (as defined on page 52) and the steps noted beginning on

page 10 have been followed — in other words, benefits are payable for treatment in a medical

emergency no matter where you are or whether treatment is from network or non-network providers.

�� If the treatment is for an urgent medical need (as defined on page 59), the steps noted beginning on

page 10 have been followed and your PCP/PCC has referred you for immediate care.

�� For routine and preventive services, benefits apply only if your designated network PCP/PCC*

provides these services — all routine and preventive care must be provided by your designated

network PCP/PCC in order to have any coverage at all.

�� For treatment of mental/nervous conditions** ***, including substance abuse, benefits apply only if

they are arranged in accordance with the provisions of the Plan and are received from a designated

network provider.





** Note for Medica Self-Insured: All mental-health and/or substance abuse treatments must be coordinated by

United Behavioral Health (UBH), a separate specialized organization, in order to be covered. The telephone number

is on the inside front cover of this booklet.

*** Note for SelectAdvantage: All mental-health and/or substance abuse treatments on or before June 30, 2001, ust

be coordinated by Value Options, a separate specialized organization, in order to be covered. The telephone number

is on the inside front cover of this booklet.

HOW THE PLAN WORKS


For HealthPartners, call 1-800-530-4966. This will connect you with PHCS, an affiliated group that can

provide you with the names and telephone numbers for participating PHCS providers or, in the U.S. and

Canada, call After Hours CareLine at the telephone number listed on your ID card for assistance in

directing your care. Outside the U.S. and Canada, contact MCI and ask to be connected on a collect-call

basis to After Hours CareLine at 952-883-7789. Services received from PHCS providers are allowed on a

discounted fee-for-service basis and you are responsible for payment.

For Aetna U.S. Healthcare, there is added flexibility for employees residing in one Aetna U.S. Healthcare

HMO service area offered through Unisys while dependents reside in a different Aetna U.S. Healthcare

HMO network area offered through Unisys (for example, children residing with a former spouse or

children while away at school). In this case, a PCP for the dependent can be selected in the network area

where the dependent resides and the full range of covered services is available to the dependent within that

network.

To determine if a dependent resides in an HMO service area:

�� Call Member Services at the toll-free number listed inside the front cover of this booklet, or

�� Visit the Aetna U.S. Healthcare website at www.aetnaushc.com.

�� Select the HMO product

�� Enter the ZIP code for the dependent

�� If providers are listed, then the ZIP code is in an Aetna U.S. Healthcare HMO service area

COST SHARING TABLES


COST-SHARING TABLES

AETNA U.S. HEALTHCARE COST-SHARING TABLE


AETNA U.S. HEALTHCARE

COST-SHARING TABLE

��ACTIVE EMPLOYEES AND THEIR COVERED DEPENDENTS

��RETIREES, DISABLED FORMER EMPLOYEES AND THEIR COVERED DEPENDENTS

NOT ELIGIBLE FOR MEDICARE




The following chart outlines benefits for those enrolled in the Aetna U.S. Healthcare self-insured option as

an active employee, including enrolled eligible dependents. It also applies to those not eligible for

Medicare who enroll as an eligible retiree or disabled former employee, including their enrolled

dependents not eligible for Medicare. All care must be provided by or coordinated by your PCP for you to

receive benefits. This chart is just a summary of the benefits. Some services may have limits. Specific

conditions, limits and exclusions are detailed in the pages that follow the cost-sharing charts.


Feature Cost-Sharing

Annual Deductible None

Annual Out-of-Pocket Limit None

Lifetime Maximum Benefit None

Precertification

PCP handles for you, except treatment for medical

emergency or urgent medical need

not provided or directed by PCP

Network Physician Visits for Preventive Services

��Well-child care; frequency/type based

on Aetna U.S. Healthcare guidelines

You pay $10/visit to PCP,

then Plan pays 100%

��Routine visits, age 18 and older (annual) You pay $10/visit to PCP,

then Plan pays 100%

��Well-woman exam (annual); no referral

required

You pay $10/visit to network OB/GYN,

then Plan pays 100%

�� Prenatal care You pay $15 for first office visit to network OB/GYN,

then Plan pays 100% for all prenatal care thereafter

�� Cancer screenings (physician services

only); frequency/type based on Aetna

U.S. Healthcare guidelines

You pay $10/visit to PCP or $15/visit to referral specialist,

then Plan pays 100%

��Vision

�� Examination by network optometrist

or ophthalmologist; no referral

required; frequency based on Aetna

U.S. Healthcare guidelines

You pay $15/visit,

then Plan pays 100%

�� Eyewear Not covered;

Discount arrangements are available through the Plan





Network Physician Visits Other Than Preventive Services

�� Treatment of illness or injury You pay $10/visit to PCP or $15/visit to referral specialist,

then Plan pays 100%

��Office surgery You pay $10/visit to PCP or $15/visit to referral specialist,

then Plan pays 100%

��Office lab and x-ray

�� Billed with office visit

�� No office visit when services

rendered

Plan pays 100%

You pay $15/test or x-ray;

then Plan pays 100%

��Allergy testing and treatment You pay $10/visit to PCP or $15/visit to referral specialist,

then Plan pays 100%

Inpatient Network Hospital Services

��Hospital semi-private room & board and

ancillary services

You pay $250/admission,

(not applicable for re-admission within 30 days for the

same condition; $750 maximum/person/year),

then Plan pays 100%

�� Lab and x-ray Plan pays 100% after the hospital copayment

�� Surgeons' charges Plan pays 100% after the hospital copayment

�� Physician hospital visits Plan pays 100% after the hospital copayment

��Anesthesia Plan pays 100% after the hospital copayment

��Delivery — normal or C-section Plan pays 100% after the hospital copayment

Network Alternatives to Inpatient Care: Precertification and referral by PCP required

��Skilled nursing facility (maximum of 90 days/lifetime)

Plan pays 100% after the hospital copayment

��Home-health care Plan pays 100%

��Home IV therapy Plan pays 100%

�� Inpatient hospice for palliative care of

terminally ill






Outpatient Services (treatment and services by network providers performed in a network

facility other than in the physician’s office or as an inpatient in a hospital)

�� Surgery, including surgeon and facility You pay $100/procedure for PCP or referral specialist,

then Plan pays 100%

�� Independent lab and x-ray facilities You pay $15/test or x-ray,

then Plan pays 100%

��Hospital emergency room (medical

emergency defined on page 52)

�� For treatment of a medical

emergency

You pay $50/visit

(waived if admitted within 24 hours for the same

condition),

then Plan pays 100%

�� For non-emergency care not

authorized in advance by PCP

Not covered

��Hospital observation room for up to 24

hours without admission

Same as outpatient hospital emergency room services

�� Follow-up care with PCP or referral

specialist�

You pay $10/visit for PCP or $15/visit for referral

specialist,

then Plan pays 100%

��Ambulance (ambulance defined on

page 50; medical emergency defined on

page 52)�

�� For a medical emergency

Plan pays 100%

�� For non-emergency transportation

approved by Aetna U.S. Healthcare

and recommended by the PCP

Play pays 100%;

otherwise, not covered





Treatment for Mental Health Conditions by Network Providers

��Inpatient hospital or specialized

treatment facility

You pay hospital copayment,

then Plan pays 100%;

up to 30 days/year, up to 90 days/lifetime;

annual and lifetime maximums include inpatient care for

detoxification and treatment of substance abuse conditions

��Physician inpatient visits Plan pays 100%,




��Office/outpatient visits You pay $15/visit for referral specialist,


up to 30 visits/year

(individual, family, group or other visits count as one visit)

Treatment for Substance Abuse Conditions by Network Providers

��Detoxification You pay hospital copayment,

then Plan pays 100%

�� Inpatient hospital or specialized

treatment facility





detoxification and treatment of mental health conditions

�� Physician inpatient visits Plan pays 100%;




��Outpatient rehabilitation You pay $15/visit for referral specialist,


up to 30 visits/year;






Other Network Services and Supplies

��Acupuncture only when provided by a physician for

anesthesia in connection with a covered surgery

Plan pays 100%

��Chiropractic services �� only for short-term treatment when there is

a reasonable expectation that a condition

will improve over a short-predictable

period of time

�� does not include maintenance or palliative

care

You pay $15/visit for referral specialist,


up to 15 visits within 60 consecutive days/incidence,

measured from start of treatment;

Aetna U.S. Healthcare Medical Director can authorize

additional therapy, provided the conditions noted to the left

continue to apply

��Dental services You pay $100/procedure for surgical removal of partial or

fully bony impacted wisdom tooth or tumors, then Plan

pays 100%; other dental procedures are not covered

��Diabetes self-management training and

education

�� Educational tools

��Blood glucose monitor

�� Program consistent with national

standards established by the

American Diabetes Association


then Plan pays 100%

��Durable medical equipment (DME) Plan pays 100% for precertified DME when obtained from

network DME vendors

�� Infertility treatments: limited to the diagnosis and treatment of

medical conditions resulting in infertility and

treatment to return the body to normal bodily

function

Covered the same as treatment for other conditions

��Nutritional supplements for the

treatment of PKU

Plan pays 100%

�� Prosthetic devises; limited to items

noted on pages 68 and 69.

Plan Pays 100% for precertified covered prosthetic devices

when obtained from network vendors;

Covered wigs limited to $350 per year

��Reconstructive and restorative surgery

that is not cosmetic in nature

Same as other surgery

��Rehabilitative services: cognitive,

physical, occupational, pulmonary, and

speech therapy �� only for short-term treatment when there is


will improve over a short, predictable

period of time

�� only to restore function lost through illness

or injury


care



up to 60 consecutive days/condition, measured from start

of treatment;

Aetna U.S. Healthcare Medical Director can authorize

additional therapy,

provided the conditions noted to the left continue to apply

HEALTHPARTNERS COST-SHARING TABLE


HEALTHPARTNERS

COST-SHARING TABLE





ELIGIBLE FOR MEDICARE




The following chart outlines benefits for those enrolled in the HealthPartners self-insured option as an

active employee, a retiree, a disabled former employee, or an enrolled dependent of an active employee,

retiree or disabled former employee. All care must be provided by or coordinated by your PCC for you to

receive benefits.

For retirees, disabled former employees and their covered dependents eligible for Medicare, plan benefits

are payable after copayments and Medicare payments are considered.

This chart is just a summary of the benefits. Some services may have limits. Specific conditions, limits and

exclusions are detailed in the pages that follow the cost-sharing charts.



Annual Deductible

None

Annual Out-of-Pocket Limit per

Individual None


Precertification

PCC handles for you,

except treatment for medical emergency or urgent medical

need

not provided or directed by PCC


�� Well-child care; frequency/type based

on HealthPartners guidelines

You pay $10/visit to PCC,

then Plan pays 100%

�� Routine visits (annual) You pay $10/visit to PCC,

then Plan pays 100%

�� Well-woman exam (annual); no referral

required

You pay $10/visit to PCC or network OB/GYN,

then Plan pays 100%

�� Prenatal care You pay $10 for first office visit to network OB/GYN,

then Plan pays 100% for all prenatal care thereafter

�� Cancer screenings (physician services

only); frequency/type based on

HealthPartners guidelines

You pay $10/visit to PCC or referral specialist, then plan

pays 100%

��Vision

�� Examination by network

optometrist or ophthalmologist; no

referral required; frequency based

on HealthPartners guidelines

You pay $10/visit,

then Plan pays 100%








�� Treatment of illness or injury You pay $10/visit to PCC or referral specialist, then Plan

pays 100%

�� Office surgery You pay $10/visit to PCC or referral specialist, then Plan

pays 100%


�� Billed with office visit


rendered

Plan pays 100%

Plan pays 100%

�� Allergy testing and treatment You pay $10/visit to PCC or referral specialist, then Plan

pays 100%

Network Convenient/Urgent Care Centers

�� Services after normal PCC hours; no

referral required

You pay $10 per visit,

then Plan pays 100%


��Hospital semi-private room & board

and ancillary services

You pay $250/admission

(not applicable for re-admission within 30 days for the same

condition; $750 maximum/person/year),

then Plan pays 100%

�� Lab and x-ray Plan pays 100% after the hospital copayment

�� Surgeons' charges Plan pays 100% after the hospital copayment

�� Physician hospital visits Plan pays 100% after the hospital copayment

��Anesthesia Plan pays 100% after the hospital copayment

��Delivery — normal or C-section Plan pays 100% after the hospital copayment

Network Alternatives to Inpatient Hospital Care

��Skilled nursing facility (maximum of 90 days/lifetime)


��Home-health care You pay $10/visit,

then Plan pays 100%

��Home IV therapy You pay $10/visit,

then Plan pays 100%


terminally ill Plan pays 100% after the hospital copayment

��Outpatient hospice Plan pays 100%







�� Surgery, including

surgeon and facility

You pay $10 for PCC or referral specialist, then Plan pays

100%

�� Independent lab and

x-ray facilities

Plan pays 100%




emergency in the service area

You pay $50/visit


condition),

then Plan pays 100%


emergency outside the service area

You pay 20%, the Plan pays 80% of the first $2,500;

then Plan pays 100%

�� For non-emergency care not

authorized in advance by PCP

Not covered




�� Follow-up care with PCC or referral

specialist�

You pay $10/visit for PCC or referral specialist, then Plan

pays 100%

��Ambulance (ambulance defined on

page 50; medical emergency defined on

page 52)�

�� For a medical emergency

You pay 20%

then Plan pays 80%

�� For non-emergency transportation

approved by HealthPartners and

recommended by the PCC

You pay 20%;

then Plan pays 80%;








treatment facility



up to 30 days/year or 90 days/lifetime;



��Physician inpatient visits Plan pays 100%,




��Office/outpatient visits You pay $10/visit,




Treatment for Substance Abuse Conditions by Network Providers

��Detoxification You pay hospital copayment






treatment facility










��Outpatient rehabilitation You pay $10/visit;









��Acupuncture (for pain relief or anesthesia only)

You pay $10/visit to referral network acupuncturist, then

Plan pays 100%

��Chiropractic services �� only for short-term treatment when there is



period of time


care

You pay $10/visit to referral network provider, then Plan

pays 100%;

up to 15 visits;

HealthPartners Medical Director can authorize additional

therapy,


��Communication or interpretation

services for a ventilator-dependent

patient during an inpatient stay

Plan pays 100%

��Dental

��Medical conditions requiring oral

surgery

You pay $10 to referral network provider,

then Plan pays 100%

�� Treatment of accidental injuries to

sound natural teeth

You pay 20% to network provider,

then Plan pays 80%

��Diabetes self management training and

education �� Medical nutrition therapy

�� Referral from PCP

�� Program consistent with national standards

established by the American Diabetes

Association

You pay $10/visit,

then Plan pays 100%

��Durable medical equipment (DME) Plan pays 100% for precertified DME when obtained from

network DME vendors



treatment to return the body to normal bodily

function


��Nutritional supplements for the

treatment of PKU

You pay 20%,

then Plan pays 80%

�� Prosthetic devices; limited to items

noted on pages 68 and 69


when obtained from network vendors; Covered wigs limited

to $350 per year














period of time

�� only to restore function lost through

illness or injury


care

You pay $10/visit to referral network specialist, then Plan

pays 100%;

up to 15 visits/therapy/condition;

HealthPartners Medical Director can authorize additional

therapy,


MEDICA COST-SHARING TABLE


MEDICA SELF-INSURED

COST-SHARING TABLE








MEDICA SELF-INSURED COST-SHARING TABLE

The following chart outlines benefits for those enrolled in Medica Self-Insured option as an active

employee, a retiree, a disabled former employee, or an enrolled dependent of an active employee, retiree or

disabled former employee. All care must be provided by or coordinated by your PCC for you to receive

Tier I benefits.

Medica Self-Insured allows you to refer yourself to network providers without referral from your PCC.

This is called “self-referral.” Tier II benefits apply for all covered services received directly from the self-

referral provider, as well as all covered services ordered or coordinated by the self-referral provider.

