2019 Individual & Family Plan UCare Gold Member Contract
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2019 Individual & Family Plan
UCare Gold
Member Contract
85736MN023_contract
UC FVC_092018_60_C IA (08202018)Important Contact Information Right to Cancel
Customer Services You may cancel this Contract within 10 days of
1-877-903-0070 receiving it by delivering this Contract and a written
notice to UCare, 500 Stinson Blvd. NE, Attn:
TTY/Hearing Impaired: 1‑800‑688‑2534 toll free Customer Services, Minneapolis, MN 55413. Or
or 612‑676‑6810 mail a written notice to us at UCare, P.O. Box 52,
Minneapolis, MN 55440‑0052. This Contract must
Hours: 8 a.m. to 6 p.m. Monday‑Friday
be returned before midnight the 10th day after the
Customer Services offers free language interpreter
date you received it. The Contract will then be
services for non‑English speakers.
considered void from the beginning. You must pay
Mailing Address any claims incurred before it was cancelled. Notice
UCare of cancellation and return of this Contract by mail
P.O. Box 52 are effective if properly addressed, postage prepaid
Minneapolis, MN 55440-0052 and postmarked within the 10-day period noted
above. UCare will return all premium payments
Street Address made for this Contract within 10 days after receipt of
500 Stinson Boulevard NE notice of cancellation and the returned Contract.
Minneapolis, MN 55413‑2615
Website If You Want to Leave this Plan – Contact
ucare.org MNsure
If you choose to leave this plan, you must contact
UCare 24/7 Nurse Line MNsure at least one month before you want your
When you or your child gets sick in the middle of coverage to end. Your request can be verbal or in
the night or on the weekend, where can you turn writing. MNsure’s phone number is 1-855-366-7873
for help? For reliable health information 24 hours a or 651‑539-2099.
day, seven days a week, call the UCare 24/7 nurse
line. The nurses will offer advice when you’re not Reasons why you may want to end your coverage
feeling well and answer your health questions. They include, but are not limited to:
can also advise about whether you should go to an
• You are about to sign up for Medicare or join a
urgent care center or the emergency room (ER).
UCare Medicare Advantage plan
This service costs you nothing. Simply call the
phone number on your member ID card. • You obtained health insurance through an
employer
Renewal • You recently got married and have coverage
through your spouse
You may keep your current plan or change coverage
for the upcoming year during the annual open • You are eligible for Medical Assistance
enrollment period. You may also be eligible for special See the Ending Coverage section to learn more.
enrollment periods under certain situations. See the
Changing Your Coverage section to learn more.
This health plan may not cover all your health care
expenses. Read this Contract carefully to learn
which expenses are covered.
2 2019 UCare Member ContractNotice of Nondiscrimination
UCare complies with applicable Federal civil rights Oral grievance
laws and does not discriminate on the basis of race, If you are a current UCare member, please call the
color, national origin, age, disability or sex. UCare number on the back of your membership card.
does not exclude people or treat them differently Otherwise please call 612-676-3200 or toll free at
because of race, color, national origin, age, disability 1-800‑203-7225 (voice); 612-676-6810 or toll free
or sex. at 1‑800‑688-2534 (TTY). You can also use these
We provide aids and services at no charge to people numbers if you need assistance filing a grievance.
with disabilities to communicate effectively with us, Written grievance
such as TTY line, or written information in other
formats, such as large print. Mailing Address
UCare
If you need these services, contact us at Attn: Appeals and Grievances
612‑676‑3200 (voice) or toll free at 1-800-203-7225 PO Box 52
(voice), 612‑676‑6810 (TTY), or 1-800-688-2534 Minneapolis, MN 55440-0052
(TTY). Email: cag@ucare.org
Fax: 612-884-2021
We provide language services at no charge to people
whose primary language is not English, such as You can also file a civil rights complaint with the
qualified interpreters or information written in other U.S. Department of Health and Human Services,
languages. Office for Civil Rights, electronically through the
Office for Civil Rights Complaint Portal, available at
If you need these services, contact us at the https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by
number on the back of your membership card or mail or phone at:
612‑676‑3200 or toll free at 1-800-203-7225 (voice);
612-676-6810 or toll free at 1-800-688-2534 (TTY). U.S. Department of Health and Human
Services
If you believe that UCare has failed to provide these 200 Independence Avenue SW
services or discriminated in another way on the basis Room 509F, HHH Building
of race, color, national origin, age, disability or sex, Washington, D.C. 20201
you can file an oral or written grievance. 1-800-368-1019, 1-800-537-7697 (TDD)
Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.
3ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al
612-676-3200/1-800-203-7225 (TTY: 612-676-6810/1-800-688-2534).
LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau
612-676-3200/1-800-203-7225 (TTY: 612-676-6810/1-800-688-2534).
XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama.
Bilbilaa 612-676-3200/1-800-203-7225 (TTY: 612-676-6810/1-800-688-2534).
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số
612-676-3200/1-800-203-7225 (TTY: 612-676-6810/1-800-688-2534).
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 612-676-3200/
1-800-203-7225（TTY：612-676-6810/1-800-688-2534）。
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.
Звоните 612-676-3200/1-800-203-7225 (телетайп: 612-676-6810/1-800-688-2534).
ໂປດຊາບ: ຖາ້ ວາ່ ທາ່ ນເວົ້າພາສາ ລາວ, ການບໍລກ
ິ ານຊວ
່ ຍເຫຼືອດາ້ ນພາສາ, ໂດຍບໍ່ ເສັຽຄາ່ ,
ແມນມີ
່ ພອ້ ມໃຫທ
້ າ່ ນ. ໂທຣ 612-676-3200/1-800-203-7225 (TTY: 612-676-6810/1-800-688-2534).
ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር
ይደውሉ 612-676-3200/1-800-203-7225 (መስማት ለተሳናቸው: 612-676-6810/1-800-688-2534).
ymol.ymo;=erh>uwdRAunDAusdmtCdAusdmtw>rRpXRvXAwvXmbl.vXmphRAeDwrHRb.ohM.vDRIA
ud; 612-676-3200/1-800-203-7225 (TTY: 612-676-6810/1-800-688-2534).
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur
Verfügung. Rufnummer: 612-676-3200/1-800-203-7225 (TTY: 612-676-6810/1-800-688-2534).
្របយ័ក�៖ េបើសិនជ឵អ� កនិយ឵ ភ឵ស឵រ �ខ� រ, រសវ឵ជំនួយរ �ផ�កភ឵ស឵ េដ឵យមិនគិតឈ��ល
គឺឤចម឵នសំរ឵ប់បរំ រ �អ� ក។ ចូ រ ទូ រស័ព� 612-676-3200/1-800-203-7225 (TTY: 612-676-6810/
1-800-688-2534)។
اﺗﺼﻞ ﺑﺮﻗﻢ. ﻓﺈن ﺧﺪﻣﺎت اﻟﻤﺴﺎﻋﺪة اﻟﻠﻐﻮﯾﺔ ﺗﺘﻮاﻓﺮ ﻟﻚ ﺑﺎﻟﻤﺠﺎن،إذا ﻛﻨﺖ ﺗﺘﺤﺪث اذﻛﺮ اﻟﻠﻐﺔ: ﻣﻠﺤﻮظﺔ
.(612-676-6810/1-800-688-2534 : )رﻗﻢ ھﺎﺗﻒ اﻟﺼﻢ واﻟﺒﻜﻢ612-676-3200/1-800-203-7225
ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement.
Appelez le 612-676-3200/1-800-203-7225 (ATS : 612-676-6810/1-800-688-2534).
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
612-676-3200/1-800-203-7225 (TTY: 612-676-6810/1-800-688-2534) 번으로 전화해 주십시오.
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad. Tumawag sa 612-676-3200/1-800-203-7225 (TTY: 612-676-6810/1-800-688-2534).
4 2019 UCare Member ContractDear UCare Member,
Welcome to UCare, where members come first. We’re pleased you chose us.
We have offered high‑quality, affordable health coverage to Minnesotans for three decades. We bring special
value to our members and communities by living our mission of improving members’ health through
innovative services and community partnerships. Our goal is to help Minnesotans of all ages, abilities and
cultures access care.
Disclosure Required By Minnesota Law
This Contract is expected to return on average 79.9% of your coverage costs for health care. The lowest
percentage permitted by state law for this Contract is 72%.
Please Read Your Contract Carefully
This Contract, together with any amendments we may send you, is your evidence of coverage and is issued
by UCare Minnesota (UCare). It is our legal Contract with you and describes your benefits and coverage. This
Contract replaces your prior Contract with UCare, if any.
IN WITNESS WHEREOF, UCare’s President and Secretary hereby sign your Contract.
Mark Traynor Hilary Marden-Resnik
President and Senior Vice President,
Chief Executive Officer Chief Administration Officer
and Secretary of the Board
Important Member Information & Member Rights and Responsibilities
MEMBER INFORMATION
1. COVERED SERVICES: Services provided by UCare will be covered at the in‑network benefit level when
services are provided by participating UCare providers or as authorized by UCare. Your Contract fully
defines what services are covered and describes procedures you must follow to obtain coverage.
