Member Guide

Transamerica Financial Life Insurance Company (Harrison, NY) and Transamerica Premier Life Insurance Company (Cedar Rapids, IA)

Welcome ________________________________________________________________ 3

Contact Member Services _______________________________________________ 3

Medical Reimbursement Coverage _____________________________________ 4

Exclusions and Limitations _____________________________________________ 5

Direct Deposit __________________________________________________________ 6

FAQs About Coverage __________________________________________________ 7

Filing a Claim ___________________________________________________________ 9

Claim Filing Guidelines _________________________________________________ 10

FAQs About Filing A Claim ______________________________________________ 12

Prescription Visa® Card __________________________________________________ 13

FAQs About the Prescription Visa® Card ________________________________ 14

Take Me Home Emergency Program ____________________________________ 15

FAQs About Take Me Home Emergency Program ________________________ 17

Confidentiality __________________________________________________________ 18

Contents

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Welcome to Ultimate Health, an ACA excepted supplemental medical reimbursement insured plan. Your employer has chosen to provide you with this health plan because of the value you bring to your company and as an example of your company’s commitment to your health and to the wellbeing of your family. This Member Guide will assist you in understanding your Ultimate Health insurance plan.

Online Member Portal and Mobile AppMembers have access to a secure user-friendly online portal and mobile app to manage the medical reimbursement part of their Ultimate Health insurance plan. Using the portal or app, you can file a non-medical claim online and upload receipts, as well as view the status of claims and reimbursements. Members can also sign up to receive claim reimbursement via direct deposit. For instructions on how to log into the portal, see the “How to Use Your Member Portal” flyer accessible from your Online Resource Guide.

Information CardsYou have received two Ultimate Health contact information cards. These cards include the Member Services telephone number, hours of operation and the Member Portal site address. Please carry this card with you at all times for immediate access to the insurance plan’s services. You do not need to show this card to your providers at the time services are received. If you would like additional member cards for family members, please contact Member Services.

Contact Member ServicesFor your convenience, we provide you with one telephone number for all your Ultimate Health services. Additional contact information is also listed below.

Welcome

Ultimate Health is underwritten by Transamerica Financial Life Insurance Company (TFLIC), Harrison, NY, and Transamerica Premier Life Insurance Company (TPLIC), Cedar Rapids, IA. TFLIC is authorized to conduct business in New York. TPLIC is authorized to conduct business in all other states.

Transamerica Financial Life Insurance Company and Transamerica Premier Life Insurance Company are both rated by A. M. Best as A+ (Superior, 2nd out of 16 categories) for financial strength as of 6/24/17.

A registered mark of UnitedHealthcare Global, Take Me Home is provided by UnitedHealthcare Global and subject to their terms, conditions, limitations and exclusions.

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Member Services1-888-902-8971

Email: support@armadacare.comFax: 1-866-431-6339

Ask questions about a claim, services, Prescription Visa®, etc.

8:30 a.m. – 8:00 p.m. EST Mon – Fri

Take Me Home Emergency Program Hours

Get help when you are hurt, sick or hospitalized when traveling more than 100 miles from home

24/7/365Call 1-410-308-2906 collect

when traveling internationally

Our fully insured plan reimburses you for eligible health care expenses beyond what is covered by your employer-provided primary health insurance plan(s) in accordance with the policy coverage described in your Certificate of Insurance. Your insurance plan provides coverage, up to specific benefit limits, for the following benefit categories, or expense types:

Medical Out-of-Pocket ExpensesUltimate Health reimburses for eligible in-network co-pays, deductibles and co-insurance amounts, as well as eligible out-of-network co-insurance amounts, balance bills and deductibles. Ultimate Health will reimburse 100% of your out-of-pocket expenses if a Tier 1 network provider was used and 50% of your out-of-pocket expenses if a Tier 2 or Tier 3 network provider was used. It also covers virtually all 213(d)-eligible flex-type expenses, including in-home care, nursing, hearing services and transportation that is primarily for and essential to medical care.