For retirees, disabled former employees, and their covered dependents eligible for Medicare, plan benefits





Feature

Tier I Cost-Sharing

All covered services provided by or

coordinated by your PCC

Tier II Cost-Sharing All covered services provided by or

coordinated by self-referral network

provider

Annual Deductible None None

Annual Out-of-Pocket

Limit per Individual None

$750/person;

$5,000/family;

applies only to Tier II benefits;

copayments for Tier I services and

prescription drugs are not included

Lifetime Maximum

Benefit None None

Precertification

PCC or self-referral network provider handles for you,

except treatment for medical emergency or urgent medical need

not provided or directed by PCC


�� Well-child care; frequency

and type based on Medica

guidelines

You pay $10/visit to PCC,

then Plan pays 100%

Not covered

�� Routine visits (annual) You pay $10/visit to PCC,

then Plan pays 100%

You pay $25/visit,

then Plan pays 100%

�� Well-woman exam

(annual)

You pay $10/visit to a network OB/GYN,

then Plan pays 100%

�� Prenatal care You pay $10/visit,

then Plan pays 100%

You pay $25/visit,

then Plan pays 100%

�� Cancer screenings (physician services only);

frequency and type based on

Medica guidelines

You pay $10/visit to PCC or referral

specialist,

then Plan pays 100%

You pay $25/visit,

then Plan pays 100%




Feature

Tier I Cost-Sharing





provider

Network Physician Visits for Preventive Services (continued)

��Vision

��Examination by

network optometrist or

ophthalmologist; no

referral required;

frequency based on

Medica schedule

You pay $15/visit,

then Plan pays 100%

��Eyewear Not covered; discount arrangements are available through the Plan


�� Treatment of illness or

injury


specialist, then Plan pays 100%

You pay $25/visit,

then Plan pays 100%

�� Office surgery You pay $10/visit to PCC or referral


You pay $25/visit

then Plan pays 100%


�� Billed with office

visit (you already

paid office visit

copayment)

�� No office visit billed

when services

rendered

Plan pays 100%

You pay $10,

then Plan pays 100%

Plan pays 100%

You pay $25,

then Plan pays 100%

�� Allergy testing and

treatment



You pay $25/visit,

then Plan pays 100%

Network Convenient/Urgent Care Centers

�� Services after normal

PCC hours; no referral

required

You pay $10 per visit,

then Plan pays 100%

Not covered


��Hospital semi-private

room & board and

ancillary services


(copayment waived for re-admission

within 30 days for the same condition;

$750 maximum/person/year),

then Plan pays 100%


and 30% (up to $450),

then Plan pays balance of network

facility charges

�� Lab and x-ray Plan pays 100% after the hospital

copayment All included in the above hospital

copayment and coinsurance

�� Surgeons' charges Plan pays 100% after the hospital

copayment

You pay 30%, then Plan pays 70%

(not subject to the $450 maximum if

billed separately from facility charge)




Feature

Tier I Cost-Sharing





provider

Inpatient Network Hospital Services (continued)

�� Physician hospital visits Plan pays 100% after the hospital

copayment


(not subject to the $450 maximum if

billed separately from facility charge)

�� Anesthesia Plan pays 100% after the hospital

copayment

All included in the above hospital

copayment and coinsurance, provided

billed with the facility charge;

otherwise, you pay 30%, then Plan

pays 70%

(not subject to the $450 maximum)

�� Delivery — normal or

C-section physician

charges

Plan pays 100% after the hospital

copayment


(not subject to the $450 maximum)

Network Alternatives to Inpatient Hospital Care: must be precertified. Call 1-800-962-9497

�� Skilled nursing facility (maximum of 90 days/lifetime

of Tier I and Tier II benefits

combined)

You pay 20%,

then Plan pays 80%

You pay 30% (no maximum),

then Plan pays 70%

�� Home-health care You pay 20%,

then Plan pays 80%;

For high-risk prenatal care, Plan pays

100%


then Plan pays 70%

�� Home IV therapy You pay 20%,

then Plan pays 80%


then Plan pays 70%

�� Inpatient hospice for

palliative care of

terminally ill

Plan pays 100% Not covered




Feature

Tier I Cost-Sharing





provider



�� Surgery

�� Facility

You pay $100,

then Plan pays 100%

You pay 30% (up to $450),

then Plan pays 100%

�� Surgeon� Plan pays 100% You pay 30% (no maximum),

then Plan pays 70%

�� Independent lab and x-ray

facilities billed outside the

PCC system

You pay $15/test or x-ray,

then Plan pays 100%


then Plan pays 100%

��Hospital emergency room

facility charge (medical

emergency defined on

page 52)

�� For treatment of a

medical emergency

You pay $50/visit

(waived if admitted within 24 hours for the same condition),

then Plan pays 100%

�� For non-emergency

care not authorized in

advance by PCC

Not covered

��Hospital observation

room for up to 24 hours

without admission

You pay $100,

then Plan pays 100%

You pay 30% (up to $450),

then Plan pays 100%

�� Follow-up care� You pay $10/visit for PCC or referral

specialist,

then Plan pays 100%

You pay $25/visit,

then Plan pays 100%

��Ambulance (see

definitions of ambulance,

page 50, and medical

emergency, page 52)�

�� For a medical

emergency

You pay 20%,

then Plan pays 80%

�� For non-emergency

transportation

approved by Medica

and recommended by

the PCC/self-referral

network provider

You pay 20%,

then Plan pays 80%;



then Plan pays 70%;





Feature

Tier I Cost-Sharing





provider

Network Treatment for Mental Health Conditions by Network Providers:

must be precertified by UBH @ 1-800-848-8327

�� Inpatient hospital,

inpatient specialized

treatment facility or

partial program

You pay standard inpatient hospital

copayment, then Plan pays 100%;

up to 30 days/year, up to 90

days/lifetime; annual and lifetime

maximums include inpatient care for

detoxification and treatment of

substance abuse conditions

Not covered

��Physician inpatient visits Plan pays 100%;




detoxification and treatment of

substance abuse conditions

Not covered

��Office/outpatient visits You pay $15/visit,



(individual, family, group or other

visits count as one visit)

Not covered




Feature

Tier I Cost-Sharing





provider

Treatment for Substance Abuse Conditions by Network Providers:

must be precertified byUBH @ 1-800-848-8327

��Detoxification You pay standard inpatient hospital





detoxification and treatment of mental

health conditions

Not covered

�� Inpatient hospital,

inpatient specialized

treatment facility, or

partial program

You pay standard inpatient hospital






health conditions

Not covered






health conditions

Not covered

�� Outpatient rehabilitation You pay $15/visit,


up to 30 visits/year (individual,

family, group or other visits count as

one visit)

Not covered




Feature

Tier I Cost-Sharing





provider

Other Network Services and Supplies: call 1-800-962-9497

��Acupuncture (only for medically necessary

services)

You pay $15/visit

then Plan pays 100%

You pay $25/visit,

then Plan pays 100%

��Chiropractic services �� only for short-term

treatment when there is a

reasonable expectation

that a condition will

improve over a short,

predictable period of time

�� does not include

maintenance or palliative

care

You pay $15/visit,


up to 15 visits

(maximum includes Tier II benefits);

Medica Medical Director or designee

can authorize additional therapy,

provided the conditions noted to the

left continue to apply

You pay $25/visit


up to 15 visits

(maximum includes Tier I benefits);





�� Communication or

interpretation services for

a ventilator-dependent

patient during an

inpatient stay

Plan pays 100%,

up to 120 hours/lifetime

(maximum includes Tier II benefits)


then Plan pays 70%,

up to 120 hours/lifetime

(maximum includes Tier I benefits)

�� Dental Limited to the surgical procedures

commonly viewed as medical rather

than dental in nature (same benefits as

other outpatient surgery) and certain

services or supplies for an accidental

injury to sound natural teeth if the

service is done or supply provided as

part of the initial emergency treatment

(same benefits as other emergency

treatment)

Limited to the surgical procedures

commonly viewed as medical rather

than dental in nature (same benefits as

other outpatient surgery) and certain

services or supplies for an accidental

injury to sound natural teeth if the

service is done or supply provided as

part of the initial emergency treatment

(same benefits as other emergency

treatment)

��Diabetes self management

training and education �� Medical nutrition therapy

�� Referral from PCP

�� Program consistent with

national standards

established by the

American Diabetes

Association

You pay $15/visit,

then Plan pays 100%

You pay $25/visit,

then Plan pays 100%




Feature

Tier I Cost-Sharing





provider

Other Network Services and Supplies (continued): must be precertified. Call 1-800-962-9497

�� Durable medical

equipment (DME)

Plan pays 100% for initial DME;

precertification required if cost is

$1,500 or greater

For replacement, repair, or revision of

artificial eyes, limbs, and breast

prosthesis made necessary by normal

wear and usage, you pay 20%,

then Plan pays 80%

You pay 30% (no maximum) for initial

DME, then Plan pays 70%;

precertification required if cost is

$1,500 or greater

�� Infertility treatments: limited to the diagnosis and

treatment of medical

conditions resulting in

infertility and treatment to

return the body to normal

bodily function

Covered the same as treatment for

other conditions

Covered the same as treatment for

other conditions

��Nutritional supplements

for the treatment of PKU

You pay 20%,

then Plan pays 80%


then Plan pays 70%

�� Prosthetic devices;

limited to items noted on

pages 68 and 69

Plan Pays 100% for precertified

covered prosthetic devices when

obtained from network vendors;

Covered wigs limited to $350 per year

You pay 30%,

then plan pays 70%;

Covered wigs limited to $350 per

year

��Reconstructive and

restorative surgery that is

not cosmetic in nature

Plan pays 100% You pay 30% (no maximum) for

precertified surgery,

then plan pays 70%

��Rehabilitative services:

cognitive, physical,

occupational, pulmonary,

and speech therapy �� only for short-term

treatment when there is a

reasonable expectation

that a condition will

improve over a short,

predictable period of time

�� only to restore function

lost through illness or

injury

�� does not include

maintenance or palliative

care

You pay $15/visit,


up to 15 visits/therapy/condition

(maximum includes Tier II benefits);





You pay $25/visit,

then Plan pays 100%

up to 15 visits/therapy/condition

(maximum includes Tier I benefits);





�� Treatment to lighten or

remove the coloration of a

port wine stain

You pay $10/visit,

then Plan pays 100%

You pay $25/visit,

then Plan pays 100%

SELECTADVANTAGE COST-SHARING TABLE


SELECTADVANTAGE

COST-SHARING TABLE









The following chart outlines benefits for those enrolled in the SelectAdvantage self-insured option as an

active employee, a retiree, a disabled former employee, or an enrolled dependent of an active employee,

retiree or disabled former employee. For services on or before June 30, 2001, all care must be provided by

or coordinated by your PCP for you to receive benefits. For services on or after July 1, 2001, all care must

be provided by a network provider, but need not be directed by a PCP.

For retirees, disabled former employees, and their covered dependents eligible for Medicare, plan benefits






Annual Deductible None

Annual Out-of-Pocket Limit per

Individual None


Precertification

PCP handles for you,

except treatment for medical emergency or urgent medical

need

not provided or directed by PCP


�� Well-child care

frequency/type based on

SelectAdvantage guidelines

�� For services on and before 6/30/01

�� For services on and after 7/01/01


then Plan pays 100%

You pay $10/visit,

then Plan pays 100%

�� Routine visits (annual)

�� For services on or before 6/30/01



then Plan pays 100%

You pay $10/visit,

then Plan pays 100%

�� Well-woman exam (annual)



You pay $10/visit to PCP or network OB/GYN,

then Plan pays 100%; no referral required

You pay $10/visit.

then Plan pays 100%

�� Prenatal care You pay $10 for first office visit

to network OB/GYN,

then Plan pays 100% for all

prenatal care thereafter





Network Physician Visits for Preventive Services (continued)

��Cancer screenings

(physician services only)

frequency and type based

on SelectAdvantage guidelines


�� For services on or after 7/01/01


then plan pays 100%

You pay $10/visit,

then Plan pays 100%

��Vision

�� Examination by network

optometrist or ophthalmologist no

referral required; frequency based

on SelectAdvantage guidelines

�� For services on or before

6/30/01


You pay $15/visit,

then Plan pays 100%

You pay $10/visit,

then Plan pays 100%




�� Treatment of illness or injury




then Plan pays 100%

You pay $10/visit,

then Plan pays 100%

��Office surgery




then Plan pays 100%

You pay $10/visit,

then Plan pays 100%


�� Billed w. office visit


rendered

Plan pays 100%

You pay $10,

then Plan pays 100%

Note: retirees, disabled former employees, and their

covered dependents eligible for Medicare have no

copayment for office lab and x-ray services

��Allergy testing and treatment




then Plan pays 100%

You pay $10/visit,

then Plan pays 100%






�� Hospital semi-private room & board

and ancillary services

You pay $250/admission,

(not applicable for re-admission within 30 days for the

same condition; maximum $750/person/year),


�� Lab and x-ray Plan pays 100% after hospital copayment

�� Surgeons' charges Plan pays 100% after hospital copayment

�� Physician hospital visits Plan pays 100% after hospital copayment

�� Anesthesia Plan pays 100% after hospital copayment

�� Delivery — normal or C-section Plan pays 100% after hospital copayment

Network Alternatives to Inpatient Hospital Care

�� Skilled nursing facility (maximum of 90 days/lifetime)

Plan pays 100% after hospital copayment


covered dependents eligible for Medicare have no hospital

copayment for approved skilled nursing care facilities

��Home-health care Plan pays 100%

�� Home IV therapy Plan pays 100%


terminally ill Plan pays 100% after hospital copayment







�� Surgery, including

surgeon and facility

You pay $100/procedure,

then Plan pays 100%

Plan pays 100%

�� Independent lab and x-ray

facilities




then Plan pays 100%


then Plan pays 100%


covered dependents eligible for Medicare have no

copayment for independent lab and x-rays; the Plan pays

100%




emergency

You pay $50/visit


condition),

then Plan pays 100%


covered dependents eligible for Medicare have a $35/visit

copayment

�� For non-emergency care Not covered




�� Follow-up care�



You pay $10/visit for PCP or $15/visit for referral


You pay $10/visit,

then Plan pays 100%

��Ambulance (see definitions of

ambulance, page 50, and medical

emergency, page 52)�

�� For non-emergency approved by

SelectAdvantage

Plan pays 100%;

otherwise, you pay 100%







treatment facility

You pay hospital copayment





��Physician inpatient visits Plan pays 100%;




��Office/outpatient visits

up to 30 visits/year (individual, family

group or other visits count as one visit,

except retirees, disabled former

employees, and their covered dependents

eligible for Medicare have up to 20

visits/year



You pay $15/visit,

then Plan pays 100%



copayment

You pay $10/visit

then Plan pays 100%





Treatment for Substance Abuse Conditions from Network Providers

��Detoxification You pay hospital copayment,

then Plan pays 100%


treatment facility






�� Physician inpatient visits Plan pays 100%,




��Outpatient rehabilitation

up to 30 visits/year (individual, family

group or other visits count as one visit),

except retirees, disabled former

employees, and their covered dependents

eligible for Medicare have up to 20

visits/year



You pay $15/visit,

then Plan pays 100%



copayment

You pay $10/visit

then Plan pays 100%






��Acupuncture (for treatment of pain or anesthesia only) �� For services on or before 6/30/01


You pay $15/visit to referral specialist,

then Plan pays 100%

You pay $10/visit,

then Plan pays 100%

Note: acupuncture is not covered for retirees, disabled

former employees, and their covered dependents eligible

for Medicare

��Chiropractic services �� Only for short-term treatment when there is



period of time;


care �� For services on or before 6/30/01


up to 15 visits within 60 consecutive days/incidence,

measured from start of treatment; SelectAdvantage Medical

Director can authorize additional services, provided the

conditions noted to the left continue to apply

You pay $15/visit to referral specialist,

then Plan pays 100%

You pay $10/visit,

then Plan pays 100%

Note: chiropractic services are not covered for retirees,

disabled former employees, and their covered dependents

eligible for Medicare

��Communication or interpretation

services for a ventilator-dependent

patient during an inpatient stay

Plan pays 100%

��Dental Not covered

��Diabetes self management training and

education

��Medical nutrition therapy

��Referral from PCP

�� Program consistent with national

standards established by the

American Diabetes Association

Plan pays 100% when services are obtained at a network

hospital.

��Durable medical equipment (DME),

prosthetics, etc.

Plan pays 100% for precertified

DME when obtained from network DME vendor



treatment to return body to normal bodily

function






Other Services and Supplies (continued)

��Nutritional supplements for treatment of

PKU

Plan pays 100%

�� Prosthetic devices;

Limited to items noted on pages 68

and 69


when obtained from network vendors; Covered wigs

limited to $350 per year









period of time

�� only to restore function lost through illness

or injury


care



up to 60 consecutive days/condition, measured from start

of treatment; SelectAdvantage Medical Director can

authorize additional therapy, provided the conditions noted

to the left continue to apply



You pay $10/visit,

then Plan pays 100%

Note: rehabilitative services for retirees, disabled former

employees, and their covered dependents eligible for

Medicare are limited to 20 visits/year and the copayment

is $10/visit

DEFINITIONS


DEFINITIONS

DEFINITIONS


DEFINITIONS

A number of the terms used in this supplement have the specific meanings noted here.

Alternative care means care and services instead of continued inpatient care in an acute care hospital. The

alternative care must be recommended to you by your physician, tailored to your specific health needs, and

approved by the appropriate third-party administrator. Such care is designed to provide special assistance if

you have a catastrophic or chronic illness. Nurses work with you and your family members, your physician,

appropriate hospital staff and other providers to develop a plan of care specific to your health needs.