2. PROVIDERS: Enrolling in UCare does not guarantee services by a particular provider on the list of
providers. When a provider is no longer part of UCare’s network for this plan, you must choose among
remaining UCare providers to receive services at the in‑network benefit level.
3. EMERGENCY SERVICES: Emergency services from providers who are not affiliated with UCare will be
covered. Your Contract explains the procedures and benefits associated with emergency care from UCare
in‑network providers and non‑network providers.
4. EXCLUSIONS: Certain services or medical supplies are not covered. You should read the Contract for a
detailed explanation of all exclusions.
5. CANCELLATION: Your coverage may be canceled by you or UCare only under certain conditions. Your
Contract describes all reasons for cancellation of coverage.
6. NEWBORN COVERAGE: If your health plan provides for dependent coverage, a newborn infant can be
covered from birth. UCare will not automatically know of the infant’s birth or that you would like coverage
under your plan. You should notify MNsure and UCare of the infant’s birth and that you would like
coverage. If your Contract requires an additional premium for each dependent, UCare is entitled to all
5premiums due from the time of the infant’s birth until the time you notify MNsure and UCare of the birth. UCare may withhold payment of any health benefits for the newborn infant until any premiums you owe are paid. 7. PRESCRIPTION DRUGS AND MEDICAL EQUIPMENT: Enrolling in UCare does not guarantee that any particular prescription drug will be available or that any particular piece of medical equipment will be available, even if the drug or equipment is available at the start of the Contract year. MEMBER RIGHTS AND RESPONSIBILITIES As a UCare member of this plan, you have the right to: 1. Available and accessible services including emergency services, as defined in your Contract, 24 hours a day, seven days a week; 2. Be informed of health problems, and to receive information regarding medically necessary treatment options and risks that is sufficient to assure informed choice, regardless of cost or benefit coverage; 3. Refuse treatment, and the right to privacy of medical and financial records maintained by UCare and its health care providers, in accordance with existing law; 4. Make a complaint or appeal a coverage decision, and the right to initiate a legal proceeding when experiencing a problem with UCare or its health care providers. (See the Appeals and Complaints section for more information on your rights); 5. Receive information about UCare, its services, its practitioners and providers, and your rights and responsibilities; 6. Be treated with respect and recognition of your dignity and your right to privacy; 7. Participate with your providers in making health care decisions; and 8. Make recommendations regarding the organization’s member rights and responsibilities policy. As a UCare member of this plan, you have the responsibility to: 1. Supply information (to the extent possible) that the organization and its providers need in order to provide care; 2. Follow plans and instructions for care that you have agreed to with your providers to sustain and manage your health; 3. Understand your health needs and problems, and participate in developing mutually agreed‑upon treatment goals to the degree possible; and 4. Pay copayments at the time of service and to promptly pay deductibles, coinsurance and, if applicable, additional charges for non‑covered services. 6 2019 UCare Member Contract
Table of Contents
Introduction..................................................................................................................................................................10
Nondiscrimination Policy..................................................................................................................................... 10
Using Your Benefits......................................................................................................................................................11
Each Time You Get Covered Services................................................................................................................. 11
Member Identification (ID) Card......................................................................................................................... 11
Using Your Plan’s Network.................................................................................................................................... 11
In‑Network Providers.................................................................................................................................... 11
Non‑Network Providers................................................................................................................................ 12
Care Outside the Service Area............................................................................................................................. 12
Emergency and Urgent Care Services................................................................................................................. 12
Emergency Services...................................................................................................................................... 12
Urgent Care.................................................................................................................................................... 13
Prescription Drugs................................................................................................................................................ 13
Mail Order Pharmacy.................................................................................................................................... 13
Authorization and Notification............................................................................................................................ 14
Continuity of Care................................................................................................................................................. 14
Important Coverage Information......................................................................................................................... 15
Approved Clinical Trials....................................................................................................................................... 15
Health Club Savings Program............................................................................................................................... 16
Health and Wellness Discounts............................................................................................................................ 16
Healthy Savings Program...................................................................................................................................... 16
Community Education Class Discounts.............................................................................................................. 16
UCare Tobacco Quit Line..................................................................................................................................... 16
Member Cost‑Sharing.................................................................................................................................................17
Cost‑Sharing When Using In‑Network Providers............................................................................................... 17
Cost‑Sharing When Using Non‑Network Providers........................................................................................... 17
Balance Billing....................................................................................................................................................... 18
Out‑of‑Pocket Limit.............................................................................................................................................. 18
Embedded Deductible and Out-of-Pocket Limit................................................................................................ 18
How UCare Pays Providers.........................................................................................................................................18
In‑Network Providers........................................................................................................................................... 18
Non‑Network Providers........................................................................................................................................ 19
Benefits Chart...............................................................................................................................................................20
Deductible.............................................................................................................................................................. 20
Out-of-Pocket Limit.............................................................................................................................................. 20
Ambulance – Emergency Transportation........................................................................................................... 20
Ambulance – Non-Emergency Medical Transportation.................................................................................... 20
Chiropractic Care.................................................................................................................................................. 21
Dental – Accidental/Medical................................................................................................................................ 22
Dental – Pediatric Basic/Major Care................................................................................................................... 24
Dental – Pediatric Check-Up................................................................................................................................ 25
Table of Contents7Diabetes Education............................................................................................................................................... 25
Drugs – Generic and Brand.................................................................................................................................. 26
Drugs – Specialty................................................................................................................................................... 27
Durable Medical Equipment, Prosthetics, Orthotics and Medical Supplies..................................................... 28
Emergency Room Services................................................................................................................................... 31
Eyewear for Children............................................................................................................................................ 32
Family Planning..................................................................................................................................................... 33
Home Health Care Services.................................................................................................................................. 34