Dental TreatmentsOur insurance plan provides coverage for various dental costs and procedures, up to plan benefit limits. Examples include expenses for crowns, child and adult orthodontia and implants

Vision TreatmentsYou will now have coverage for vision expenses such as designer prescription glasses, contact lenses and even LASIK surgery, subject to your plan benefit limits.

Prescription Drug TreatmentsOur insurance plan provides coverage for co-pays, brand name and lifestyle prescriptions. This benefit also includes a Prescription Visa® that provides point-of-purchase convenience and virtually eliminates the need to file claims manually.

Mental Health Our insurance plan provides coverage for Mental Health services and treatments as outlined in your Certificate of Insurance.

Medical EquipmentItems such as wigs, hearings aids, and orthotics are covered when medically necessary and prescribed by a physician.

Elective Executive PhysicalsOur insurance plan provides coverage toward comprehensive Executive Physicals to assist with benchmarking your current health status. These top-to-toe exams may include a thorough medical review, extensive blood work, vision and hearing tests, electrocardiogram, skin cancer screening and other tests for chronic conditions. You often receive a review of the available exam results that day along with recommendations for follow-up care.

Wellness TreatmentsThe Ultimate Health insurance plan includes coverage for certain wellness treatments. Wellness care treatments eligible for reimbursement include acupuncture and prescribed massage therapy. Chiropractic treatment would also fall under this category, too, unless it is covered by your primary medical plan, then it would fall under medical.

Medical Reimbursement Coverage

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For more information on covered expenses, exclusions and limitations please refer to your

Certificate of Insurance or call Member Services.

There are certain limitations and exclusions in your Ultimate Health insurance plan. Covered medical expenses are defined as reasonable expenses for necessary medical care. The following is a summary of common exclusions and is not a full list of exclusions. For a full list of exclusions, please refer to your Certificate of Insurance or call Member Services.

Benefits that will not be paid for:

w Expenses in excess of the policy or per-occurrence maximums and/or those expenses incurred prior to the coverage effective date.

w Treatment, services or supplies that: are not recommended, approved or certified by a provider as medically necessary to treat a sickness or injury; are received without charge or legal obligation to pay; would not routinely be paid in the absence of insurance; or are received from any family member.

w Expenses incurred as a result of loss due to war, or any action of war, declared or undeclared, or service in the armed forces of any country.

w Treatments, services or supplies provided by or reimbursable under Medicare or any other government program (except Medicaid).

w Injury or sickness arising out of or in the course of employment or which is reimbursable under any workers’ compensation or Occupational Disease Act or Law.

w Expenses incurred as a result of a cosmetic surgical procedure, cosmetic dental procedure or drug or medicines prescribed for cosmetic use, except reconstructive surgery incidental to or following surgery resulting from trauma, infection or other disease of the involved part or reconstructive surgery because of congenital disease or anomaly.

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Exclusions And Limitations

This is a partial summary of exclusions and limitations. Please see your Certificate of

Insurance for a complete list.

Direct Deposit will enable you to get your reimbursements faster, as we process direct deposits daily, regardless of the dollar amount of your reimbursements. You can receive your reimbursements via direct deposit regardless if you submit your claims online or by fax or mail.

Keep in mind that if you decide not to enroll in direct deposit, you will receive your reimbursements via check. Checks are only processed weekly and will only be issued once your reimbursements reach $25 or more. If your reimbursement total is less than $25, your check will not be processed until either the $25 level is reached or until the end of the month when we process checks for all amounts.

Setting up your direct deposit:

w Log onto the Member Portal and click on the Profile tab and then on Bank Account to fill in your bank information using this secure portal.

OR

w Complete a Direct Deposit Authorization form. Submit it via fax to 1-855-458-4479 or mail to 230 Schilling Circle, Suite 140, Hunt Valley, MD 21031

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Direct Deposit

What are per –occurrence limits? Per-occurrence refers to covered medical expenses that are incurred by the same covered person during any one plan year and that result from the same or related injury or sickness, the same course of dental treatment or the same course of vision treatment. For instance, if you break an arm, any eligible expenses for that arm break falls under that occurrence. If you later break a leg, those expenses would be a separate occurrence.