Alternative care might include a home-care program or transfer from an inpatient hospital setting to a

rehabilitation facility or extended care facility. Alternative benefits may be provided on a case-by-case

basis, subject to determinations made by the appropriate third-party administrator.

Ambulance means the following requirements are met:

�� Provided by an authorized agency in a vehicle staffed by trained personnel, equipped to handle

medical emergencies, and

�� Transport you from the place where you are injured or stricken by illness/disease to the nearest hospital

where treatment can be provided, or

�� Transport you from a hospital unable to treat your physical condition to the nearest hospital that can

treat your physical condition or hospital affiliated with your care network, or

�� Transport you from a hospital to the nearest convalescent or rehabilitation facility or hospice with

available space to which you are moved upon discharge, or

�� Transport you from a hospital, a convalescent, or rehabilitation facility to your home, or a hospice, or

�� Transport you from a non-network hospital to a network hospital if approved in advance by the third-

party administrator.

Ambulatory surgical facility or surgery center means a licensed facility equipped and operated

primarily for the purpose of performing surgical procedures. The facility must have:

�� Continuous physician services and registered professional nursing services whenever a patient is in the

facility;

�� A certified anesthesiologist attending whenever general or spinal anesthesia is performed;

�� Full-time skilled nursing services in the operating and recovery rooms, and personnel and equipment to

handle medical emergencies; and

�� A written agreement with a nearby hospital for the immediate transfer of patients in case of an

emergency.

The facility must not provide services or accommodations for overnight stays.

Birthing center means a facility operated under the direction of at least one doctor specializing in

obstetrics and gynecology, with a doctor or legally qualified midwife present at all births and during the

immediate postpartum period. Full-time skilled nurses must be present in the delivery and recovery rooms.

In addition, the birthing center must have:

��At least two beds or birthing rooms;

�� The equipment and trained personnel needed to handle medical emergencies related to complications

of labor and newborn abnormalities; and

��A written agreement with a nearby hospital for the immediate transfer of patients in case of emergency.

Benefits for services at a network birthing center are the same as those for outpatient hospital care.

DEFINITIONS


Convenient/Urgent Care Center means a health-care facility whose primary purpose is to offer and

provide immediate, short-term medical care for minor, immediate medical conditions. For HealthPartners

and Medica Self-Insured participants, access to these centers is considered the same as a PCC office visit

when the care is required on an urgent basis after normal PCC clinic hours.

Copayment means a fixed dollar amount that you must pay each time you receive a particular covered

service. If the Unisys plan is the secondary plan, copayments required by the primary plan are not

reimbursed through this Plan when this Plan is secondary payer.

The copayments that apply to specific services under your plan are noted in the Cost-Sharing Table for

your Plan. Refer to the information beginning on:

�� Page 15 for Aetna U.S. Healthcare

�� Page 21 for HealthPartners

�� Page 29 for Medica Self-Insured

�� Page 39 for SelectAdvantage

Cosmetic services and procedures improve physical appearance but do not correct or improve a

physiological function and are not medically necessary. These services are not covered under the Plan.

Course of treatment means a planned program of services or supplies furnished by a health-care provider

or team of providers. The program must be:

�� Developed in connection with the diagnosis or treatment of an illness or injury,

�� Of a definite duration, and

�� Approved by your PCP/PCC* **.

Custodial supportive care means services and supplies that are primarily for meeting personal needs in

conducting the activities of daily living. Some examples of custodial supportive care are:

�� Services and supplies furnished mainly to train or assist in personal hygiene and other activities of

daily living rather than to provide therapeutic treatment (activities of daily living include, but are not

limited to: bathing, feeding, taking oral medications, walking, getting in and out of bed, and dressing).

�� Preparation of special diets and supervision of medications that are ordinarily self-administered.

�� Services and supplies that can safely and adequately be provided by persons without the technical

skills or professional training of a covered health-care provider.

Custodial supportive care is not covered under the Plan.

Designated transplant facility means a hospital that has entered into a separate contract with the

appropriate third-party administrator to provide certain transplant-related health services to members

receiving transplants. Once you have been evaluated and listed as a potential recipient at a designated

transplant facility, you are required to remain with that designated transplant facility, unless it is medically

necessary for the transplant to be rendered at another facility. If you choose independently to be listed at

additional transplant facilities, any charges incurred for services provided by the additional facility(ies) are

not covered under the Plan.





** Note for SelectAdvantage for services on or after July 1, 2001: SelectAdvantage allows you top refer yourself to

any network provider. This is called “self-referral.”

DEFINITIONS


Diabetic supply means insulin and disposable supplies used for the treatment and control of diabetes.

Covered disposable supplies include glucose and ketone test strips, lancettes, syringes, and supplies for

insulin pumps, such as tubing. They do not include alcohol swabs that have a use other than the treatment

of diabetes or a medical condition.

Diabetic supplies are covered under the separate Prescription Drug Program offered through Unisys.

Glucometers and insulin pumps are considered durable medical equipment and are covered under the

medical portion of the Plan described in this booklet.

Drugs or medicines dispensed by a pharmacy are payable under the separate Prescription Drug Program

offered through Unisys.

Take-home drugs billed by the hospital as part of your confinement or outpatient services, and drugs

dispensed by your doctor’s office for which there is a charge are considered under the appropriate benefit

(that is, inpatient care, outpatient hospital care, or office visit) and are subject to the appropriate copayment

rates noted in the cost-sharing charts beginning on the following pages:





Elective admission means an admission that is scheduled in advance.

Elective surgery means a surgical procedure that is scheduled in advance.

Emergency means a condition for which symptoms are severe and occur suddenly, resulting in the need

for immediate medical attention, that is found to be necessary, generally provided within four (4) hours of

onset of the condition, to:

�� Preserve life, or

�� Prevent serious impairment to bodily function, organs, or parts, or

�� Prevent placing your physical or mental health in serious jeopardy.

Examples of medical emergencies include, but are not limited to:

�� Difficulty swallowing

�� Fractures

�� Heart attach or suspected

heart attack

�� High fever in infants

�� Loss of consciousness

�� Poisoning

�� Severe burns

�� Severe shortness of breath

�� Suspected overdose of

medication

�� Uncontrolled bleeding

Medically necessary treatment in these cases is considered emergent care and is covered, regardless of

where you are or what covered provider renders the care. Treatment may include the use of a hospital's

emergency room and emergency transportation by an ambulance. Follow-up care, however, must be

provided by or coordinated by your PCP/PCC* ** in order for benefits to be payable.

When reviewing services for coverage as emergency services, the appropriate third-party administrator

imposes the standard that a reasonable layperson would believe that the circumstances required immediate

medical care that could not wait until the next working day or next available office hours.





** Note for SelectAdvantage for services on or after July 1, 2001: SelectAdvantage allows you top refer yourself to


DEFINITIONS


The steps you should take in a medical emergency are provided beginning on page 10.

If you are in doubt about whether your situation constitutes a medical emergency, call your PCP/PCC

or call Member Services at the telephone number listed inside the front cover of this supplement.

Health-care providers means providers who are: not members of your household or family members; and

are practicing within the scope of their applicable licenses or, in the absence of licensing requirements, are

certified by the appropriate professional association. For benefits to be payable, the services provided must

be covered services under the Plan. Covered health-care providers include, but are not limited to:

�� Certified Nurse Anesthetist — CNA.

�� Doctor or physician — Doctor of Medicine

(MD), Doctor of Osteopathy (DO), Doctor of

Podiatry (DPM), Doctor of Chiropractic

(DC), Doctor of Optometry (OD), or

Christian Science Practitioner

�� Mental disorder providers — licensed

masters social worker (MSW), licensed

masters psychiatric nurse (MSN), doctoral

psychologist (PhD, PsyD, or EdD), and

Doctor of Medicine (MD)

�� Midwife — legally qualified midwife

�� Nurse — licensed practical nurse (LPN),

licensed vocational nurse (LVN), or

registered nurse (RN)

�� Physical therapist

�� Physician’s Assistant (PA), if legally

qualified

�� Physiologist

�� Physiotherapist

�� Registered Physical Therapist (RPT)

�� Speech pathologist

Homebound means that leaving the home would directly and negatively impact the patient’s physical

health. The home could mean the patient’s own dwelling, a relative’s home, an apartment complex that

provides assisted living services, or some other type of institution. However, an institution is not

considered to be the home if it is a hospital or skilled nursing facility.

Home-health agency means a licensed agency or organization specializing in providing medical care and

treatment in the home. To be covered, the agency and the services must be precertified by the appropriate

third-party administrator and:

�� Be primarily engaged in providing skilled nursing services and other therapeutic services;

�� Have policies established by a professional group associated with the agency; this professional group

must include at least one physician and at least one registered graduate nurse to govern the services

provided;

�� Have a full-time administrator and provide full-time supervision of services by a physician or

registered graduate nurse;

�� Maintain a complete medical record on each individual; and

�� Be licensed to operate in the state in which the facility is located.

Hospice care means a defined inpatient or outpatient program of care for individuals with a terminal

condition whose life expectancy is six months or less. To be covered, the program must be precertified by

the appropriate third-party administrator. Although palliative care and respite care normally are excluded

from any benefits coverages, they may be considered when approved by the appropriate third-party

administrator through a precertified hospice program.

Hospice services are comprehensive palliative medical care and supportive social, emotional, and spiritual

services that are provided to the terminally ill and their families, primarily in the patient’s home.

A hospice interdisciplinary team, composed of professionals and volunteers, coordinates an individualized

plan of care for each patient and family. The goal of hospice care is to make patients as comfortable as

possible to enable them to live their final days to the fullest in the comfort of their own homes and with

loved ones.

Respite care is a form of hospice services that gives the patient’s uncompensated primary caregivers (that

DEFINITIONS


is, family members or friends) rest and/or relief when necessary to maintain a terminally ill covered patient

at home.

Hospital means an institution that is engaged primarily in providing medical care and treatment of sick and

injured persons on an inpatient basis at the patient’s expenses and fully meets these criteria:

�� Is accredited as a hospital by the Joint Commission on accreditation of Healthcare Organizations;

�� Is approved by Medicare as a hospital;

�� Maintains inpatient diagnostic and treatment services for surgical and medical patients;

�� Provides treatment and care of injured and sick persons by or under the supervision of physicians; and

�� Provides 24-hour nursing service by or under the supervision of registered nurses..

The following are not considered to be hospitals; care at these facilities is not payable as hospital care:

�� Convalescent homes or similar institutions; or

�� Institutions primarily for custodial care, rest or as domiciles; or

�� Health resorts, spas, sanitariums, or tuberculosis hospitals; or

�� Other facilities and institutions which are not classified in general usage as short-term acute care

general hospitals.

Inpatient means an uninterrupted stay of 24 hours or more in a hospital, skilled nursing facility, or

licensed acute care facility.

Investigative refers to procedures, tests, medical treatments, drugs, devices, or other services that are not

supported by reliable medical evidence permitting conclusions concerning its safety, effectiveness, or

effect on health outcomes.

The Medical Director for the appropriate third-party administrator determines if one of the above is

investigational. In making this determination, the Medical Director considers the following reliable

evidence, none of which is determinative in and of itself:

�� Whether there is final approval from the appropriate U.S. government regulatory agency, if required.

This includes whether a drug or device can be lawfully marketed for its proposed use by the U.S. Food

and Drug Administration (FDA); if the drug or device or medical treatment or procedure is the subject

of ongoing Phase I, II, or III clinical trials; or if the drug, device or medical treatment or procedure is

under study, or if further studies are needed to determine its maximum tolerated dose, toxicity, safety,

or efficacy as compared to standard means of treatment or diagnosis; and

�� Whether there are consensus opinions and recommendations reported in relevant scientific and medical

literature, peer-reviewed journals, or the reports of clinical trial committees, and other technology

assessment bodies; this includes consideration of whether a drug is included in the American Hospital

Formulary Service as appropriate for its proposed use; and

�� Whether there are consensus opinions of national and local health-care providers in the applicable

specialty or subspecialty that typically manages the condition as determined by a survey or poll of a

representative sampling of these providers, including whether there are protocols used by the treating

facility or another facility studying the same drug, device, medical treatment or procedure.

The Medical Director also evaluates:

�� The patient’s medical record,

�� Medical protocols for treatment,

�� Informed consent documents, and

�� Authoritative medical literature.

DEFINITIONS


The Medical Director's determination is a question of professional judgment.

With respect to medications, investigational also means medications with no approved FDA indications,

medications used for investigational indications, and/or medications used for investigational dosage

regimens or delivery routes.

Notwithstanding the above, a procedure, test, treatment, drug, device, or other service will not be

considered investigative when it is the subject of ongoing Phase III clinical trials and the third-party

administrator determines on a case-by-case basis that:

�� Reliable evidence demonstrates that it is safe and efficacious; and

�� Network providers practicing in the applicable specialty or subspecialty conclude that it is not

investigative; and

�� If applicable, the FDA has indicated that the approval of the drug or device for the proposed use, dose,

and delivery route is pending and likely to occur.

Life-threatening illness or injury means a condition resulting from an illness or traumatic accidental

injury which, if not immediately diagnosed and treated, would result in permanent physical disability or

loss of life. (Also see page 52 for the definition of medical emergency.)

Maintenance care means services and supplies furnished mainly to:

�� Maintain, rather than improve, a level of physical or mental function; or

�� Provide a protected environment free from exposure that can worsen a physical or mental condition.

No benefits are payable for services which are mainly maintenance in nature.

Medically necessary care means services which are:

�� Appropriate for the diagnosis, treatment or prevention of the illness or health problem;

�� Consistent with medical standards and accepted practice parameters of the community as determined

by health-care providers in the same or similar general specialty as typically manage the condition,

procedure, or treatment;

�� Require the skills of a covered health-care provider;

�� Help to restore, improve, or maintain the patient’s health;

�� Provided in the appropriate setting; and

�� Not for the convenience of the patient, the patient's family, or the patient's physician or other provider.

Generally, benefits are available under the Plan only for covered services that are medically necessary. The

fact that your physician prescribes care or services does not automatically mean the care or services qualify

for benefits under the Plan. The final decision of whether or not a service is medically necessary is made

by the Medical Director for the appropriate third-party administrator or the director's designee.

However, even though the following services do not fit the above definition of medically necessary care,

they are covered services under the Plan:

�� Certain voluntary procedures (such as circumcision, tubal ligation, vasectomy and elective termination

of pregnancy);

�� Preventive services administered by your designated network PCP/PCC or designated network

OB/GYN that are consistent with local medical practice for your age and sex;

�� Detection services administered by your designated network PCP/PCC or designated network

OB/GYN that are consistent with local medical practice for your age and sex; and

�� Specific wellness care provided by your designated network PCP/PCC or designated network

OB/GYN.

DEFINITIONS


Medical supplies mean small and often disposable items that are part of medical treatment for an illness or

injury. To be covered under the Plan, the supply must be consistent with the diagnosis and generally must

not be useful in the absence of illness or injury. Covered medical supplies include, but are not limited to:

ostomy bags and skin bond for a colostomy, surgical support stockings for a diagnosis of phlebitis or other

circulatory condition.

Over-the-counter products are not covered. Examples of excluded over-the-counter products include, but

are not limited to: band aids, bandages, pads for incontinence, ankle braces, wrist braces, elbow braces,

knee braces, or neck braces.

Mental disorder means a condition having an emotional or psychological origin as defined in the current

edition of the Diagnostic and Statistical Manual of Mental Disorders. It includes conditions commonly

understood to be mental disorders whether based on a physiological or organic origin and for which

treatment is generally provided by or under the direction of a mental-health professional, such as a

psychiatrist or psychologist.

The precertified care the Plan covers include, but are not limited to treatment of the following mental

disorders:

�� Alcoholism and drug

abuse

�� Attention deficit disorder

�� Bipolar disorder

�� Major depressive disorder

�� Obsessive compulsive

disorder

�� Panic disorder

�� Pervasive Mental

Developmental Disorder

(Autism)

�� Psychotic depression

�� Schizophrenia

Coverages available and limitations are noted in the cost-sharing table for the appropriate third-party

administrator beginning on the following pages:





Morbid obesity means a body weight of greater than 150 percent of expected body weight according to

the MetLife Tables for sex, age, height, and body build. A medical condition must be directly exacerbated

by the obesity before the Plan considers the limited treatments that are covered (see page 73). The types of

medical conditions that could be directly exacerbated by the obesity include hypertension, cardiac disease,

respiratory disease, or Type I diabetes mellitus.

Negotiated fee means the maximum amount a network provider may be paid for covered services and

supplies in accordance with a contract between the provider and the appropriate third-party administrator.

Network provider means any hospital, physician, specialist, or other provider under agreement with the

appropriate third-party administrator to make covered services available under the Plan for a negotiated fee

or reimbursement arrangement.

Palliative care means care that relieves pain or symptoms immediately following treatment, but does not

result in permanent improvement. In general, no benefits are available for any care considered to be

palliative in nature. However, benefits may be payable for precertified palliative care provided through a

covered hospice program.