Home Hospice Services........................................................................................................................................ 35
Infertility Diagnosis............................................................................................................................................... 37
Injections and In-Office Treatments.................................................................................................................... 38
Inpatient Hospital Services................................................................................................................................... 38
Inpatient Hospital Services – Maternity Care..................................................................................................... 39
Laboratory Services.............................................................................................................................................. 40
Mental Health Inpatient and Residential Services.............................................................................................. 41
Mental Health Outpatient Services, Including Office Visits............................................................................... 42
Office Visits............................................................................................................................................................ 44
Online Visits (E-Visits)......................................................................................................................................... 44
Orthodontia – Child.............................................................................................................................................. 44
Outpatient Facility (e.g., Ambulatory Surgery Center) and Outpatient Surgery Physician Services............. 45
Ovarian Cancer Screenings................................................................................................................................... 45
Physical Therapy, Occupational Therapy and Speech Therapy........................................................................ 46
Port Wine Stain Removal Services....................................................................................................................... 46
Preventive Care, Screenings and Immunizations................................................................................................ 47
Reconstructive Surgery Due to Cancer............................................................................................................... 52
Retail Clinic/Convenience Care Clinic Visits...................................................................................................... 52
Skilled Nursing Facility Services.......................................................................................................................... 52
Substance Use Disorder Inpatient and Residential Service................................................................................ 53
Substance Use Disorder Outpatient Services, Including Office Visits.............................................................. 54
Transplant Services............................................................................................................................................... 55
Vision...................................................................................................................................................................... 56
X‑rays and Imaging................................................................................................................................................ 56
Exclusions – Services Not Covered...........................................................................................................................57
Submitting a Claim......................................................................................................................................................58
How to Submit a Claim......................................................................................................................................... 58
Paying Claims During the Grace Period.............................................................................................................. 59
Coordination of Benefits (COB)................................................................................................................................59
When COB Applies............................................................................................................................................... 59
Order of Benefit Determination Rules................................................................................................................. 59
Effect on the Benefits of this Plan........................................................................................................................ 60
Right to Receive and Release Needed Information............................................................................................. 61
Facility of Payment................................................................................................................................................ 61
Right of Recovery.........................................................................................................................................................61
8 2019 UCare Member ContractAppeals and Complaints.............................................................................................................................................62
Coverage Decisions............................................................................................................................................... 62
To File an Appeal................................................................................................................................................... 62
Expedited Review.................................................................................................................................................. 63
External Review of an Adverse Decision............................................................................................................. 63
Independent Review of an Adverse
Non-formulary Drug Coverage Decision............................................................................................................. 63
Complaints............................................................................................................................................................. 63
Eligibility and Enrollment..........................................................................................................................................64
Eligibility................................................................................................................................................................ 64
Service Area........................................................................................................................................................... 64
Dependents............................................................................................................................................................ 64
Effective Date of Coverage.................................................................................................................................... 65
Changing Your Coverage....................................................................................................................................... 65
Renewing Coverage............................................................................................................................................... 65
Premiums............................................................................................................................................................... 65
Grace Period.......................................................................................................................................................... 66
Ending Coverage..........................................................................................................................................................66
If You Want to Leave this Plan – Contact MNsure.............................................................................................. 66
When Coverage Ends............................................................................................................................................ 66
Harmful Use of Services..............................................................................................................................................67
Important Notice from UCare About Your Prescription Drug Coverage and Medicare...................................68
General Contract Provisions......................................................................................................................................70
Entire Contract and Changes to this Contract.................................................................................................... 70
Acceptance of Coverage in this Contract............................................................................................................ 70
Clerical Error......................................................................................................................................................... 70
Access to Records and Confidentiality................................................................................................................ 70
Relationship Between Parties............................................................................................................................... 70
Assignment............................................................................................................................................................ 70
Notice..................................................................................................................................................................... 70
Discretionary Authority........................................................................................................................................ 70
Misstatement Time Limit..................................................................................................................................... 70
Notice of Privacy Practices.........................................................................................................................................71
Definitions.....................................................................................................................................................................74
Table of Contents9Introduction
This Contract is the evidence of coverage for the Many words in this Contract have specific meaning
plan issued by UCare and UCare Health, Inc. It is and are defined in the Definitions section at the end of
approved by the State of Minnesota. This plan is this Contract. Examples include the words “benefits,”
certified as a Qualified Health Plan (QHP) and is “claim,” “medically necessary,” “member,” “network,”
offered through MNsure. “premium” and “provider.”