What is the difference between the per-occurrence benefit and the other benefit categories?The policy per-occurrence benefit limit can be applicable to multiple treatments for multiple enrolled family members during the course of the year, whereas the other limits are maximum annual limits per person and everything in that category accumulates to the single benefit maximum. For instance, if one family member has several different dental treatments, those would all accumulate toward the dental benefit as opposed to being tracked separately for each treatment or occurrence.

Are my family members covered?Generally, we provide coverage for your spouse and/or family when they are also covered by your company’s primary medical plan. Eligible dependents include your spouse and/or domestic partner and dependent children up to age 26.

What types of expenses are covered?Premiums, plans and programs vary by state. Generally, the policy follows most of the IRS 213(d) guidelines for what is a medically necessary and eligible expense. For information about coverage, exclusions and limitations, please refer to your Certificate of Insurance or call Member Services.

Are there any expenses that are not covered?Yes, there are certain limitations and exclusions. Covered medical expenses are reasonable expenses for necessary medical care. A summary of common exclusions is listed on page 5. For a full list of exclusions, please refer to your Certificate of Insurance or call Member Services.

FAQs About Coverage

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Can my long-term care premiumsbe reimbursed?No, this is not an eligible expense under this plan.

Can my employee health plan premiums be reimbursed?No, this is not an eligible expense under this plan.

Can I also submit an Ultimate Health claim to my FSA?Expenses previously reimbursed by any other plan or program, such as FSAs, are not eligible for reimbursement. IRS rules do not allow reimbursement for an expense that has already been paid for through another health plan or pre-tax account.

We take special care to ensure the reimbursement process is as simple and convenient as possible. Claims are reimbursed quickly, with average turnaround times between 5 to 7 business days of receipt.

In order to file a claim, first you must submit all medically necessary, eligible health care expenses to your company’s primary health plan(s) and any secondary insurance carrier(s). This is needed even if the medically necessary services are not covered by the primary plan. When you receive your Explanation of Benefits (EOB) from your primary (and secondary, if applicable) medical carrier, the remaining patient responsibility expense due can be filed with ArmadaCare for reimbursement.

Medical ClaimsMedical claims must be submitted using the medical claim form, which can be downloaded from your Online Resource Guide or visit www.ArmadaCare.com/myaccount. Send it along with supporting documentation to:

Human Resources AdventHealth 900 Hope Way Altamonte Springs, FL 32714 Phone: 407-357-2032

To maintain confidentiality, the claims filing process comes directly from you, unless you request someone to handle claims on your behalf, in which case we need a signed authorization form. To maintain privacy standards for Protected Health Information per HIPAA law, we cannot communicate to anyone except the adult plan participant (over age 18) about his or her claims unless we have a written authorization from that plan participant.

Filing A Claim

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Three Convenient Ways to File a Non-Medical Claim

1. OnlineVisit: www.ArmadaCare.com/myaccount

to submit non-medical claims online for the fastest reimbursement.

2. MobileDownload ArmadaCare on your mobile

device. Take a picture of your documentation and submit for reimbursement right from

your mobile device.

3. Paper ClaimsSend completed non-medical claim form

and supporting documentation by:Mail:

P.O. Box 449, Hunt Valley, MD 21031Fax:

1-866-431-6339Forms can be downloaded

from your Online Resource Guide, or visit the Member Portal at

www.ArmadaCare.com/myaccount.

Therefore, the following individuals should complete the authorization form, which stays in effect for 2 years:

• You: If you want your spouse or another trusted individual to contact ArmadaCare to ask about claims status or to follow up on requests for additional documentation.

• Your Spouse: If your spouse wants you or another trusted individual to contact ArmadaCare to ask about claims status or to follow up on requests for additional documentation.