DEFINITIONS


Prenatal care means a comprehensive package of medical and psychosocial support provided throughout

a pregnancy and related directly to the care of the pregnancy, including risk assessment, serial surveillance,

prenatal education, and use of specialized skills and technology, when needed, as defined by Standards for

Obstetric-Gynecologic Services issued by the American College of Obstetricians and Gynecologists.

Psychologically necessary care means care which is:

�� Appropriate and essential for the diagnosis, evaluation or treatment of a mental disorder, including

substance abuse, other than mental retardation;

�� In line with U.S. standards of mental-health professional practices (psychiatry, clinical psychology,

clinical social work);

�� Provided at the appropriate level of care based on the severity of the illness and capacity to respond to

professional treatment;

�� Within the professional competence of the provider; and

�� Reasonably expected to improve the condition or level of functionality, or at least prevent further

deterioration.

Reasonable and Customary (R&C) means the amount that the Plan uses to determine payment for a

particular service when it is rendered by a covered provider, based on the usual, customary and reasonable

fee in the area. Charges received are considered only up to the R&C limit established by the Plan. The

R&C limit is:

�� The amount customarily charged for the service by other providers in the geographical area where the

service is provided;

�� Reasonable considering the type of service provided;

�� Determined solely by the appropriate third-party administrator; and

�� Subject to change at any time.

Some providers may charge a fee that is higher than R&C. Any difference between R&C and the amount

billed by a non-network provider is always your responsibility. The difference is not considered for

reimbursement under the Plan. Under the terms of their contracts, network providers never bill amounts in

excess of R&C.

Covered emergency care by non-network providers are paid at the billed rates.

Reconstructive refers to surgery to rebuild or correct:

�� A body part when such surgery is incidental to or following surgery resulting from injury, sickness, or

disease of the involved body part; or

�� A functional defect determined by a physician to have been present at birth and that adversely affects

your ability to perform routine activities of daily living.

Surgery that is primarily cosmetic in nature is not considered to be reconstructive and is not covered under

the Plan. For covered reconstructive surgery, refer to page 76.

DEFINITIONS


Referral* ** means a specific written or electronic authorization from your designated network PCP/PCC

to seek medically necessary services from another provider when such services are not available from your

PCP/PCC. Your PCP/PCC must issue a written or electronic referral according to specific referral

guidelines that include:

�� The time period during which services must be received,

�� The specific services to be provided, and

�� The provider to whom you are referred.

A general statement by your PCP/PCC that you should seek a particular type of service or provider is not

considered a referral under the Plan.

Respite care means care rendered by individuals other than your primary caregivers (primary caregivers

may be family members or friends) to give them rest and/or relief when necessary in order to maintain you

at home. In general, no benefits are available for any care considered to be respite care. However, respite

care may be covered under a hospice program, if approved through the Plan’s precertification process.

Restorative surgery means surgery to rebuild or correct a physical defect that has direct adverse effect on

the physical health of a body part and the restoration or correction is determined to be medically necessary.

Surgery that is cosmetic is not considered to be restorative under the Plan.

Self-insured means that the Plan sponsor, Unisys in this case, makes benefit payments as services occur,

including a fee for the use of the third-party administrator’s network and the third-party administrator’s

services. Costs are variable rather than fixed because Unisys, not the plans, bears the risk of volatility of

expenses. State insurance taxes and state mandates do not apply. Instead, the plan is subject to the federal

Employee Retirement Income Security Act.

Skilled nursing convalescent facility means a licensed, Medicare-approved facility other than a hospital

and meets all of the following requirement:

�� Maintains permanent and full-time facilities for bed care of ten or more resident patients;

�� Has available at all times the services of a physician;

�� Has a registered nurse or physician on full-time duty in charge of patient care, and one or more

registered nurses or licensed practical nurses on duty at all times;

�� Maintains a daily medical record for each patient;

�� Is primarily engaged in providing continuous skilled nursing care for ill or injured persons during the

convalescent stage of their illness or injury and is not, other than incidentally, a place for rest, the aged,

drug addicts, alcoholics, or a nursing home. Nor is it a place providing custodial care, educational care,

or the care of mental disorders or mental retardation; and

�� Has transfer arrangements with one or more hospitals and a utilization review plan in effect.

Coverage under the Plan is limited to precertified, medically necessary treatments provided as an

alternative to inpatient hospital services and the cost is less than inpatient hospital care. Custodial or

maintenance services are not covered.





** Note for SelectAdvantage for services on or after July 1, 2001: SelectAdvantage allows you to refer yourself to


DEFINITIONS


Specialized licensed treatment facility means a facility that specifically treats mental health conditions,

including substance abuse conditions. In order to be covered under the Plan, the facility must meet local

licensing standards for the effective treatment of mental health or substance abuse conditions.

Specialized mental health facilities also must provide:

�� All normal infirmary-level medical services required during the treatment period, whether or not

related to the mental health condition, and an agreement with a hospital in the area to provide any

other medical services required;

�� Continuous supervision by a psychiatrist who has the overall responsibility for coordinating patient

care and who is at the facility on a regularly scheduled basis; and

�� Staff psychiatrists who are directly involved in the treatment program, at least one of whom is present

at all times during the treatment day, and the continuous services of a psychiatric nurse.

Specialized substance abuse facilities also must provide:

�� A full-time inpatient or outpatient program for the diagnosis, evaluation, and rehabilitation of

alcoholism or drug abuse;

�� 24-hour medical detoxification services;

�� Normal medical services (unless the treatment facility has an agreement with a nearby hospital to

provide other medical services);

�� Skilled nursing services by licensed nurses under the direction of a full-time registered graduate nurse

— all under the supervision of a staff of doctors; and

�� A prepared written plan of treatment for each patient which is followed under a doctor’s supervision.

Surgical procedures include, but are not limited to procedure in the following categories:

�� Incision or excision of any part of the body;

�� Electrocauterization;

�� Manipulative reduction of a fracture or dislocation;

�� Suturing of a wound (removal of sutures by a physician who is not the operating physician also is

considered part of a surgical procedure); or

�� Endoscopic removal of a stone or foreign object from the larynx, bronchus, trachea, esophagus,

stomach, urinary bladder, or ureter.

Urgent care center (See Convenient/Urgent Care Center on page 51.)

Urgent medical need means an acute, non-life-threatening medical condition which could not have been

anticipated and for which a delay in treatment would be detrimental to your health. Some examples of

urgent medical need include, but are not limited to:

�� Earache

�� Respiratory or flu-like symptoms with high fever

�� Severe abdominal cramps

�� Severe diarrhea

�� Severe sore throat

�� Severe vomiting

To be covered, urgent-care treatment must be coordinated by your PCP/PCC* **. The steps you should

take in case of an urgent medical need are provided beginning on page 10.







PRECERTIFICATION


PRECERTIFICATION

PRECERTIFICATION


PRECERTIFICATION

When your PCP/PCC* coordinates your care with network providers, precertification generally is handled

for you by your PCP/PCC. In emergency situations involving an inpatient stay outside your network

service area, you are required to initiate the precertification process. If a network referral specialist directs

services, you should verify with the provider and Member Services to ensure that the required

precertification process is completed.

* Note for Medica Self-Insured and for SelectAdvantage: If you self-refer to a network provider, you should verify

with the provider and Member Services that the required precertification process is completed for the services noted

in this section that require precertification.

Emergency Services

If you are admitted to a facility due to a medical emergency (see page 52 for the definition of medical

emergency) or urgent medical need (see page 59 for the definition of urgent medical need), you , a family

member, or the attending physician should call Member Services within 24 hours after the emergency

occurs. If your plan includes a PCP or PCC, you also should notify your PCP/PCC.

If the appropriate third-party administrator considers your admission to be the result of a medical

emergency or urgent medical need, the Plan will approve payment for the care, regardless of the network

status of the providers involved in your emergency care. You must pay the appropriate copayments or

coinsurances.

Your PCP/PCC must provide or coordinate your follow-up care (or a network self-referral specialist, in the

case of Medica Self-Insured, or any network provider in the case of SelectAdvantage for services on or

after July 1, 2001).

For additional information on what to do in the event of an emergency, refer to page 10.

Non-Emergency Services

The following chart indicates services also requiring precertification. Follow up with Member Services

within one week before the date services are to be provided to verify that the precertification process has

been completed.

Type of non-emergency

services requiring

precertification Network Provider Role Your role

Inpatient stay Obtain certification for inpatient

admissions for any reason,

including medical, surgical, or

maternity admissions.

��Verify that services have

been approved in advance of

admission.

��Comply with any

requirements resulting from

the precertification process.

Durable Medical Equipment Obtain certification for durable

medical equipment items that fall

under certification review

procedure.

�� If approved, purchase the

equipment from the approved

network vendor.



the precertification process

PRECERTIFICATION



services requiring


Home Health Care Obtain certification for home

health care services.



receiving services.




Home IV therapy Obtain certification for Home IV

therapy.



admission.




Hospice Obtain certification for hospice

care.



admission.




Mental Health or Substance

Abuse Treatments

For Aetna U.S. Healthcare, your

PCP obtains certification for

mental health/substance abuse

treatments.

�� For HealthPartners, you can

self refer for outpatient

services from network

behavioral health providers.

�� For Medica Self-Insured,

specialized precertification

vendors apply to these types

of treatments. You must

precertify these services.

Refer to the telephone

number on the front cover of

this booklet for the

appropriate contact.

�� For SelectAdvantage

members for services on and

before June 30, 2001,

specialized precertification

vendors apply to these types

of treatments.




��Note the limitations for

coverage.

PRECERTIFICATION



services requiring


Organ or Tissue Transplants Obtain certification for the organ

or tissue transplants.

�� The third-party

administrators designate

specialized facilities for

organ or tissue transplants.



receiving treatments.




Rehabilitative services: cognitive,

physical, occupational,

pulmonary, and speech therapy

Provide the referral for the

treatments.

�� If approved, obtain services

from designated provider.




��Note the limitations for

coverage.

Skilled Nursing Care Obtain certification for skilled

nursing care services.



admission.




Skilled Nursing Facility Obtain certification for inpatient

admissions to a skilled nursing

facility.



admission.




Surgery Obtain certification for any

surgical procedures requiring

certification.



admission.




COVERED EXPENSES/SERVICES






If medically necessary, charges from network providers for the supplies or services listed in this section are

covered under the Plan.

Even if they are not medically necessary, the following voluntary services/procedures are covered under

the Plan when provided by your PCP/PCC* ** or referral specialist:

�� Certain voluntary procedures (such as circumcision, tubal ligation, vasectomy, and elective termination

of pregnancy);

�� Preventive services administered by your designated network PCP/PCC* ** or designated network

OB/GYN that are consistent with local medical practice for your age and sex;

�� Detection services administered by your designated network PCP/PCC* ** or designated network

OB/GYN that are consistent with local medical practice for your age and sex; and

�� Specific wellness care provided by your designated network PCP/PCC* ** or designated network

OB/GYN.

Unless otherwise specified, the copayment levels apply as described in the Cost-Sharing Table for the

appropriate third-party administrator beginning on the following pages:





If services are not medically necessary, they are not covered. The Plan also does not cover chiropractic or

rehabilitative services if they are custodial, maintenance, or palliative in nature.

Acupuncture

Refer to the Cost Sharing Table for the appropriate third-party administrator. Coverage for these services

generally is limited to specific circumstances.

In no event is acupuncture covered for maintenance or palliative care.

Ambulance

Refer to page 50. The covered services are noted in the definition.

Ambulatory surgical facility or surgery center

The Plan covers services provided by a network ambulatory surgical facility or surgery center in the same

manner as applies to outpatient surgery in a hospital.

Amniocentesis and chromosomal analysis

These services are covered only when medically necessary as determined by the network physician in

accordance with guidelines established by the appropriate third-party administrator.









Anesthetic services

The Plan covers expenses for the administration of anesthetics when rendered by a licensed

anesthesiologist or certified registered anesthetist in connection with a covered surgical procedure or

maternity care.

The Plan does not provide additional payment for the administration of anesthetics if the physician who

administers the anesthesia also performs the care (or assists the physician who performs the care) and

receives payment under any other part of the Plan.

Assistant surgeons

Services of assistant surgeons are covered only when the assistance by another physician is medically

necessary during the course of an operation.

Birthing centers

The Plan covers expenses for birthing centers in the same manner in which expenses are covered for

outpatient services at a hospital (see page 71).

Cancer screenings

The Plan supports the early detection of breast cancer, prostate cancer, ovarian cancer, and colorectal

cancer by covering testing to identify individuals that are at higher risk for these diseases. The physician

fees associated with the screenings done in a doctor’s office are covered the same as any office visit. The

professional laboratory or x-ray fees are covered the same as independent lab and x-rays. Scoping

procedures are handled the same as surgical fees.

Chemotherapy

The Plan covers medically necessary, non-investigational chemotherapy regimens. The Plan does not cover

investigative services associated with chemotherapy or investigative dosage regimens. (See page 54 for a

definition of investigative and page 75 for information on radiation.)

Contact lenses/prescription lenses (eyeglasses)

The Plan covers the initial prescription for contact lenses or eyeglasses following cataract surgery*.

For all other purposes, contact lenses or eyeglasses are not covered under the Plan. The third-party

administrator may offer a discount that applies to any purchase of prescription contact lenses or eyeglasses.

If not, Unisys provides discounted eyewear through the Cole Vision Program that is described on the

Unisys Employee Network at iwww.unisys.com/employee.

* Note for Medica Self-Insured: Medica does not cover contact lenses or eyeglasses following cataract surgery.



Dental services and treatment

In general, dental services and treatment are not covered. However, the Plan does cover oral surgeries that

typically are considered medical rather than dental in nature or are medically necessary for the treatment of

an underlying medical condition. Some examples include, but are not limited to:

�� Surgical removal of unerupted impacted wisdom teeth

��Removal of tumors or non-dental cysts and lesions

��Repair of cleft palate

��Removal of teeth to complete radiation treatment for cancer of the jaw

In addition, the Plan covers certain services or supplies for the repair of sound natural teeth damaged as the

result of an accidental injury, if the service is done or supply provided as part of the initial emergency

treatment or within the guidelines established by the third-party administrator.

The Plan covers precertified facility charges (but not the surgical charges) for outpatient surgical services

in a hospital or surgicenter for dental surgeries only if the patient is:

��Under the age of 5, or

�� Severely disabled, or

��Has a medical condition requiring outpatient hospital care or general anesthesia for dental treatment.

Coverage for similar services under a dental plan is primary to coverage under this Plan.

Diabetic supplies

Glucometers and insulin pumps are covered as durable medical equipment (see below). Insulin and

disposable diabetic supplies, such as syringes, test strips, and lancettes are covered separately under the

Unisys Prescription Drug Program.

Diagnostic services

The Plan covers radiology and pathology procedures done by, or ordered by your network physician to

determine the nature and/or extent of a condition or illness for which you show symptoms. The Plan does

not cover diagnostic services done for research, study, or investigational programs. (See page 54 for a

definition of investigational.)

Dialysis treatment

The Plan covers dialysis treatment for acute or chronic kidney ailments.

Drugs or medicines dispensed by a pharmacy

Drugs or medicines requiring a prescription and dispensed by a pharmacy are covered separately under the

Unisys Prescription Drug Program.

Durable medical equipment (DME) and prosthetic devices

The Plan covers certain durable medical equipment and some prosthetics, provided they meet Medicare

guidelines for coverage. Some DME also requires advance approval by the third-party administrator.

Contact Member Services at the number listed on the inside cover of this booklet to determine if prior

approval is required by the Plan.

Durable medical equipment: Requests for any type of durable medical equipment for prolonged use and

for treatment of an illness or an injury, must be made in writing by your PCP/PCC and coordinated with a

DME coordinator in Member Services. If approved, the DME or prosthetic device is ordered through the

designated DME vendor identified by the third-party administrator.

The Plan covers the rental or purchase of approved DME, including expenses related to necessary repair

and maintenance. The third-party administrator determines whether rental or purchase will be covered.

Glucometers and insulin pumps are included as covered DME for patients diagnosed with diabetes.



Supplies for glucometers and insulin pumps are covered separately under the Unisys Prescription Drug

Program.

Replacement equipment is covered only if it can be shown that replacing the equipment is required due to

a change in physical condition or purchasing new equipment is less expensive than the repair of existing

equipment.

Charges for more than one item of equipment for the same or similar purposes are not covered.

Note: Even if prescribed by a physician, a number of items are not covered under the Plan. Items not

covered include, but are not limited to: air conditioners, air filter systems, air purifiers, arch supports, bath

chairs, bathtub rails, breast pumps, corsets, dehumidifiers, exercise equipment, humidifiers, jobst

stockings, molded shoes, orthotics, raised toilet seats, shoe inserts, shower stools, stair glides, swimming

pools, toilet rails, or tub benches.