This plan is subject to state and federal laws and UCare may arrange for other persons or
regulations. organizations to provide administrative services on
its behalf. This may include claims processing and
UCare Minnesota (UCare). UCare is a nonprofit utilization management services. To ensure efficient
corporation licensed by the State of Minnesota as a administration for your benefits, you must cooperate
Health Maintenance Organization (HMO). UCare with them as they perform their duties.
underwrites and administers the covered services
provided by an in‑network provider as described in Members must follow all terms and conditions of
this Contract. UCare is the parent company of UCare this Contract. All covered health services must be
Health, Inc. to which UCare provides administrative medically necessary.
services. When used in this Contract, “we”, “us” or
“our” has the same meaning as UCare and UCare While a member of our plan, you must use your
Health, Inc. current member ID card when you receive covered
services, including prescription drugs at in‑network
UCare Health, Inc. UCare Health, Inc. is the pharmacies. If you do not show your member ID
nonprofit service insurance corporation underwriting card, you may have to pay more.
the covered services provided by a non‑network
provider as described in this Contract. UCare Health, For some services, your provider must request
Inc. is a subsidiary of UCare. authorization (approval) from us before you receive
those services. Information on which services may
The HMO coverage described in this Contract may require approval is in the Benefits Chart section of
not cover all of your health care expenses. Read this Contract. More details about these processes are
this Contract carefully to learn which expenses are in the Authorization and Notification section of this
covered. Contract.
The laws of the State of Minnesota provide
members of an HMO certain legal rights, including Nondiscrimination Policy
rights described in this Contract. UCare’s nondiscrimination policy is to treat all
persons alike, without bias based on race, color,
This Contract covers the enrollee and the enrolled creed, religion, national origin, gender, marital
dependents (if any) as named on the enrollee’s status, disability, sexual orientation, age, genetic
membership application. The enrollee and his or information, public assistance status or any other
her enrolled dependents are our members. In this class protected by law.
Contract, the words “you,” “your” and “yourself ”
refer to the member. Members have equal cost-sharing for covered
services without discrimination on the basis of sex,
This Contract describes health services that are including gender identity. Services that are ordinarily
eligible for coverage and the steps you must follow or exclusively available to members of one sex will
to obtain benefits. This Contract contains important not be denied to a transgender person based on the
information, so read this entire Contract carefully. If sex assigned at birth, gender identity, or if the gender
you have questions or need more information, call otherwise recorded is different from one to which
UCare Customer Services at the phone numbers on coverage is ordinarily and exclusively available.
the inside cover of this Contract or your member
ID card.
10 2019 UCare Member ContractUsing Your Benefits
The services covered under this Contract are in the There are several ways to find current information
Benefits Chart section of this Contract. The Benefits about in-network providers and their professional
Chart also identifies some non‑covered items. A list qualifications. This includes medical school attended,
of general and service‑specific exclusions not covered residency completed and board certification status.
by this Contract is in the Exclusions section. See
those sections to identify covered and non-covered Search the Network
services. Information about our medical policies is on
our website. Visit ucare.org and search for medical Visit ucare.org to use the Search Network tool. This
policies. listing is updated daily. It lets you search by many
criteria, including location. Be sure to select UCare
Individual & Family Plans as the health plan to
Each Time You Get Covered Services identify the in-network providers for this plan.
Make sure that your provider is an in-network
provider to be eligible for in‑network benefit UCare must update the Search Network tool at
coverage. Identify yourself as a UCare member of this least once a month. If you receive services from an
plan. Show your current member ID card. in-network provider who becomes a non-network
provider before the change is posted in the Search
Network tool, we must reprocess the claim as an
Member Identification (ID) Card in-network benefit. If UCare told you of the provider
While a member of our plan, you must use your changing from in-network to non-network in the
current member ID card when you access covered Search Network tool before you obtained services, we
services, including prescription drugs. If you do not will process the claim as a non-network benefit.
show your ID card, you may have to pay more.