• Dependents (Over 18): If you have dependents over 18 years old, each of those dependents will need to have an authorization form on file for a family member or another trusted individual to inquire about claims status or to follow up on requests for additional documentation.

Whether you submit a claim online, through the mail or fax, follow these simple steps:

1. Complete the Claim Information section with details pertaining to the expenses incurred, including:

» Date of Service

» Benefit Category/Condition Treated: insert accurate benefit category–Medical, Prescription, Dental, Vision, Mental Health, Preventive Care, Wellness, Durable Medical Equipment

» Diagnosis/Reason for Service: You do not need to provide a diagnosis code, but we do need at least a layman’s

description of the treatment in order to properly classify the claim. Please do not write “see attached” if using the claim form as it will cause the claim to be denied.

» Amount eligible for payment under Ultimate Health. This is the balance you are responsible for after the primary carrier(s) has processed the expense and made adjustments to the amount due. If more than one insurance carrier is paying toward this expense, the amount eligible reflect the balance after all the carriers have made their payments.

» Your signature and current date if using the claim form.

» You may list multiple claims at once. If another covered person in the family incurs a medical expense it must be submitted as a separate claim.

2. Always include the corresponding EOB(s) from the primary carrier(s) with the claim form.

» Out-of-Network (OON) Claims: Be sure to submit your primary insurance EOB, even if the OON doctor visit wasn’t covered by your primary insurance. If you owe more than the deductible/ coinsurance identified on the EOB, please provide the invoice for the balance due to the provider.

» Dental or Vision Claims: Please indicate that you have no primary coverage on the claim and submit an itemized bill and proof of payment for each service listed on the claim.

Claim Filing Guidelines

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» Elective Executive Physical Claims: Submit the detailed bill, along with the contract, demonstrating the entire amount that is your responsibility, and you will be reimbursed up to the plan benefit limit. Executive Physicals can only be conducted at specific AdventHealth facilities that offer Executive Physicals.

» Orthodontic Claims: Orthodontic treatments are commonly performed on a multi-yearcontracted basis. If you pay for the entire contract upfront, you must submit this expense in that plan year for reimbursement up to the plan year’s dental benefit limit. If you pay installments over the course of the contract, we will reimburse those installments as they are made up to the plan year’s dental benefit limit. In either case, provide a copy of the treatment plan contract along with a detailed receipt, and your primary plan EOB as applicable. In terms of adult orthodontia, we do cover adult orthodontia as long as it meets the basic medical necessity rule of the policy. This needs to be supported by a letter of medical necessity. It is not sufficient to send just a contract and payment records.

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FAQs About Filing A Claim

Why do I have to file a claim for reimbursement?ArmadaCare is not automatically notified by your primary health plan carriers when you have incurred a claim, and we do not pay providers directly. It is necessary for you to notify us and request reimbursement for eligible expenses.

Why do I have to submit an Explanation of Benefits (EOB) with a claim?All claims must first be processed by your primary insurance plan to ensure they have paid (or denied) their portion of the coverage. The EOB statement shows the amount that you owe after your primary plan has adjusted the charges and applied their portion of the payment. The resulting patient responsibility amount is what can be submitted to us for reimbursement. A medical claim must be submitted with an EOB.

Why do I have to file a claim for each dependent?Each covered person has separate per-occurrence coverage and dental, vision and other benefits up to the total Annual Family Maximum of your plan, which is why we need to track incurred claims individually.

When is the filing deadline for claims?The policy requires the claim to be filed within 90 days after the covered expense has been incurred. However, recognizing that it is not always reasonably possible to do so, claims are accepted up until 90 days after the Ultimate Health plan year end.

How quickly do I get reimbursed?The fastest way to get reimbursement is to submit your claims online and sign up for direct deposit. Typically, claims are processed 5 to 7 business days from when they are received, not including mailing time. A claim will take longer if the claim does not include all the required information.

Can my assistant file my claims?Yes, you can provide your assistant with your Member Portal log in information to submit and manage your claims. Keep in mind that in order for Member Services to speak to anyone (other than the claimant) about a claim, we must have an authorization form on file—whether the person inquiring is your assistant or a family member. Learn more.