Prosthetic devices: The Plan covers the original placement and fitting of approved devices which replace

all or part of an absent body part. The Plan also covers the original placement and fitting of approved

devices that replace all or part of the function of a permanently inoperable or malfunctioning body part.

Coverage for prosthetic devices is determined by the Medical Director for the appropriate third-party

administrator or the director's designee, unless otherwise required by law.

Also included are charges for the repair or replacement of a prosthesis. However, replacement is covered

only if the appropriate individual plan administrator is shown that both of the following conditions have

been met:

�� It is needed due to a change in physical condition, and

�� It is likely to cost less to purchase a new one than to repair the existing one.

Further, the Plan covers only one repair or replacement per year, unless more than one repair or

replacement is medically necessary due to a change in physical condition.

The Plan does not cover the repair or replacement of a prosthetic device due to loss or misuse of the

device.

Wigs or artificial hairpieces: The Plan covers wigs or artificial hairpieces when they are required as a

result of illness, injury, or treatments for a medical condition. These include alopecia areata and hair loss

following chemotherapy. Wigs and artificial hairpieces are covered when coordinated through the

appropriate plan administrator. The annual maximum for these supplies is $350.

Elective termination of pregnancy

The Plan covers expenses related to the elective termination of a pregnancy, regardless of medical

necessity for the procedure.

Enteral formula

The Plan covers nutritional supplements specifically associated with therapeutic treatment of

phenylketonuria (PKU), branched chain ketonuria, galactosemia, and homocystinuria, if administered

under the direction of a physician.



Home-health care

Home-health services are covered if approved and coordinated in advance by the appropriate third-party

administrator and provided upon the prior written or electronic referral by your PCP/PCC* **.

The following services for the homebound may be covered, provided that the primary purpose of the care

is skilled in nature:

�� Part-time or intermittent skilled nursing services provided by or under the supervision of a registered

professional nurse;

�� Part-time or intermittent services of a home-health aide under the supervision of a registered

professional nurse, or if appropriate, a qualified speech or physical therapist;

�� Medical social services by or under the supervision of a qualified medical or psychiatric social worker

in conjunction with other home-health services, if your PCP/PCC* **certifies that such services are

essential for the effective treatment of the medical condition;

�� Short-term physical or speech therapy provided by or under the supervision of a qualified speech

pathologist or physical therapist in connection with other home-health services, provided your

PCP/PCC* ** certifies that such services are likely to result in significant improvement within a 60-

day period;

�� Short-term occupational therapy (except vocational rehabilitation or employment counseling) rendered

by or under the supervision of a qualified occupational therapist in connection with other home-health

services, provided the PCP/PCC* ** certifies that such services are likely to result in significant

improvement within a 60-day period.

No benefits are payable for home-health services:

�� That are not ordered or coordinated by your PCP/PCC* **, or

�� That are of a maintenance or custodial nature, or

�� That are used as respite for primary caregivers.

Hospice

The Plan covers inpatient hospice services for the palliative care of a terminal illness, provided the care has

been requested in writing by your PCP/PCC* **, precertified in advance, and is provided by a designated

hospice program.

To qualify, the patient must be considered to be terminally ill, as indicated in a written medical prognosis

by the attending physician, with a life expectancy of six (6) months or less if the terminal illness runs its

normal course. The patient must have chosen a palliative treatment focus (that is, one that emphasizes

comfort and supportive services) rather than treatment attempting to cure the condition. If you elect to

receive hospice services, you do so in lieu of curative treatment for the terminal illness for the period you

are enrolled in the hospice program.









Hospital (acute care general hospital)

Emergency room expenses: The Plan covers services performed in a hospital emergency room only in the

case of care rendered to treat a medical emergency or properly referred treatment for an urgent medical

need (see page 52 for a definition of medical emergency and page 59 for a definition of urgent medical

need), or if your designated PCP/PCC* ** authorizes the care. If care is received in a hospital emergency

room for situations not meeting the definition of medical emergency (or your designated PCP/PCC* ** did

not authorize the use of the emergency room), no benefits are payable.

Inpatient expenses: The Plan covers medically necessary services customarily furnished by an acute care

general hospital when you are a registered inpatient. These include, but are not limited to:







�� Administration and processing of whole

blood, blood products and blood derivatives

�� Anesthesia and anesthesia services

�� Cardiography/encephalography

�� Drugs, medications, biologicals

�� General nursing care

�� Intensive care or coronary care

�� Intravenous injections and solutions

�� Labor and delivery room services

�� Laboratory and x-ray testing and services

�� Magnetic resonance imaging (MRI)

�� Medical social work

�� Nuclear medicine

�� Oxygen and oxygen therapy

�� Pathology

�� Physical and rehabilitation therapy as

described beginning on page 76

�� Pre- and post-operative care, and operating

room services

�� Semi-private room and board

If you occupy a private room, you must pay the full difference between the hospital's charges for a private

room and the hospital's most common charge for a semi-private room. However, if it is medically necessary

that you have a private room, or if a semi-private room is not available, the Plan will cover the private-

room rate.

The Plan does not cover expenses associated with personal convenience items. These include, but are not

limited to: telephone and television rentals, guest trays, or guest accommodations.

Note: each person’s confinement, including that of a newborn, is treated separately and distinctly from the

confinement of any other person. In other words, an inpatient admission for childbirth will generally result

in two (or more) independent and separately determined hospital benefits. For the newborn to be covered,

you must call the Unisys Benefits Services Center at 1-800-600-2015 within 30 days of the birth.

Outpatient expenses: The Plan covers services performed in the outpatient department of a hospital. Also

covered as if they are outpatient hospital expenses are services performed at birthing centers, ambulatory

surgical centers, or hemodialysis centers, provided the facility possesses all licenses, permits, certifications,

and approvals required by applicable state, local, and federal law.



Hospital visits

Medical visits by a physician while you are a registered inpatient in a hospital are covered, provided the

visits are for care of illnesses or conditions other than those related to surgery or maternity care (these visits

generally are included in the physician's surgical or delivery fee). The maximum covered is one visit per

day per diagnosis per physician, unless more visits are determined to be medically necessary.

Medical consultations in a hospital: Medical consultations in a hospital are covered if all of the following

apply:

�� Your physician calls in another physician for a medically necessary consultation, and

�� The physician who is called in is a specialist in your illness or disease, and

�� The consultation takes place while you are a registered inpatient in a hospital.

Newborn care: The initial examination of an enrolled newborn child in a hospital is covered when the

examination is done by a physician other than the delivering physician. If the newborn is not enrolled in

the plan within 30 days of the date of birth, these services and the hospital stay for the newborn are not

covered. To enroll the newborn, call the Unisys Benefits Services Center at 1-800-600-2015.

Second physician: Visits by a second physician are covered if it is determined by the appropriate third-

party administrator that an “exceptional complication” in your surgery, maternity, or inpatient hospital

stays warrants a second physician. An exceptional complication is a condition that is either:

�� Not related to that for which you were admitted to the hospital, or

�� So unusual that it requires more than the customary surgical, maternity or medical care.

Infertility treatments

The Plan covers only limited services for the diagnosis and treatment of infertility to restore normal bodily

function. It does not cover artificial insemination, in vitro fertilization, GIFT, ZIFT, surrogates, storage of

eggs or semen, embryo implants, or fetal implants.

Mental health services

Services for mental disorders (see page 56 for a definition of mental disorder) are covered only when

provided by network providers under the terms required by the appropriate third-party administrator. For

example, treatment for mental-health services may require precertification and/or the oversight of a

separate utilization review group affiliated with the third-party administrators.

Outpatient: The Plan covers a maximum of 30 outpatient visits per year to a psychiatrist, clinical

psychologist, or psychiatric social worker in individual, group, or family therapy sessions.

For retirees, disabled former employees, and their covered dependents eligible for Medicare and

participating in the SelectAdvantage option, the Plan covers a maximum of 20 outpatient visits per year.

Inpatient: The Plan covers a maximum of 30 days of inpatient care per year for the treatment of mental or

nervous disorders, up to 90 days in a lifetime. Covered services include:

�� Pre- and post-hospital planning, including treatment and discharge planning,

�� Referral to (but not payment for) community health and social welfare agency services, and

�� Referral to (but not payment for) related family counseling services except as specified under

Substance Abuse Services.

Inpatient non-hospital residential facility: The Plan covers medical, nursing, counseling or therapeutic

services for substance abuse or dependency in an approved residential facility licensed by the Department

of Health, according to an individual treatment plan, subject to the following limitations:

�� Up to 30 days per year, and

�� Up to 90 days per lifetime.

Covered services include, but are not limited to, the following for non-hospital residential facilities:



�� Drugs, medicines, equipment and supplies provided by the facility;

�� Family counseling and intervention;

�� Physician, psychologist, nurse, certified addictions counselor and trained staff services;

�� Psychiatric, psychological and medical laboratory testing;

�� Rehabilitation therapy and counseling; and

�� Room charges.

Consideration of treatments for substance abuse conditions: Services for treatment of mental-health

conditions and substance abuse conditions are combined when determining if annual and/or lifetime

maximum benefits have been reached.

Morbid obesity treatments

The Plan covers certain medical and/or surgical treatment for morbid obesity (refer to page 56 for a

definition of morbid obesity.

Surgery for morbid obesity is covered only if referral is from a legitimate eating disorder program, under

physician supervision, and in circumstances that fulfill medical necessity, and only if precertified by the

appropriate third-party administrator.

Covered outpatient treatment of morbid obesity includes the following elements:

��Must be physician-directed;

��May involve modified fasting;

��Must include exercise (however, no benefits are payable for the cost of exercise equipment or

programs); and

��Must include a psychological assessment (not necessarily ongoing psychotherapy).

Note: Self-help programs (food supplements, nutri/system, Optifast and store-front diet centers), exercise

equipment, health club dues, or spa treatments are not covered.

Nursing home

See skilled nursing facility on page 79.



Office visits/services

The following office services are covered at the benefit levels noted in the cost-sharing charts. Note: a

number of the services are payable only if they are provided by your PCP/PCC* **.

Allergy testing and treatment: Covered services include tests to determine the nature of allergies, test

materials, desensitization treatment (allergy shots), and treatment materials (syringes, serum) to alleviate

allergies. To be covered, services must by provided by your PCP/PCC* ** or requested by a written or

electronic referral by your PCP/PCC* ** to a network specialist.

Chemotherapy/radiation therapy: Non-investigative chemotherapy or radiation therapy services are

covered under the applicable benefit levels.

Diagnosis and treatment: Covered are the services of physicians and other medical staff for the diagnosis

and treatment of illness, injury, or other conditions, as well as emergency and urgent care. This includes

surgical procedures done in a physician's office, consultations with specialists, and a diagnostic workup to

confirm a diagnosis of infertility.

Medication and supplies for use in the physician's office: Covered services include medically necessary

medications, injectables, radioactive materials, dressings, and casts when administered or applied by your

physician in the physician's office for treatment purposes.

Medication or supplies for preventive purposes are covered only when provided by your PCP/PCC* **.

Obstetrical/gynecological services: Routine well-woman examinations are covered only when performed

by your PCP/PCC* ** or network OB/GYN. You do not need a referral for your routine visit (one/calendar

year). This direct access apples to general OB/GYN care from a network OB/GYN only, not subspecialty

care, such as perinatology care, or gynecologic oncologic care* **. Expenses related to pregnancy are

covered under the applicable benefit levels. The Plan also covers the diagnosis and treatment of medical

conditions resulting infertility and treatment to return the body to normal bodily function. Note, however,

that the Plan does not cover artificial insemination or other infertility procedures.

Office surgery: All provisions noted on page 81 with respect to surgical procedures also apply to surgery

done in a physician's office, with the exception of the differences in copayments.

Preventive health services: Each of the third-party administrators establishes the type and frequency of

routine preventive services that are covered based on their internal policies and local market practices.

X-ray and laboratory services: These services, when performed in a network doctor's office, are included

in the appropriate PCP/PCC or specialist office visit copayment (for a network specialist, a PCP/PCC* **

referral is required). Covered services include non-investigative diagnostic x-rays, x-ray therapy,

electrocardiograms, laboratory tests, and diagnostic clinical isotope services which are medically necessary

and ordered by your physician. Routine x-ray and laboratory services performed in your doctor's office are

covered only when provided by your PCP/PCC* ** ***. A separate copayment applies if services are

provided by an independent x-ray or laboratory service***.




coinsurance are higher under Tier II than when you obtain a referral from your PCC (Tier I). ** Note for SelectAdvantage for services on or after July 1, 2001: SelectAdvantage allows you to refer yourself to

any network provider. This is called “self-referral.” *** Note for HealthPartners: No copayment applies for network x-ray and lab services, regardless of the setting

where services are rendered.



Organ and tissue transplants

Transplant procedures that are covered include only precertified non-investigative human transplants

performed at hospitals specifically approved and designated to perform these procedures by the appropriate

third-party administrator. Some examples of covered transplants include, but are not limited to:

�� Bone marrow transplants or stem cell

recoveries for certain conditions, specifically

aplastic anemia, leukemia, severe combined

immunodeficiency disease and Wiskott-

Aldrich Syndrome

�� Corneal transplants

�� Heart transplants

�� Kidney transplants

�� Liver transplants for children with biliary

atresia

Additional transplants are covered when they are deemed by the appropriate third-party administrator, in

their sole discretion, no longer to be investigative in nature. (See page 54 for the definition of

investigative.)

Outpatient surgery

See surgical procedures on page 81.

Oxygen and oxygen equipment

See durable medical equipment on page 68.

Pap tests

The Plan covers expenses associated with Pap tests performed as often as medically necessary when

symptoms indicate possible cancer.

In addition, routine Pap tests are covered, even if there are no symptoms of cancer, provided they are

ordered by your designated network PCP/PCC* ** or your network OB/GYN.

Phenylketonuria (PKU) nutritional supplements

The Plan covers nutritional supplements specifically associated with therapeutic treatment of

phenylketonuria (PKU), branched chain ketonuria, galactosemia, and homocystinuria, if administered

under the direction of a physician. Nutritional supplements for any other conditions are not covered.

Physical therapy

See rehabilitative services on page 76. Note that there are limitations as noted in the cost-sharing tables.

Preadmission testing

The Plan covers these expenses when performed in conjunction with a scheduled hospital admission or

outpatient surgical procedure.

Prescription drugs and medicines dispensed by a pharmacy

These are covered separately under the Unisys Prescription Drug Program described in the appropriate

Summary Plan Description booklet noted on the inside cover of this booklet as revised from time-to-time

in the annual Summary of Plan Changes booklet issued each fall.

Radiation services

The Plan covers medically necessary, non-investigative radiation services, including the use of x-rays,

radiation, or radioactive isotopes. The Plan does not cover radiation services associated with investigative

uses or dosage regiments of radiation therapy. (See page 54 for a definition of investigative.)









Reconstructive surgery

The Plan covers reconstructive surgery, including plastic surgery, only to:

�� Correct a severe birth defect or congenital abnormality which is accompanied by a functional medical

disorder;

�� Repair damage caused by an injury or covered surgery that occurred while covered under a medical

plan sponsored by Unisys;

�� Reconstruct breast after a total mastectomy performed following the diagnosis of cancer and/or

reconstruct the other breast to produce symmetrical appearance; or

�� Restore a body part that is injured or deformed by acute trauma, infection or other pathological disease

such that the essential function of that body part is compromised.

The Plan covers plastic or reconstructive surgery expenses only when the procedure is expected to improve

the function of a body part. Improvement in the function of a body part is considered to occur only if:

�� The surgery is expected to partially or fully restore or improve the physiological function, passive

function or normal function of an organ, a tissue or a body part; or

�� The surgery is expected to eliminate or substantially reduce an impairment causing pain or discomfort

to a body part or a body area resulting from an illness, injury or previous covered surgery.

Improvement in function does not include the repair of body changes associated with the aging process or

congenital deformities of a generalized nature which are not causing a restorable loss of function.

Other services and supplies that improve, alter, or enhance appearance, whether for psychological or

emotional reasons, are not covered.

Rehabilitation services

The Plan covers the rehabilitation services noted below. Be sure to note the limitations indicated on the

cost-sharing tables. The Plan does not cover any of these services if they are for maintenance care or are

palliative in nature.

Cardiac rehabilitation: Benefits for cardiac rehabilitation are available only as part of an inpatient stay.

Cognitive therapy: Benefits for short-term cognitive therapy are available upon referral by your

PCP/PCC* **. To be covered, the treatment must be approved by the Medical Director for the appropriate

third-party administrator or the director’s designee. In all cases, the network provider must certify that the

treatment is expected to result in a significant improvement in your condition within a short time frame,

generally 60 days or less.