We will issue you a member ID card when we receive Call us
your payment for the first month’s premium. If any Call Customer Services for help finding a provider in
information on your ID card is wrong or if you lose your network. The number is inside the front cover
your card, contact Customer Services right away. of this Contract and on your member ID card.
Using Your Plan’s Network Check with your provider
Important: This health plan has a provider network. Doctors and other providers may perform certain
This network may be different from other UCare services at non-network hospitals, surgical centers
provider networks. Know your plan’s provider and other facilities. We recommend that you confirm
network and use those in-network providers to get with the provider that they are still in the plan’s
the highest level of benefit coverage. network at the time of service.
In‑Network Providers If you need emergency care, you don’t have to
receive services from an in-network provider or
In-network providers are the physicians, other health
facility. However, you are responsible for paying any
care professionals, medical groups, hospitals, other
charges from a non-network provider that exceed the
facilities and pharmacies that have a contract with
allowed amount UCare pays that provider. For more
UCare to deliver covered health care services to
information on coverage for emergency services, see
members of this plan. To get the highest level of
the Emergency Room Services section of the Benefits
benefits for covered services, you should receive
Chart in this Contract.
services from an in‑network provider. Some
services obtained from non-network providers will Your primary care provider may deliver, set up or
receive in-network benefits. See the Non‑Network help you get a range of health care services. To
Providers section to learn more. contact your primary care provider, go online to their
website or call the clinic. UCare Customer Services
may be able to help you schedule appointments.
Using Your Benefits11You do not need a referral to see a specialist, such as Services outside of the United States are not covered.
behavioral health or cardiology, in the Plan network. See the Benefits Chart and the Authorization and
Notification sections in this Contract.
Your provider will usually set up your hospital
admission and care if needed. If you do not know
which hospital your provider is associated with, Emergency and Urgent Care Services
ask your provider or clinic. If you prefer a specific
Emergency Services
hospital, see our list of network hospitals in the
Provider Directory or in the Search Network tool at Emergency services include evaluating and treating
ucare.org. an illness, injury, symptom or condition so serious,
including severe pain, that a reasonable person would
seek care right away to avoid severe harm. This
Non‑Network Providers
includes seeking treatment to stop the illness, injury,
This Contract covers some services received from symptom or condition from getting worse.
non‑network providers. Non‑network benefits are
generally covered at a lower level, because non- You may get covered emergency services whenever
network providers do not have a contract with UCare you need them, anywhere in the United States, from
to provide services at a discounted fee. If you receive an in‑network or non‑network provider. To get help
services from a non‑network provider, you may have as quickly as possible call 911.
to pay more compared to your costs for services from
an in‑network provider. This higher amount can Our plan covers ambulance services when getting
apply to copayments, coinsurance and deductibles to the emergency room in any other way could
(see the Benefits Chart for details). endanger your health. Emergency ambulance
services are covered anywhere in the United States.
In addition to higher cost-sharing amounts, you
may have to pay any charges from the non-network If your emergency services are provided by
provider that exceed the allowed amount that UCare non‑network providers, we can help arrange for
will pay the provider. This is called balance billing. network providers to take over your care as soon as
See the How UCare Pays Providers and Balance Billing your medical condition and circumstances allow.
sections to learn more. If you are admitted to a non-network hospital due
State law requires that some services from to an emergency, UCare must be notified as soon as
in-network and non-network providers be covered reasonably possible. Call Customer Services at one of
at the same benefit level. These services include the numbers inside the front cover of this Contract or
emergency services, testing and treatment of sexually on your member ID card.
transmitted diseases, testing for AIDS, services to If you must stay in a non-network hospital due to an
diagnose infertility and voluntary family planning emergency, your emergency coverage will continue
services. When using a non-network provider, you at the in-network level until it is safe to move you to
may still have to pay the provider costs that exceed an in-network facility.
the allowed amount that UCare pays providers for
a given service. See the Benefits Chart section for Please be aware: Cost-sharing for emergency room
details. services from non-network providers is at the in-
network benefit level. However, you are responsible
for paying the non-network provider any charges that
Care Outside the Service Area
exceed the allowed amount that UCare will pay the
If you need care when outside of the plan’s service provider. This amount can be costly for emergency
area and it is not an emergency, find a doctor and room services. See the Balance Billing section to learn
get the care you need. UCare’s nurse line is open more.
24 hours a day, seven days a week. Except for
emergencies, most services provided outside of the If the services you need do not meet the definition of
UCare service area or the State of Minnesota are an emergency, refer to the Benefits Chart section to
considered a non-network service. Non‑network learn about your benefits.
benefits would apply for these services. In some
cases, UCare approvals and notifications are required.