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Prescription Visa® Card

Your insurance plan includes a pre-paid Prescription Visa® card to use for prescription co-pays at pharmacies whether online, mail order or in drug stores, grocery stores or any other convenient location. You cannot use this card to pay for over-the-counter items or for physician, dental or vision co-pays.

You will receive two Prescription Visa® cards. Each card will have the member’s name printed on the front. Any persons insured under Ultimate Health may use these cards. For additional cards, please contact Member Services.

Your Ultimate Health insurance plan prescription benefit is divided into two benefit level amounts: Prescription Benefit A and Prescription Benefit B. All prescription claims will initially apply to the first benefit level (Prescription Benefit A) amount of $10,000, regardless of the submission method (Prescription Visa® card, online or paper). After the first benefit amount (Prescription Benefit A) is exhausted, then claims will be applied to the second level (Prescription Benefit B). At the second level, only paper and online claims will be accepted as the Prescription Visa® card is only funded up to the first prescription benefit level (Prescription Benefit A). Your card will be replenished at the beginning of the new Ultimate Health plan year.

For more information on your Prescription Benefit Limits and the Prescription Visa® card, see “Your Prescription Benefit and Limits” flyer accessible from your Online Resource Guide. *Remember, if you are using the Prescription Visa® for mail order prescriptions, use the primary plan participant’s billing address.

Rx Plus ProgramIn 2015, all maintenance medications, in excess of the initial 30-day supply must be filled via mail order by Rx Plus Pharmacy, a member of AdventHealth. For more information, please visit www.myahsrx.com.

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FAQs About the Prescription Visa® Card

Can I purchase over-the-counter items with my Prescription Visa® card?No, you cannot pay for these items with your Prescription Visa® card as most such items are not eligible for coverage under IRS guidelines. .

Will the Prescription Visa® card charges show up on my credit report?No, you are not the account holder, and this is a prepaid card, not a credit card.

Will I need to check available funds on my Prescription Visa®?No, you don’t have to as we will monitor card balances. If you are concerned about reaching the limits on your card, please call Member Services, or check your prescription benefit status online.

Should I select “credit” when using my Prescription Visa®?Yes, you should select “credit” instead of “debit” as it is a prepaid card.

Why would my Prescription Visa® card charges be declined?Your card would be declined if you try to purchase over-the-counter medications without a prescription, pay for any medical, dental or vision co-pays or have depleted the limit set by the carrier. If you encounter any problems with your card, please contact Member Services.

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Take Me Home Emergency Program

Now you can have peace-of-mind whenever you are traveling more than 100 miles from home, whether for business or pleasure. Available through a partnership with UnitedHealthcare Global, our services include:

Paid Air Evacuation Services If you are hospitalized more than 100 miles away from home domestically or internationally, you will receive fully paid air evacuation services to a hospital of your choice. This benefit is not subject to your medical expense benefit maximums or per-occurrence limits but is subject to evacuation policy terms and conditions.

This service includes the cost and coordination of the following: 

w Emergency medical evacuationsw Transportation to join a hospitalized memberw Return of dependent children/traveling companionsw Transportation after stabilization w Repatriation of mortal remains Travel and Medical Emergency Support ServicesWhen traveling away from home, you have access to valuable travel and medical emergency support, including:

1. Medical Assistancew Urgent care referrals to pre-certified phys- cians, dentists and hospitals while traveling domestically and internationally w Medical translation services

w Transfer of insurance information to medical

providers, facilitation and/or guarantee of hospital payment to avoid treatment disruption

w Medical records transfer w Assistance in coordination of medication, vaccine and blood transfers or the replace- ment of contact lenses and medical devices

2. Travel Assistancew Emergency travel arrangements w Assistance in the replacement of lost or stolen travel documents w Legal referrals w Translation services w Emergency pet housing and/or pet return

3. Personal Security Assistance w Assistance with political evacuation (Performed on a fee-for-service basis)

w Referrals to specialized security providers w Assistance with crisis management/ evacuation planning

IF YOU HAVE WHAT YOU BELIEVE IS A MEDICAL EMERGENCY,

GO DIRECTLY TO THE EMERGENCY ROOM OR CALL YOUR LOCAL

EMERGENCY NUMBER.