For Aetna U.S. Healthcare and SelectAdvantage members (other than retirees, disabled former employees,

and their covered dependents eligible for Medicare and participating in the SelectAdvantage option, as

noted below), covered services include precertified treatment within a 60-day period per incident of illness

or injury. The 60-day period is measured from the first day of treatment for the incident.


participating in the SelectAdvantage option, covered services are limited to 20 visits per calendar year.

For HealthPartners and Medica Self-Insured, covered services are limited to 15 visits per condition.

* Note for Medica: Medica allows you to refer yourself to network providers without referral from your PCC. This

is called “self-referral.” Tier II benefits apply for all covered services directly from the self-referral provider, as well

as all covered services ordered or coordinated by the self-referral provider. Copayments and coinsurance are higher

under Tier II than when you obtain a referral from your PCC (Tier I).





Manipulative therapy: Benefits for short-term manipulative therapy are available upon referral by your

PCP/PCC* ** to a licensed network chiropractor or a network osteopathic physician. Alternately, you may

select a network osteopathic PCP/PCC* ** who performs these services. To be covered, the treatment must

be approved by the Medical Director for the appropriate third-party administrator or the director's designee.

In all cases, the network provider must certify that the treatment is expected to result in a significant

improvement in your condition within a short time frame, generally 60 days or less.








Occupational therapy: Benefits for short-term occupational therapy are available upon referral by your












Physical therapy: Benefits for short-term physical therapy are available upon referral by your




















Pulmonary rehabilitation: Benefits for short-term pulmonary rehabilitation services are available upon

referral by your PCP/PCC* **. To be covered, the treatment must be approved by the Medical Director for

the appropriate third-party administrator or the director’s designee. In all cases, the network provider must

certify that the treatment is expected to result in a significant improvement in your condition within a short

time frame, generally 60 days or less.








Speech therapy: Benefits for short-term speech therapy are available to restore speech lost due to an

illness, accident, or surgery upon referral by your PCP/PCC* **. To be covered, the treatment must be

approved by the Medical Director for the appropriate third-party administrator or the director’s designee.

In all cases, the network provider must certify that the treatment is expected to result in a significant

improvement in your condition within a short time frame, generally 60 days or less.








Scoping procedures

Medical necessary scoping procedures to determine the nature and/or extent of an illness or an injury are

covered in the same manner as surgery (see page 81). The copayments vary, depending on where the

procedure is performed. Refer to the cost-sharing tables.









Second surgical opinions

Charges associated with a second opinion for a proposed surgery which are obtained at your request are

covered under the following conditions:

�� The second opinion is given by a network specialist who, by specialty, is an appropriate physician to

consider the surgical procedure; and

�� The proposed surgery is of a non-emergency nature and is a covered procedure under the Plan; and

�� The physician who renders the second opinion does not perform the surgery; and

�� A written or electronic referral by your PCP/PCC* ** is issued.

Skilled nursing facility

If daily skilled care is medically necessary, the Plan covers up to 90 days of precertified care per lifetime

provided at:

�� Nursing homes,

�� Skilled nursing facilities,

�� Transitional care facilities, and

�� Rehabilitation facilities.

Coverage is limited to skilled nursing care as defined by Medicare and subject to precertification by the

appropriate third-party administrator.

Services from these types of facilities are covered when room, board and miscellaneous services for

medically necessary treatment are an alternative to higher cost inpatient hospital services, the charges are

less than inpatient hospital care, and the care has been precertified by the appropriate third-party

administrator.

Charges for custodial supportive care or maintenance care are not covered (see page 51 for a definition of

custodial supportive care and page 55 for a definition of maintenance care).

Sterilization surgeries

Tubal ligations and vasectomies are covered regardless of medical necessity for the procedure. Surgical

reversals of voluntary sterilizations are not covered.









Substance abuse treatments

Substance abuse treatments are covered only when provided by network providers under the terms required

by the appropriate third-party administrator. For example, treatment for substance abuse conditions may

require precertification and the oversight of a separate utilization review group affiliated with the third-

party administrator.

The substance abuse treatments noted below are covered, provided treatment is obtained under the terms

proscribed by the appropriate third-party administrator.

Outpatient: The Plan covers diagnostic services, medical treatment, and medical referral services for the

abuse of or addiction to alcohol or drugs.

The Plan covers a maximum of 30 outpatient visits per year for treatment of substance abuse or

dependency. However, for retirees, disabled former employees, and their covered dependents eligible for

Medicare and enrolled in the SelectAdvantage option, a maximum of 20 outpatient visits per year applies

for treatment of substance abuse or dependency.

Covered services include, but are not limited to:

�� Services by a physician, psychologist, certified addictions counselor and trained staff;

�� Rehabilitation therapy and counseling,

�� Family counseling and intervention,

�� Psychiatric, psychological and medical laboratory tests, and

�� Drugs, medicines, equipment use and supplies dispensed by the outpatient provider.

Inpatient hospital: The Plan covers a maximum of 30 days of inpatient care per year for detoxification,

medical treatment and referral services for substance abuse or addiction, up to 90 days in a lifetime.

Covered services include, but are not limited to:

�� Room charges;


�� Diagnostic x-rays;

�� Psychiatric, psychological and medical laboratory testing; and

�� Drugs, medicines, equipment and supplies dispensed by the facility.

Inpatient non-hospital residential facility: The Plan covers medical, nursing, counseling or therapeutic

services for substance abuse or dependency in an approved residential facility licensed by the Department

of Health, according to an individual treatment plan, subject to the following limitations:

�� Up to 30 days per year, and

�� Up to 90 days per lifetime

For non-hospital residential facilities, covered services include, but are not limited to:

�� Drugs, medicines, equipment and supplies dispensed by the facility;

�� Family counseling and intervention;


�� Psychiatric, psychological and medical laboratory testing;

�� Rehabilitation therapy and counseling; and

�� Room charges.

Consideration of treatments for mental-health: Services for treatment of mental-health conditions and

substance abuse conditions are combined when determining if annual and/or lifetime maximum benefits

have been reached.



Surgical procedures

The Plan covers medically necessary procedures which involve an incision or puncture of the skin or tissue

requiring the use of surgical instruments. In addition, the Plan covers the following voluntary surgical

procedures which are not medically necessary: circumcision, elective termination of pregnancy, tubal

ligation, and vasectomy.

Covered surgical procedures include, but are not limited to, medically necessary:

�� D&C procedures;

�� Electrocauterization;

�� Endoscopic removal of a stone or other foreign object from the larynx, bronchus, trachea, esophagus,

stomach, urinary bladder or ureter;

�� Manipulative reduction of a fracture or dislocation;

�� Normal delivery, Caesarean section delivery, procedures resulting from complications of pregnancy,

and procedures required following a miscarriage;

�� Scoping procedures; and

�� Suturing of a wound (removal of sutures by a physician who is not the operating physician also is

considered part of a surgical procedure).

Note: Surgical procedures and related expenses, including hospital care, that are not covered include, but

are not limited to: procedures to alter sex from one gender to the other; radial keratotomy; in vitro

fertilization; elective reversal of sterilization; treatment of obesity (other than treatment for morbid obesity

as noted on page 73); investigational procedures.

TMJ (temporomandibular joint) syndrome treatments

Only precertified medically necessary surgery for TMJ is covered under the Plan. Services not covered

include, but are not limited to: appliances and the x-rays related to the appliance, x-rays related to covered

surgery for TMJ, therapy, and other medical supplies.

Transitional care facility

See skilled nursing facility on page 79.

X-ray and laboratory services

See X-ray and laboratory services on page 74.

EXCLUSIONS


EXCLUSIONS

EXCLUSIONS


EXCLUSIONS

The Plan does not cover expenses for services which are not medically necessary. Medical necessity is

discussed on page 55.

Care that may be personally desirable, but not medically necessary, is not covered. Some examples of

personal necessity which are not considered medically necessary are cosmetic care, in vitro fertilization,

and artificial insemination.

Further, the Plan does not cover:

��Any expense for which no services are provided;

��Any care, treatment, service, or supply furnished, paid for, or for which benefits are provided or

required by reason of past or present service of any family member in the armed forces of a

government;

�� Services not provided by a covered health-care provider; and

��Care for conditions that state or local law require be treated in a public facility, including, but not

limited to, commitments due to mental disorders, including substance abuse conditions.

Other exclusions are noted below and on the following pages.

Acupressure, or hypno-therapy

Acupressure and hypno-therapy are not covered under any circumstances.

Admission to a hospital before you become covered under the Plan

If you are admitted as a registered inpatient before the date you become covered under the Plan, the Plan

will not cover any charges associated with your stay.

Adoption expenses

Expenses not covered include, but are not limited to: adoption fees; court costs; expenses related to the

natural mother; and all expenses for the child prior to the date the child begins to reside with you in a

regular parent/child relationship.

Air conditioners, dehumidifiers, humidifiers, or other equipment to alter the air or temperature

These are not covered under any circumstances. Refer to pages 68 and 86.

Annual maximums

Services in excess of annual maximums are not covered under any circumstances, with the exception of

Tier II benefits through Medica Self-Insured.

Appointments missed/canceled

Charges for missed or canceled appointments are not covered under any circumstances.

Artificial insemination

Artificial insemination is not covered under any circumstances.

Autologous blood donations/storage

The Plan does not cover charges related to donating and storing your own blood for any reason, even if the

services are performed prior to a planned surgical procedure that would generally require a blood

transfusion.

Autopsy

The Plan does not cover the expenses associated with an autopsy.

EXCLUSIONS


Blood or blood plasma

The Plan does not cover expenses related to the acquisition of blood or blood plasma (it does, however,

cover the cost of transfusions).

Chelating agents

Any service, supply or treatment for which chelating agents are used are not covered, except for treatment

of heavy metal poisoning.

Complications arising from any non-covered surgery

If the initial surgery is not covered, treatments for complications arising from the surgery are not covered.

Confinement in an institution not covered under the Plan

The Plan does not cover charges for confinement in an institution which is not covered under the Plan.

Contact lenses/prescription lenses (eyeglasses)*

Except as noted on page 67 for the first pair of corrective lenses immediately following cataract surgery,

charges for contact lenses or eyeglasses are not covered.

Convenience items

Convenience items are not covered under any circumstances. Such items include, but are not limited to:

telephone and television rental, guest meals, and guest accommodations.

Correction of structural imbalance, distortion, or subluxation

The Plan does not cover the diagnosis, detection, and correction (by manual or mechanical means) of

structural imbalance, distortion, or subluxation to remove nerve interference and its effects. This exclusion

applies when the nerve interference is the result of or related to distortion, misalignment, or subluxation of

or in the vertebral column.

Cosmetic or plastic surgery

The Plan does not cover any procedure, service, equipment or supply which improves, alters, or enhances

appearance, whether or not for psychological or emotional reasons, except as noted on page 76.

Court appearances

The Plan does not cover costs related to any court appearance, proceeding or hearing.

Custodial supportive care or maintenance care (including sanitorium care, rest care, unskilled

nursing, or unskilled rehabilitation services)

These types of care are not covered under any circumstances. (See page 51 for the definition of custodial

supportive care and page 55 for the definition of maintenance care.)

* Medica Self-Insured does not cover contact lenses or eyeglasses following cataract surgery.

EXCLUSIONS


Dental services or treatment

The Plan does not cover any dental services or treatment other than those noted on page 68. Services not

covered include, but are not limited to:

��Alveolectomy

��Apicoectomy (dental root

resection)

��Care of gums or bones

supporting teeth

��Dental cleanings or

fillings

��Dental implants

��Dental prosthesis, braces,

and in-mouth appliances

�� False teeth

�� Frenectomy

�� Incision and drainage of

cellulitis

�� Incision of sinuses,

salivary glands, or ducts

��Myofunctional alteration

��Orthodontics, including

braces

��Orthognathic surgery

�� Placement of

subperiosteal orthopedic

bone plates

�� Planing or scaling

��Removal of exostosis

��Repair, removal or

replacement of teeth

��Root canal therapy

�� Simple tooth extractions

�� Soft tissue impactions

�� Treatment of cavities

�� Treatment of injuries to

or diseases of the teeth or

gums other than the

initial emergency

treatment

�� Treatment of periodontal

abscess or dentigerous

cysts

�� Treatment of

temporomandibular joint

(TMJ) syndrome, unless

precertified as medically

necessary (see page 81)

Discount

The Plan does not cover the portion of any charge which represents a discount.

Durable medical equipment (DME) and other equipment

The following items are not covered:

��Air conditioners

��Air filter systems

��Air purifiers

��Arch supports

��Back-up generators

��Bath chairs

��Bathtub rails

��Breast pumps

��Corsets

��Dehumidifiers

�� Environmental control

equipment

�� Exercise equipment,

including but not limited

to weight training

equipment

�� Foot orthotics or

special/corrective shoes

��Humidifiers

�� Jobst stockings

��Raised toilet seats

�� Shoe inserts

�� Shower stools

�� Stair glides

�� Swimming pools

�� Toilet rails

�� Tub benches

��Whirlpools

Education, special education, or job training

These services are not covered, even if provided in a facility that also provides treatment for medical,

mental disorders or substance abuse conditions.

Educational, vocational, or other training services, counseling or supplies

These are not covered for any purpose, including speech, language, learning deficiencies or behavioral

problems. (Diabetic education is covered, however, as noted in the cost-sharing charts.)

Embryo implants

Embryo implants are not covered under any circumstances.

Eyeglasses*

Except as noted on page 67 for the first pair of corrective lenses immediately following cataract surgery,

charges for contact lenses or eyeglasses are not covered.

* Medica Self-Insured does not cover contact lenses or eyeglasses following cataract surgery.

EXCLUSIONS


Family members/household members

The Plan does not cover expenses associated with care you get from an individual who normally resides in

your household or is a member of your immediate family. Your immediate family includes parents,

siblings, spouses, children, grandparents, aunts, uncles, nieces and nephews, as well as similar family

members related to you by marriage.

Fetal implants

Fetal implants are not covered under any circumstances.

First aid supplies

Common first aid supplies and medical supplies for home use are not covered under any circumstances.

Food supplements, or food substitutes/nutritional supplements

These are not covered under any circumstances, except as noted on pages 69 and 75 for treatment of PKU

and related conditions.

Free care

The Plan does not cover any care if the care is given to you without charge or would normally be given to

you without charge. This exclusion applies if the care would have been given to you with no charge if you

had not been covered under the Plan or under any other health-benefit plan or insurance.

Gender reassignment

Services for gender reassignment are not covered under any circumstances. Also not covered are any

complications arising from procedures to alter your sex from one gender to the other. Further, other

services related to gender reassignment or disturbance of gender identification or circumstances are not

covered.

Genetic testing or genetic counseling

Charges for genetic testing or genetic counseling are not covered.

Government hospitals

Except for payment for non-military service connected disabilities, the Plan does not pay for care or

supplies in any hospital or other institution which is owned, operated, or maintained by the Veterans

Administration or the federal government, unless the hospital is a network hospital. The Plan does not

cover any other care or supplies in any other hospital or other institution which is owned, operated, or

maintained by the federal government. (The Plan does cover, however, services in such a hospital if,

because of serious injury or sudden illness, you are taken there for emergency care because it is the closest

facility to the place where you were injured or became ill that can render care. In that case, the Plan covers

the services which are considered to be medically necessary as emergency care, provided it was not

possible for you to be sent to another hospital.)

Government programs

The Plan does not cover:

�� Services to the extent that such services are payable by Medicare as the primary payer, or any other

federal, state, or local government program;

�� Treatment of disabilities from diseases contracted or injuries sustained as a result of military service or

war, declared or undeclared, or any act of war, for which you are legally entitled to services at

government facilities, where available;

�� Services or supplies that any school system is required by law to provide; or

�� Services or supplies required by law to be covered under the provisions of any Workers'

Compensation, no-fault automobile insurance, or similar law.

Hearing aids and related supplies

These are not covered under any circumstances.

EXCLUSIONS


Hospice services that are not covered

The following hospice services are not covered:

�� Services by volunteers or persons who do not normally charge for their services;

�� Services by a licensed pastoral counselor to a congregation member in the normal course of duties as a

pastor or minister;

��Charges for funeral arrangements;

��Charges for financial or legal counseling, including estate planning and the drafting of a will;

��Homemaker or caretaker services; and

��Bereavement counseling in excess of Plan maximums determined by the third-party administrators as

consistent with local practice.

Illegal acts

The Plan does not cover expenses arising as the result of or in the course of the patient committing an

illegal act.

Infertility treatment

The Plan does not cover artificial insemination, in vitro fertilization, fertility drugs, GIFT, ZIFT, charges

involving surrogates, storage of eggs or semen, fetal implants, embryo implants, sonograms, or other

infertility or surgical procedures. (The Plan does, however, cover the diagnostic workup to confirm a

diagnosis of infertility.)

Instructional programs

The Plan does not cover instructional or educational programs (such as, but not limited to, childbirth

classes, vocational training and testing, weight-loss or smoking cessation – some of the plans do offer

optional specialized programs for certain of these conditions). Diabetic education is covered, however, as

noted in the cost-sharing tables.