12 2019 UCare Member ContractTo be eligible for in-network benefits after an may not cover the drug. The formulary states
emergency, follow-up care or scheduled care must be which drugs need approval or authorization.
obtained from an in-network provider. • Step therapy: Even if a drug is on the formulary,
we may require you to try one or more alternative
Urgent Care drugs on the formulary before this drug will be
Urgent care is medical care for an illness, injury or covered.
condition serious enough that a reasonable person • Quantity limits: We limit the amount of some
would seek care, but not as severe as an emergency. covered drugs you can receive each time you fill a
prescription.
For a list of in-network urgent care providers, go to
the Provider Directory or the Search Network tool • Specialty drugs: Fairview Specialty Pharmacy
at ucare.org. You must get care from in-network (Fairview) is the only network provider of
providers to receive the highest level of benefit specialty drugs for plan members. Specialty drugs
coverage. To find out how to get urgent care or care are injectable or oral drugs that often require
after normal business hours, call your primary care special handling or monitoring by a pharmacist or
provider, or call the UCare 24/7 Nurse Line. The nurse. If you use a specialty drug, you or your
Nurse Line is answered 24 hours a day, seven days doctor must contact the specialty pharmacy to
a week. The phone number is on your member order the prescription. Your drug and any needed
ID card. supplies will be shipped to your home, work or
doctor’s office. Fairview also provides clinical
support to you and your caregivers. A Fairview
Prescription Drugs pharmacist is on call 24 hours a day if you have an
This plan has a prescription drug formulary. This urgent need related to your specialty drug. Call
is a list of generic and brand drugs that are covered Fairview Specialty Pharmacy at 1-800-595-7140
by this plan. To be covered, a drug must be on toll free. TTY users may call the National Relay
our formulary, or a formulary exception must be Center at 711 and ask for 1-800-595-7140.
obtained. The most recent formulary for this plan is
at ucare.org. Mail Order Pharmacy
To be covered, you must fill your prescription at You can fill prescriptions you take regularly through
a network pharmacy. The Provider Directory and the Express Scripts Mail Order Pharmacy. You can
Search Network tool include in‑network pharmacies. order up to a 90-day supply of certain generic and
Go online to ucare.org for the most current brand drugs. You can get a 90-day supply of most
information. preferred generic drugs for the price of two copays.
In a medical emergency, we cover prescriptions To start using the Mail Order Pharmacy service:
filled at a non‑network pharmacy. However, the • Create an account on Express-Scripts.com and
prescription must be related to the emergency care. follow the prompts or
In this case, you will likely need to pay the full cost
when you fill your prescription, rather than your • Call 1-877-567-6320 or TTY: 1-800-716-3231
normal share of the cost. UCare will then reimburse toll free
you for the difference paid. Call Customer Services If you have questions or need help, call Express
to learn how to be reimbursed for the cost of the Scripts Customer Service at the numbers above.
prescription.
Note: Specialty drugs must be filled through Fairview
The Benefits Chart section of this Contract shows Specialty Pharmacy. See the section above to learn
cost‑sharing information for covered drugs. more.
Some formulary drugs have special requirements for
coverage: To Request a Formulary, Step Therapy or Drug
Restriction Exception
• Authorization: Some drugs require you or your
provider to get UCare’s approval before you fill If your doctor or prescriber believes you need
your prescription. If you do not get approval, we coverage for a drug that is not on the formulary but
is medically appropriate, there is a process to request
Using Your Benefits13an exception. You, your representative or your doctor If your standard or expedited exception request is
can ask UCare to make an exception and cover the denied, you have the right to request an external
drug, or remove the step therapy requirements, drug appeal (see the Appeals and Complaints section of this
restrictions or limits. Your doctor must submit a Contract). You or your representative and prescriber
statement supporting the request. If your exception will be notified of the determination within 24
request is approved, the drug will be covered at the hours of the request. If approved, the non-formulary
copay or coinsurance amount, based on the drug's drug will be covered for the duration of your health
level or tier in the plan formulary. condition or treatment related to the expedited
request up to one year from date of approval.
A formulary exception may be approved when your
prescriber provides an oral or written statement
to UCare stating one of the following criteria has Authorization and Notification
been met: two or more of the covered drugs on the For some services, your provider must request
formulary (if available) to treat your condition would authorization from us before you receive those
not be as effective as the non-formulary drug; two services. There may be other services that require
or more of the covered drugs on the formulary (if your provider to obtain approval after a point in your
available) to treat your condition would have harmful therapy to continue. See the Benefits Chart section for
medical effects; the formulary drug has caused an information on which services need authorization.
adverse reaction; the formulary drug poses a risk;
and/or the prescriber shows that a prescription drug For other services, we may require your provider
must be dispensed as written to provide maximum to notify us within a certain period of time after the
medical benefit to you. service occurs. The Benefits Chart section provides
information on which services require this notice.