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Take Me Home Emergency Program

Travel and Medical Emergency Support PortalYou have constant access to a travel portal to help you be prepared before you leave and stay protected during travel.

The travel portal includes the UnitedHealthcare Global Intelligence Center, which provides the latest medical and security information for more than 200 countries. You can:

w Learn medical facts about your destination including the quality of emergency services and medications as well as details on seeking and paying for routine emergency care.

w Find out about immunization requirements, medical alerts, general travel advice and country-specific diseases and health risks.

w Access a handy medical phrase translation tool and a drug translator to find out about drug equivalents in a specific country.

w Request a medical intelligence report outlining information and helpful travel tips if you are traveling with a specific health issue.

To learn more, please see the insert “How to Use Your Take Me Home Travel Program.”

*Take Me Home provides emergency medical evacuation to the hospital of the ArmadaCare® insured’s choice and repatriation of remains when traveling 100 miles or more from home. Take Me Home Emergency Travel services are provided by UnitedHealthcare Global and subject to their terms, conditions, limitations and exclusions.

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FAQs About Take Me Home Emergency Program

How do you help in the case of an emergency when I’m traveling? Whenever you are more than 100 miles away from your primary home and faced with a travel or medical emergency, our emergency response team stands ready to help you 24/7/365.

What is medical air evacuation? We have partnered with a well-known air evacuation company to provide worldwide medical evacuation services to our members 24/7. Our partner operates a fleet of state-of-the-art, medically equipped aircraft staffed with trained physicians and nurses to transport you from one hospital to another whenever you or a family member is hospitalized more than 100 miles away from home. This is subject to UnitedHealthcare Global terms and conditions.

What if medical air evacuation costs more than the per-occurrence or overall annual benefit?The medical air evacuation benefit is independent of the medical reimbursement benefit limits. There should be no out-of-pocket cost for you for covered medical air evacuations. However, you may incur medical costs for hospital or physician services. Such costs should first be submitted to your primary health plan carrier and then to ArmadaCare for reimbursement. These medical treatment charges are subject to your per-occurrence benefit limits.

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Confidentiality

We are required by law to maintain the privacy of your Personal Health Information (PHI) and have appropriate policies and procedures in place to do so. Your confidential information includes your PHI, whether oral, written or electronic and other non-public financial information. In accordance with the federal and state privacy laws, we have the right to use and disclose your PHI for payment activities and health care operations as explained in the Notice of Privacy Practices and where permitted by law. Because we are responsible for making sure your claims are processed and ensuring you can obtain important services related to your coverage, we may from time to time need to use and disclose your PHI to the plan sponsor and in situations where we are required by law to perform such disclosure.

Notice of Privacy Practices ArmadaCare is committed to keeping the confidential information of members private. Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), we are required to make our Notice of Privacy Practices available to our members. The notice outlines the uses and disclosures of protected health information, the individual’s rights and our responsibility for protecting the member’s health information. The Notice of Privacy Practices is accessible online from your Online Resources Guide. Please review it carefully. The privacy of your information is important to us. To obtain a paper copy of our Notice of Privacy Practices, please call Member Services.

Making Enrollment Changes To best serve you, it is important that ArmadaCare is kept apprised of dependent changes or address changes. A dependent change can result from a marriage, divorce, birth or adoption of a child. If you need to add or remove a dependent from the Ultimate Health insurance plan, or if you have a new address, we request that you contact your company’s Ultimate Health plan administrator as soon as possible.

Inquires or Complaints You may address any notices, inquiries or complaints by writing to:

Consumer Affairs Department2700 W. Plano Parkway-3DPlano, TX 75075

1308382 2/19 AHS