Investigative procedures, tests, treatments, drugs, devices, or services

These are not covered under any circumstances. (See page 54 for the definition of investigative.)

In vitro fertilization

Expenses related to in vitro fertilization are not covered under any circumstances.

Lasix surgery

Charges related to Lasix eye surgery are not covered under any circumstances.

Learning disorders, developmental delays or mental retardation, defects and deficiencies

Expenses related to services, treatment, educational testing, or training for learning disorders,

developmental delays, or mental retardation, defects and deficiencies are not covered. This exclusion does

not apply, however, to covered mental health services or to medical treatment of those with these listed

conditions which would otherwise be covered under the Plan.

Lifetime maximums

Expenses in excess of lifetime maximums are not covered under any circumstances.

Mammaplasty

The Plan does not cover mammaplasty done for augmentation, reduction, asymmetry, or removal of

silicone implants unless it is determined by the appropriate third-party administrator’s Medical Director to

be medically necessary or is required by law to achieve symmetry following a covered mastectomy.

EXCLUSIONS


Mandated or court-ordered care

The Plan does not cover any medical, psychological, or psychiatric care which is the result of a court order

or mandated by a third party (such as your employer, licensing board, recreation council, or school). The

Plan does not cover care for conditions that state or local law requires to be treated in a public facility,

including but not limited to, commitment due to mental disorders.

Massage therapy

The Plan does not cover charges for massage therapy under any circumstances.

Medical reports

The Plan does not cover charges for medical reports or for provider appearances at hearings or court

proceedings.

Motor-vehicle-accident-related services

The Plan does not cover services that are eligible for payment under the provisions of an automobile

insurance contract or pursuant to any federal or state law which mandates indemnification for such services

to persons suffering bodily injury from motor vehicle accidents, where permitted by state law.

Nutritional counseling

The Plan does not cover dietary control counseling or weight maintenance programs.

Obesity

The Plan does not cover any surgery, medical service or supply meant for the control of obesity or morbid

obesity (such as dietary control, counseling or weight maintenance programs), even if the obesity or

morbid obesity aggravates another condition or illness, except as noted under “Covered expenses/supplies”

on page 73.

Occupational therapy supplies

The Plan does not cover occupational therapy supplies, even if the occupational therapy itself is covered.

Organ and tissue transplant services

The Plan does not cover artificial organs, artificial parts, non-human donors, implantation services, and

other related services. Only transplant expenses as specified on page 75 are covered.

Medical expenses of an organ donor are typically charged to the organ recipient. The Plan does not cover a

non-Unisys donor in a transplant procedure unless the recipient of the transplant is a Unisys participant in

this Plan or another Unisys health plan. If the Unisys Plan participant is the recipient, coverage is provided

only for a live donor, to the extent benefits are unavailable from any other source.

Palliative care

See the definition on page 56. The Plan excludes treatments which are solely of a palliative nature, with

the exception of precertified palliative care given to the terminally ill through a covered hospice program.

Personal convenience items

The Plan does not cover expenses associated with personal convenience items. Excluded items include,

but are not limited to, telephone and television rentals, guest trays, or guest accommodations.

Plastic or reconstructive surgery

See pages 57 and 76.

Premarital laboratory work

Premarital laboratory work is not covered under any circumstances.

EXCLUSIONS


Preparation of itemized bills or benefits requests

The Plan does not cover expenses associated with the preparation of itemized bills, benefits requests or

claim forms.

Preventive or routine care

Preventive or routine examinations, immunizations, and inoculations are covered only if the services are

provided by your PCP/PCC* ** or network OB/GYN, subject to the frequency and services deemed

appropriate by the third-party administrator for the patient’s age, sex and geographic location.

Private duty nurses

Private duty nurses generally are not covered. The few exceptions are described elsewhere in this booklet

and must be approved by the Medical Director for the appropriate third-party administrator or the

director’s designee.

Private room

If you occupy a private room, you must pay the difference between the hospital's charges for a private room

and the hospital's most common charge for semi-private accommodations. If the appropriate third-party

administrator determines that it was medically necessary for you to have a private room, or if a semi-

private room was not available, however, the Plan will cover the private room.

Refractive eye procedures

Charges for refractive eye procedures to improve/correct vision are not covered under any circumstances.

The excluded procedures include, but are not limited to: radial keratotomy, laser eye surgery, and lasix

surgery.

Required examinations

The Plan does not cover examinations for obtaining or maintaining employment, insurance or professional

or other licenses. Further, the Plan does not cover examinations before athletic or recreational activities or

for school, camp, or other program unless it is coincidentally the periodic routine examination by your

designated PCP/PCC* ** or network OB/GYN.

Resident physician or intern

The Plan does not cover services provided by a resident physician or intern rendered in that capacity.

These typically are billed as part of the inpatient or outpatient care from the facility.

Respite care

Respite care is not covered with the exception of precertified respite care given to temporarily relieve the

primary caregiver of the terminally ill through a covered hospice. To be covered, the respite care must be

precertified.

Reversal of any sterilization procedure

The reversal of any sterilization procedure is not covered, even if the sterilization procedure was covered.

Routine foot care

The Plan does not cover routine foot care for the cutting or removal of corns or calluses, or the trimming of

nails (including mycotic nails) when not medically necessary. (Note: Diabetic foot care coordinated by

your PCP/PCC* ** is covered, as well as routine foot care if you have a peripheral vascular disease,

peripheral neuropathies, or blindness.)







EXCLUSIONS


Safe surrounding

Charges for care furnished mainly to provide a surrounding free from exposure that can worsen a medical

condition or mental disorder are not covered.

Second surgical opinion and consultation with specialist

The Plan does not cover both a second surgical opinion and a consultation with the same specialist for the

same surgical procedure.

Self-referred services* **

The Plan does not cover most services obtained without prior written or electronic referral by your

PCP/PCC* **. The exceptions are:

�� Routine gynecological care by a network specialist;

�� Covered vision examinations by a network specialist; and

�� Self-referral services that the third-party administrator endorses throughout their network – if in doubt,

contact Member Services at the telephone number on the inside front cover of this booklet to

determine if self-referral is available for the services you require

Speech therapy

Except as noted on page 78, the Plan does not cover speech therapy, evaluation, diagnosis, or treatment.

The Plan does not cover the diagnosis and correction of speech impediments (stuttering or lisps, for

example), assistance in the development of verbal clarity, or treatment of children diagnosed with learning

disorders, developmental delays or non-severe communication deficits.

Surrogate mother's expenses

Expenses related to surrogate mothers are not covered under any circumstances.

Telephone calls

The Plan does not cover charges for telephone calls, including calls made by your provider to another

provider or to a health-care plan. The telephone expenses and provider's time spent on the phone are

excluded.

Transfer to a different hospital

The Plan does not cover admission to a different hospital when care for the condition is available at the

network hospital where you were first admitted.

Travel, transportation, or living expenses

The Plan does not cover the travel, transportation, or living expenses of a physician or a covered person

except professional ambulance services as listed under “Covered Expenses” or travel expenses for

treatment authorized through the case management programs of the third party administrator. These

programs generally are limited to situations involving highly specialized care at designated treatment

facilities or for organ or tissue transplants at designated treatment facilities. In those situations, the case

manager will indicate what travel expenses may be reimbursed.



provider, as well as all covered services ordered or coordinated by the self-referral provider. You pay more under

Tier II than when you obtain a referral from your PCC (Tier I).



EXCLUSIONS


Travel-related immunizations

Travel-related immunizations are not covered.

EXCLUSIONS


Treatment not prescribed or recommended by a physician

Treatment not prescribed or recommended by a physician is not covered under any circumstances.

Vaccinations, inoculations, or immunizations

These services are covered only if provided by your PCP/PCC* ** and not done strictly for travel

requirements.

Vision training therapy or vision perception training

These services are not covered under any circumstances.

Voice training and voice therapy

Except as noted on page 78, the Plan does not cover voice or speech therapy, evaluation, diagnosis, or

treatment. The Plan does not cover the diagnosis and correction of speech impediments (stuttering or lisps,

for example), assistance in the development of verbal clarity, or treatment of children diagnosed with

learning disorders, developmental delays or non-severe communication deficits.

Work-related condition or disability treatments

The Plan does not cover any service, supply, or treatment due to a condition or disability that would entitle

you to any benefit under a Workers' Compensation act or similar legislation.







SPECIAL PROGRAMS


SPECIAL PROGRAMS

SPECIAL PROGRAMS


SPECIAL PROGRAMS

In addition to the numerous benefits described earlier in this booklet, the third-party administrators provide

a number of special programs designed to:

�� Enhance your life style,

�� Keep you healthy, or

�� Assist you when you have complex special health-care needs.

Some offer discounts on alternative medical treatments that are not covered by the Plan.

These programs are described separately in literature provided by the appropriate third-party administrator,

in newsletters, and on their websites (see page 6 for URL addresses). You are encouraged to read literature

you receive at home and to access the websites frequently.

CLAIMS, COMPLAINTS, APPEALS


CLAIMS AND COMPLAINT/APPEALS

PROCEDURE



HOW TO FILE A CLAIM

Network providers submit benefits requests for all services they perform. You are required to submit a

written request for payment of expenses associated with services you receive from non-network providers

— for example, for treatment of a medical emergency.

Information needed for a claim

Your written request should include all of the following information:

��Name and Social Security number of the Unisys employee or former Unisys employee;

��Contract number shown on your medical ID card (not your Paid Prescription Drug ID card); and

�� Itemized statement from the provider showing the dates of service, the diagnosis code, the procedure

codes for their services, the full name and address of the provider, and the charge for each service.

Address for claims submissions

Your written request with the information noted above, should be forwarded to the appropriate third-party

administrator at one of the following addresses:

Aetna U.S. Healthcare

Member Services

980 Jolly Road

PO Box 129

Blue Bell PA 19422-0770

HealthPartners, Inc.

Claims Department

8100 – 34th Avenue South

PO Box 1289

Minneapolis MN 55440-1289

Medica Self-Insured

Route 2901

PO Box 169061

Duluth MN 55816-8310

For services on and before 6/30/01

SelectCare, Inc.

PO Box 369

Troy MI 48007

For services on and after 7/01/01

Select Advantage

ABS, Inc.

PO Box 37506

Oak Park MI 48237-0506

You will receive an explanation of benefits (EOB) statement that indicates payments and the balance of

submitted expenses for which you are responsible.

Some expenses are not reimbursable

Following are some examples of situations for which benefits may not be payable. The list is not all-

inclusive.

��You receive treatment from a provider other than your PCP/PCC* ** in a non-emergency situation

without a prior written or electronic referral from your PCP/PCC* **.

��You obtain services in the emergency room of a hospital and your condition did not meet the

requirements for a medical emergency or urgent medical need.

��You receive post-emergency (or post-urgency) follow-up treatment without a prior written or electronic

referral from your PCP/PCC* **.

��You receive services not covered under the Plan.

* Note for Medica Self-Insured members: Medica allows you to refer yourself to network providers without referral

from your PCC. This is called “self-referral.” Tier II benefits apply for all covered services directly from the self-

referral provider, as well as all covered services ordered or coordinated by the self-referral provider. You pay more

under Tier II than when you obtain a referral from your PCC (Tier I).





Following are some examples of situations for which part, but not all, of the submitted expenses may be

payable. The list is not all-inclusive:

�� Part or all of the expenses are payable under other coverage which pays before this Plan.

�� The expenses submitted exceed R&C (see page 57 for a definition of R&C).

�� Services exceed benefit maximums (for example, chiropractic care, physical therapy, treatment for

mental health or substance abuse, or home-health care).

Filing limitations

Your request for payment should be submitted as early as possible, and in no event later than 12 months

after you receive the service. If the Plan is ever terminated, final benefits requests must be received within

90 days of the date the Plan is terminated.

Payees

Payment is made directly to the provider.

Delayed payments

In the event that a benefit is denied in whole or in part and a complaint is filed or an appeal is made, the

Plan is not obligated to pay any part of the disputed expense until a final determination has been made

under the complaint and appeals procedure described below.

Right to recover excess payments

If payments are made in excess of the benefits due under the Plan, Unisys has the right to recover these

excess payments from any person or organization to whom the excess payments are made. If excess

payments are made to you, and upon request to do so you fail to return the excess payments, further

payments are withheld until the full excess payment amount is recovered.

COMPLAINT AND APPEALS PROCEDURE

You have the right to register complaints and appeal determinations made by the third-party administrator.

The Plan is obligated to hear and resolve complaints, according to the procedures described in this section.

This includes complaints about network providers and disagreements with benefit determinations.

Registering a Complaint or Disagreement with a Determination

If you submit a request for medical benefits and your request is denied in whole or in part, you will receive

a determination explaining why your request has been denied, and advising you of your right to appeal the

determination.

The following pages outline the informal process to resolve disagreements and the formal process for

submitting complaints or appealing medical benefit determinations under the Plan.

1. Contact Member Services

If you have a complaint, or a benefit has been denied in part or in full and you disagree

with this determination, call Member Services at the telephone number listed inside the

front cover of this supplement. To assist in the investigation of your complaint or

disagreement, provide as many of the pertinent details relating to your complaint as

possible. For example, be sure to include the full names of the persons involved, the dates

involved, and the chronological sequence of events.

If your complaint involves issues relating to quality of health care rendered by a network

provider, you also should attempt to discuss the quality of care issues with the provider.

The Member Services representative will assist you in trying to resolve the complaint or



disagreement on an informal basis. The representative also will document the complaint.

Most disagreements can be resolved at this level.

2. Submit missing information or an informal written complaint

The written notice explaining why a benefit request is denied refers to the provision upon

which the denial is based. If the denial is because you did not submit all the required

information, the written notice will tell you what is missing so that you can resubmit the

request. The written notice also explains the review procedure.

If discussions with the Member Services Department are not satisfactory, you may submit

a written complaint or disagreement with a benefits determination to the appropriate plan

administrator at:

Aetna U.S. Healthcare

Member Services

MidAtlantic Grievance Appeals

PO Box 936, Mail Stop U296

Blue Bell PA 19422

Fax 215-775-5168

Member Services

HealthPartners, Inc.

8100 – 34th Avenue South

PO Box 1309


Medica Self-Insured

Customer Services

Route 0501

PO Box 9310


SelectAdvantage

ABS, Inc.

PO Box 37506

Oak Park MI 48237-0506

You will receive a reply within 45 days of receipt of the written request unless additional

information is necessary from you or the provider, in which case, the reply will be

forwarded within 45 days of receipt of the additional information.

It will be assumed that the complaint has been satisfactorily resolved unless you file a

formal grievance within 60 days of the date of the reply to your initial complaint.

3. Submit a formal grievance for review by the third-party administrator

The grievance committee or equivalent group for each of the third-party administrators

reviews and investigates all formal grievances within 30 days of receipt unless additional

information required to resolve the grievance is not received from you or the provider

during the 30-day period. The decision of the grievance committee or equivalent group is

final and binding unless you appeal to the Unisys Employee Benefits Administrative

Committee within 30 days of the date of the decision by the grievance committee.

4. Request review by the Unisys Employee Benefits Administrative Committee

If a request for benefits is denied in whole or in part by the third-party administrator’s

grievance committee, and you disagree with the determination, you have the right to

appeal the determination and request a review by the Unisys Employee Benefits

Administrative Committee, which is responsible for ensuring that the Plan is administered

in accordance with the terms of the Plan and for interpreting the Plan provisions.

Your appeal must be in writing and should be sent to the appropriate third-party

administrator within 60 days after you receive the determination from the grievance

committee. Your appeal should include all information, evidence, and documents that may

support your request, and you may review pertinent documents the third-party

administrator may have.

The third-party administrator will ensure that no mistake has been made at an earlier level



of review, and will forward your appeal to the Unisys Benefits Administrative Committee

on your behalf.

You will be notified of the Unisys Employee Benefits Administrative Committee's

decision within 60 days after your appeal is received. This period may be extended if you

are required to submit additional information, or if special circumstances require delay. In

any event, you will be notified of the Committee's decision no later than 120 days after

your appeal is received.

If your appeal is denied, the decision will be written in a manner calculated to be

understood by you and will specify the particular reasons for the decision.

A determination by the Unisys Employee Benefits Administrative Committee exhausts

your appeal rights under the Plan.

Appeals of Precertification Determinations

If you or your physician disagree with a precertification determination, you or your physician may appeal

by writing to the appropriate third-party administrator within 60 days of the date the decision is made.

Your case will be reviewed by a Medical Director or physician consultant different from the one who

originally determined that the care was not medically necessary.

Circumstances which may have prevented you from following the precertification guidelines and

procedures also are taken into consideration.