Standard exception requests You and your provider are responsible for getting
You or your representative, and prescriber will authorization and sending notification to UCare.
be notified of UCare’s determination (approval or When required, authorization and notification
denial) within 72 hours for a standard formulary must be obtained for services from in‑network and
exception request. If approved, the non-formulary non‑network providers. For a list of services that
drug will be covered for the duration of the require approval or notification, visit ucare.org. Or
prescription, including refills up to one year from call Customer Services at one of the phone numbers
date of approval. If the standard exception request inside the front cover.
is denied, you have the right to request an external If you have questions about how to request approval
appeal. You or your representative and prescriber or notify UCare, call Customer Services at one of the
are notified of the determination within 72 hours of phone numbers inside the front cover.
the request. For approved external appeal review of
standard exception requests, the non-formulary drug Authorization and notification requirements may
will be covered for the duration of the prescription, change.
including refills up to one year from date of approval.
Continuity of Care
Expedited exception requests As a member, you have the right to continuity of
An expedited exception request may be made when care in some situations. If we end our network
you are suffering from a health condition that may relationship with your provider without cause, so
seriously harm your life, health or ability to regain your provider becomes a non‑network provider,
maximum function or when you are undergoing a you may be able to continue care from that provider
current treatment using a non-formulary drug. You or at the in‑network benefit level for a period of time
your representative and prescriber will be informed before you transfer to an in‑network provider.
of the determination within 24 hours. If approved,
Continuity of care applies only if your provider agrees
the non-formulary drug will be covered for the
to follow UCare’s authorization and notification
duration of health condition or course of treatment
requirements, provides us with all necessary medical
up to one year from date of approval.
information related to your care, and accepts UCare’s
payment amount for covered services.
14 2019 UCare Member ContractYou may request that we approve continuity of care • UCare uses information from many sources in our
for up to 120 days for the following: evaluation efforts, including the Hayes, Inc.
• An acute condition Technology Assessment Reports, published peer-
reviewed medical literature, consensus statements
• A life‑threatening mental or physical illness and guidelines from national medical associations
• Pregnancy beyond the first trimester and physician specialty societies, the U.S. Food
• A physical or mental disability defined as inability and Drug Administration (FDA), other regulatory
to engage in one or more major life activities, bodies, and internal and external expert sources.
provided the disability has lasted or is expected to • Medical policies do not constitute coverage
last for at least one year, or can be expected to authorization, nor do they explain benefits.
result in death • UCare encourages your doctors and health care
• A disabling or chronic condition in an acute phase team to talk openly with you. We do not restrict
• For the rest of your life, if a doctor, advance doctors from talking with you about care options,
practice registered nurse or physician's assistant regardless of cost.
certifies that you are expected to live 180 days or To learn more, visit the About Us section at ucare.org
less and click Important Coverage Information. To learn
UCare will consider continuity of care services for about our specific medical policies, including
up to 120 days if you request care from a current initiating and developing medical policy requests,
provider that was terminated, if: visit ucare.org and search for medical policies.
• You are receiving culturally appropriate services,
and there are no in‑network providers with this Approved Clinical Trials
expertise within the time and distance We do not deny members from participating in
requirements approved clinical trials; deny, limit or impose more
• You do not speak English, and an in‑network conditions on the coverage of routine patient costs for
provider cannot communicate with you either items or services furnished in connection with being
directly or through an interpreter within the time in an approved clinical trial; or discriminate against
and distance requirements members for participating in an approved clinical
trial. Based on the cost‑sharing and other obligations
We will not approve continuity of care if: explained in this Contract, this plan will cover costs
• Your provider ends its network contract with for covered services that are related to an approved
UCare clinical trial, regardless of whether a person is in the
• We end our contract with your provider for cause approved clinical trial (for example, doctor visits).
UCare will help you transition from a non‑network UCare reserves the right to decide if a clinical trial is
provider to an in‑network provider if you ask us. Call an approved clinical trial based on the law. If you have
Customer Services at the number on the inside front questions about whether a clinical trial is an approved
cover if you have questions about continuity of care. clinical trial, please call Customer Services.
Important Coverage Information
When new technologies enter the marketplace
(devices, procedures or drugs), UCare’s medical
leaders carefully evaluate them for effectiveness.
We use information gathered from many sources and
standard-setting organizations in our evaluation.
• UCare’s clinical and quality committees and
medical directors carefully research and review
new technologies before determining their
medical necessity and/or appropriateness.
Using Your Benefits15You can also read