The third-party administrator will reach a decision within 30 days from the date your appeal of a

precertification determination is received. The administrator will tell you, your physician and any other

provider involved in your care of the decision. If you continue to disagree with the determination, you can

request that your appeal be heard by the Unisys Benefits Administrative Committee by following the

guidelines described in the preceding pages.

Appeals for the denial of a precertification when there is a serious medical emergency requiring rapid

processing, are handled in an expedited appeal process upon request.

ADDITIONAL INFORMATION



ABOUT THE PLAN



ADDITIONAL INFORMATION ABOUT THE PLAN

Refer to the Summary Plan Description (SPD) booklet referenced on the inside front cover of this

supplement for general information about the Official Plan Name, Plan Number, Plan Sponsor, Employer

Identification Number, Plan Year, Plan Administration and Named Fiduciary, Type of Plan,

Administration, Right of Recovery, Third Party Liability, Agent for Legal Process, Conflicts with Existing

Law, and Your Rights Under ERISA. In addition, the following is important information about the Plan.

In addition, the following information about the Plan is important.

Funding

Benefits are funded by Unisys Corporation and contributions by employees, former Unisys employees, and

their dependents.

Right to Receive and Release Needed Information

Certain facts are needed to apply some of the provisions of the Plan. The third-party administrators rely

mainly upon the information that you provide. The administrators also may collect information from other

sources to perform its functions with regard to application of the provisions of the Plan.

The third-party administrators have the right to decide which facts are needed.

Consistent with applicable state and federal law, needed facts may be obtained from or given to any other

organization or person, without your further approval or consent unless applicable federal or state law

prevents disclosure of the information without your consent. Information may be made available to:

�� The third-party administrators and their representatives in connection with benefits requests and

financial administration of the Plan. This includes Plan audits.

��Other health-care coverage providers, if the possibility of other coverage exists or there is a need to

preserve the continuity of your coverage.

�� Peer Review Organizations and other agencies to determine whether or not health-care services were

medically necessary or reasonably priced.

��Government regulators of health-care businesses and to others as required by law.

�� Law enforcement authorities when necessary to prevent or prosecute fraud or other illegal activities.

Right to develop guidelines

The third-party administrators have the right to develop or adopt guidelines that establish in more detail the

instances and procedures when the Plan will pay for services. Examples of the use of the guidelines are to

determine whether care was:

��Medically necessary,

��Covered or excluded emergency care in the outpatient department of a hospital, or

��Of a custodial, maintenance or palliative nature.

These guidelines interpret and illustrate the Plan provisions and will not be contrary to any term or part of

the Plan.



Access to records and confidentiality

By receiving benefits under the Plan, you authorize access to any health records and medical information

held by any health-care provider who delivers services to you under the Plan. You also authorize use of

your health records, when necessary, for: claims processing, including claims made for reimbursement or

subrogation; quality of care assessment; referrals to other providers; performance of case management;

underwriting; utilization review; utilization information to your treating providers; and evaluation of

potential or actual coverage under the Plan.

Medical records and information about your care that the Plan gets from providers are confidential. The

Plan will disclose information to others only as required to coordinate benefits, or with your written

consent. State and federal laws governing the confidentiality of medical records are followed at all times.

Amendments to this Supplement

Amendments included in this supplement, or sent to you at a later date, are incorporated and fully made a

part of the Plan.

Case review

The services of professional medical reviewers may be retained to examine and render expert opinions

regarding any charges, records or other documentation relating to expenses submitted to the Plan for

determination of benefits payable.

Extension of benefits

If you are confined in any institution in which benefits are available under the Plan when coverage ends,

benefits for the facility continue to be paid for the stay until the earlier of 90 days, the date of discharge

from the institution, or the date upon which the Plan's maximum benefit is reached.

INDEX


INDEX

INDEX


INDEX

A

Abortion, legal ..............................55, 66, 69, 81

Access to records ..........................................105

Acupresure......................................................84

Acupuncture ...................................................66

Aetna U.S. Healthcare ................................20

HealthPartners ............................................27

Medica ........................................................36

SelectAdvantage .........................................46

Adoption.....................................................8, 84

Air conditioner....................................69, 84, 86

Air filter ....................................................69, 86

Air purifier................................................69, 86

Allergy testing and treatment..........................74


HealthPartners ............................................24

Medica ........................................................31


Alternates to hospital care...............................50


HealthPartners ............................................24

Medica ........................................................32

Precertification............................................62

....................................................................42

Alternatives to hospital care


Ambulance......................................................66


Covered services.........................................50

Definition....................................................50

HealthPartners ............................................25

Medica ........................................................33


Ambulatory surgical center.................50, 66, 71

Amendments.................................................105

Amniocentesis ................................................66

Anesthesia ......................................................71

Covered services.........................................67

Dental treatment .........................................68

Anesthesia, inpatient


HealthPartners ............................................24

Medica ........................................................32


Arch support .............................................69, 86

Artificial insemination ..................72, 74, 84, 88

Autologous blood donations ...........................84

Automobile accidents .....................................89

Autopsy ..........................................................84

B

Bath chair ................................................. 69, 86

Bathtub rail............................................... 69, 86

Birthing center.......................................... 67, 71

Definition ................................................... 50

Blood/blood plasma.................................. 71, 85

Breast pump ............................................. 69, 86

C

Cancer screening ...................................... 67, 75

Aetna U.S. Healthcare................................ 16

................................................................... 23

Medica........................................................ 30

SelectAdvantage......................................... 41

Cardiac rehabilitation ..................................... 76

Cardiography.................................................. 71

Case review .................................................. 105

Cataract .................................................... 85, 86

Cataracts......................................................... 67

Chelating agents ............................................. 85

Chemotherapy .......................................... 67, 74

Chiropractic services ...................................... 77


HealthPartners ............................................ 27

Medica........................................................ 36


Chromosomal anlaysis.................................... 66

Circumcision ...................................... 55, 66, 81

Claims ............................................................ 98

Filing limitations ........................................ 99

Cognitive therapy ........................................... 76


HealthPartners ............................................ 28

Medica........................................................ 37


Complaints and appeals.................. 99, 100, 101

Contact lenses..................................... 67, 85, 86

Convenient/urgent care center

Definition ................................................... 51

HealthPartners ............................................ 24

Medica........................................................ 31

Copayment

Definition ................................................... 51

Corset ....................................................... 69, 86

Cosmetic................................. 51, 58, 76, 84, 85

Cost-sharing tables ......................................... 13

Aetna U.S. Healthcare.. 15, 16, 17, 18, 19, 20

HealthPartners ........ 21, 23, 24, 25, 26, 27, 28

INDEX


Medica ..............29, 30, 31, 32, 34, 35, 36, 37

SelectAdvantage39, 40, 41, 42, 43, 44, 46, 47

Custodial supportive care .51, 54, 58, 66, 70, 79,

85, 104

D

Deductible


HealthPartners ............................................23

Medica ........................................................30


Dehumidifier.......................................69, 84, 86

Delivery


HealthPartners ............................................24

Medica ........................................................32


Dental .......................................................55, 86


Covered ......................................................68

HealthPartners ............................................27

Medica ........................................................36

Not covered ................................................86


Developmental delays.....................................88

Diabetes self-management ........................86, 88


HealthPartners ............................................27

Medica ........................................................36


Diabetic supply

Glucometer ...........................................52, 68

Insulin pump...............................................68

Insulin pump supplies...........................52, 68

Lancettes...............................................52, 68

Syringes ................................................52, 68

Test strips .............................................52, 68

Dialysis .....................................................68, 71

Directory of network providers.........................6

Drugs and medicines, fertility.........................88

Drugs and medicines, inpatient...........71, 73, 80

Drugs and medicines, investigative ..........54, 88

Drugs and medicines, prescription......52, 68, 75

Drugs and medicines, take-home........52, 74, 80

Durable medical equipment (DME)


Covered ......................................................68

HealthPartners ............................................27

Medica ........................................................37

Not covered ................................................86



E

Education ....................................................... 86

Elective admission.......................................... 52

Elective surgery.............................................. 52

Embryo implant.................................. 72, 86, 88

Emergency........................ 10, 11, 52, 62, 71, 98

Emergency room .................. 11, 52, 62, 71, 104


HealthPartners ............................................ 25

Medica........................................................ 33


Encephalography............................................ 71

Environmental equipment .............................. 86

Exercise equipment ............................ 69, 73, 86

Extension of benefits .................................... 105

Eyeglasses .......................................... 67, 85, 86

F

Family or household members........................ 87

Fee, negotiated ............................................... 56

Fetal implant....................................... 72, 87, 88

First aid supplies ............................................ 87

Food supplements/substitutes......................... 87

Foot care......................................................... 90

Funding ........................................................ 104

G

Gender reassignment ...................................... 87

Generator, back-up ......................................... 86

Genetic testing/counseling.............................. 87

GIFT......................................................... 72, 88

Glucometer ........................................68, 69. See

Government programs.................................... 87

Guideline development................................. 104

H

Health club dues............................................. 73

Hearing aid ..................................................... 87

Home health care............................................ 53


Covered ...................................................... 70

HealthPartners ............................................ 24

Medica........................................................ 32

Not covered ................................................ 70

Precertification ........................................... 63


Home IV therapy


HealthPartners ............................................ 24

INDEX


Medica ........................................................32



Homebound ....................................................53

Hospice...........................................................53


Covered ......................................................70

HealthPartners ............................................24

Medica ........................................................32

Not covered ................................................88



Hospital ..........................................................54

Government ................................................87

Inpatient......................................................71

Transfer ......................................................91

Hospital emergency room .............11, 52, 62, 71


HealthPartners ............................................25

Medica ........................................................33


Hospital services

Covered ......................................................71


Private room .........................................71, 90

Hospital services, inpatient


HealthPartners ............................................24

Medica ..................................................31, 32


Hospital services, outpatient .............68, 71, 104


HealthPartners ............................................25

Medica ........................................................33


Hospital visits


Covered ......................................................72

HealthPartners ............................................24

Medica ........................................................32


Humidifier ..........................................69, 84, 86

Hypno-therapy ................................................84

I

In vitro fertilization.............................72, 84, 88

Infertility diagnosis .............................72, 74, 88


HealthPartners ............................................27

Medica ........................................................37


Infertility treatment .............................72, 74, 88


HealthPartners ............................................ 27

Medica........................................................ 37


Infertility treatments ....................................... 88

Inpatient ......................................................... 54

Instructional.................................................... 88

Insulin pump ............................................ 52, 68

Intern .............................................................. 90

Investigative/investigational ......... 54, 55, 68, 88

Itemized bill preparation................................. 90

J

Jobst stockings.......................................... 69, 86

L

Lab and x-ray ................................. 8, 68, 81, 89

Lab and x-ray, in office .................................. 74


HealthPartners ............................................ 24

Medica........................................................ 31


Lab and x-ray, independents..................... 67, 74


HealthPartners ............................................ 25

Medica........................................................ 33


Lab and x-ray, inpatient...................... 71, 73, 80


HealthPartners ............................................ 24

Medica........................................................ 31


Lab and x-ray, outpatient.......................... 74, 80

Laser eye surgery............................................ 90

Lasix surgery ............................................ 88, 90

Learning disorders.......................................... 88

Life-threatening .............................................. 55

Lifetime maximum ......................................... 88


HealthPartners ............................................ 23

Medica........................................................ 30


M

Maintenance care...... 55, 58, 66, 70, 79, 85, 104

Mammaplasty ................................................. 88

Mandated care ................................................ 89

Massage therapy ............................................. 89

Medical necessity ................. 52, 58, 66, 71, 104

Definition ................................................... 55

Medical report ................................................ 89

INDEX


Medical supplies .............................................56

Mental disorder...............................................56

Mental health treatments...........................72, 80


HealthPartners ............................................26

Medica ........................................................34



Missed appointments ......................................84

N

Newborn ...............................................8, 71, 72

Nutritional counseling ....................................89

O

Obesity............................................................89

Obesity, morbid ........................................56, 73

Occupational therapy ......................................77


Covered ......................................................70

HealthPartners ............................................28

Medica ........................................................37


Supplies ......................................................89

Office visits ....................................................74


HealthPartners ............................................24

Medica ........................................................31


........................................................................75

Orthotics ...................................................69, 86

Out-of-pocket maximum.................................84


HealthPartners ............................................23

Medica ........................................................30


Outside the service area ..................................11


HealthPartners ............................................12

Oxygen ...........................................................75

P

Palliative care ...........53, 56, 66, 70, 76, 89, 104

Aetna U.S. Healthcare ..........................17, 20

HealthPartners ................................24, 27, 28

Medica ............................................32, 36, 37

SelectAdvantage .............................42, 46, 47

Pathology........................................................68

Personal convenience..........................71, 85, 89

Physical therapy........................................75, 77


Covered ...................................................... 70

HealthPartners ............................................ 28

Medica........................................................ 37


PKU.......................................................... 69, 75


HealthPartners ............................................ 27

Medica........................................................ 37


Port wine stain

Medica........................................................ 37

Preadmission testing....................................... 75

Precertification ............................................... 62


HealthPartners ............................................ 23

Medica........................................................ 30


Premarital lab ................................................. 89

Prenatal care


Definiton .................................................... 57

HealthPartners ............................................ 23

Medica........................................................ 30


Private duty nurse........................................... 90

Prosthetic devises


Covered ...................................................... 69

HealthPartners ............................................ 27

Medica........................................................ 37


Provider, network ........................................... 56

Providers, covered .......................................... 53

Psychologically necessary care....................... 57

Pulmonary therapy.......................................... 78


HealthPartners ............................................ 28

Medica........................................................ 37


R

Radial keratotomy .......................................... 90

Radiation ........................................................ 75

Radiology ....................................................... 68

Reasonable and customary (R&C) ..... 57, 66, 99

Reconstructive surgery ................................... 76


Definition ................................................... 57

HealthPartners ............................................ 27

Medica........................................................ 37


Referral

INDEX


Definition....................................................58

Refractive eye procedure ................................90

Rehabilitative services ....................................76


HealthPartners ............................................28

Medica ........................................................37



Release of information..................................104

Resident physician..........................................90

Respite care ..................................53, 58, 70, 90

Restorative......................................................58

Reversal of sterilization ..................................90

Routine exams


HealthPartners ............................................23

Medica ........................................................30


S

Safe surrounding.............................................91

Scoping procedures.............................67, 78, 81

Second surgical opinion..................................91

Second surgical opinions ................................79

Self-insured managed-care option ....................2

Self-referral.....................................................91

Shoes, corrective.............................................86

Shoes, insert....................................................69

Shoes, inserts ..................................................86

Shoes, molded.................................................69

Shower stool .............................................69, 86

Skilled nursing..................50, 53, 58, 59, 70, 85


Skilled nursing facility..................54, 73, 79, 81


Definition....................................................58

HealthPartners ............................................24

Medica ........................................................32



Spa..................................................................73

Specialized treatment facility....................72, 80


Definition....................................................59

HealthPartners ............................................26

Medica ..................................................34, 35

SelectAdvantage ...................................44, 45

Speech therapy....................................78, 91, 93


Covered ......................................................70

HealthPartners ............................................28

Medica ........................................................37


Stair glide ....................................................... 69

Stair glides...................................................... 86

Storage of eggs or semen.......................... 72, 88

Substance abuse treatments ...................... 73, 80


HealthPartners ............................................ 26

Medica........................................................ 35



Surgery ........................................................... 81

Definition ................................................... 59


Surgery, assistants .......................................... 67

Surgery, inpatient


HealthPartners ............................................ 24

Medica........................................................ 31


Surgery, office ................................................ 74


HealthPartners ............................................ 24

Medica........................................................ 31


Surgery, outpatient ......................................... 75


HealthPartners ............................................ 25

Medica........................................................ 33


Surgical center.................................... 50, 66, 68

Surrogate ............................................ 72, 88, 91

Swimming pool ........................................ 69, 86

T

Telephone calls............................................... 91

Third-party administrators ................................ 2

TMJ................................................................ 81

Toilet rail .................................................. 69, 86

Toilet seat, raised...................................... 69, 86

Transplant

Covered ...................................................... 75

Designated facility...................................... 51

Not covered ................................................ 89


Travel ............................................................. 91

Tub bench................................................. 69, 86

Tubal ligation ............................... 55, 66, 79, 81

U

Urgent medical need......... 10, 11, 59, 62, 71, 98

Definition ................................................... 59

INDEX


V

Vascetomy ..........................................55, 66, 79

Vasectomy ......................................................81

Vision


HealthPartners ............................................23

Medica ........................................................31


Vision training ................................................93

Vocational rehabilitation.................................70

W

Well-child care


HealthPartners ............................................ 23

Medica........................................................ 30


Well-woman exams


HealthPartners ............................................ 23

Medica........................................................ 30


Whirlpool ....................................................... 86

Wigs and artificial hairpieces ......................... 69

Work-related................................................... 93

Z

ZIFT ......................................................... 72, 88

INDEX


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