Unitedhealthcare HRA Medical Plan Benefits

 
Unitedhealthcare HRA Medical Plan Benefits
2014 – 2015
Unitedhealthcare
HRA Medical Plan
Benefits
An overview of the UnitedHealthcare HRA Medical Plan
benefits offered to you as a Centura Health associate
This plan does not apply to Centura Health Associates who work at
St. Catherine’s or St. Rose in Kansas. Details about the Medical Plan
for these associates can be found on My Virtual Workplace. Click on
Associates, then Human Resources and select Medical Benefits.
Unitedhealthcare HRA Medical Plan Benefits
Table of Contents
UnitedHealthcare HRA Plan
   Tiered Network Benefits . . . . . . . . . . . . . . . . .                                                1
                                                                                                                This guide is intended to provide you with a general overview
   Use your Primary Care Provider (PCP) . . . . . .                                                         1   of your medical plan benefits. While this guide should answer
   Pick your specialist . . . . . . . . . . . . . . . . . . . . .                                           1
   Choose your treatment . . . . . . . . . . . . . . . . . .                                                1   most of your questions, it does not provide all the details of
   Stay well . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                      2   the plan. For plan details please refer to the Summary Plan
   Use any Centura Health hospital or
   Children’s Hospital . . . . . . . . . . . . . . . . . . . .                                              2   Description. Any information in this guide may be subject to
   Out-of-area dependents . . . . . . . . . . . . . . . .                                                   2
                                                                                                                change. Contact the Centura Health Benefits
Administrative Information
  Plan year . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                         2   Service Center at 1-888-622-1111 if
  Plan administrator & sponsor . . . . . . . . . . . .                                                      2
  When coverage begins . . . . . . . . . . . . . . . . .                                                    2   you have questions about the benefits
  Acquisitions and mergers  . . . . . . . . . . . . . . .                                                   2   described in this guide.
  When coverage ends . . . . . . . . . . . . . . . . . .                                                    2
  Eligibility  . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                      3
  Care coordination—notification . . . . . . . . . . .                                                      3
  Filing a claim . . . . . . . . . . . . . . . . . . . . . . . . .                                          3
  Your benefits  . . . . . . . . . . . . . . . . . . . . . . . .                                            3
What makes up your UnitedHealthcare HRA
plan? .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .     4
                                                                                                                2014 – 2015
How does the UnitedHealthcare HRA work?
UnitedHealthcare HRA for the 2014–15 plan
year .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
                                                                                                            4

                                                                                                            5
                                                                                                                UnitedHealthcare
Terms you need to know .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
Prescription benefits .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
UnitedHealthcare HRA plan is easy to use . .
                                                                                                            5
                                                                                                            6
                                                                                                            6
                                                                                                                HRA Medical Plan
   Health Risk Assessment  . . . . . . . . . . . . . . . .                                                  7   The Centura UnitedHealthcare HRA plan
   How to find a health care provider . . . . . . . .                                                       7   is all about you
   Got a question? . . . . . . . . . . . . . . . . . . . . . .                                              7
   Finding fast answers on myuhc.com . . . . . . .                                                          7   The UnitedHealthcare HRA (Health Reimbursement Account) plan gives you
Centura UnitedHealthcare HRA plan summary                                                                       unprecedented control over your health care choices. It gives you access
  HRA medical plan fundamentals . . . . . . . . . .  8                                                          to health care dollars you can spend before you dip into your own wallet.
  Preventive care benefit . . . . . . . . . . . . . . . . .  8
  Prescription benefit . . . . . . . . . . . . . . . . . . . .  8
                                                                                                                It gives you more control and more responsibility for managing your health
  Medical services . . . . . . . . . . . . . . . . . . . .  8–9                                                 care costs.
  Mental health and substance abuse service . . 9
                                                                                                                Offered through UnitedHealthcare, the UnitedHealthcare HRA plan is
UnitedHealthcare HRA plan examples . 10–11
General plan limitations
                                                                                                                a medical plan that consists of a Centura-funded HRA account to pay
   Alternative treatments . . . . . . . . . . . . . . . . .  12                                                 for covered medical expenses first. If you deplete your HRA, you are
   Comfort or convenience . . . . . . . . . . . . . . .  12                                                     responsible for any other qualified medical expenses you incur, excluding
   Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  12
                                                                                                                preventive care, as well as mental health services and substance abuse
   Experimental / unproven services . . . . . . . .  12
    Foot care  . . . . . . . . . . . . . . . . . . . . . . . . . .  12
                                                                                                                treatment, until your deductible is met. After the deductible is met, Centura
   Medical supplies and appliances  . . . . . . . .  13                                                         will pay the covered expenses based upon the benefit tier level and you will
   Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . .  13                                          pay any remaining coinsurance. If you meet the plan-year out-of-pocket
   Physical appearance . . . . . . . . . . . . . . . . . .  13                                                  maximum, Centura pays 100 percent of covered expenses for the remainder
   Providers  . . . . . . . . . . . . . . . . . . . . . . . . . .  13
                                                                                                                of the plan year.
   Reproduction . . . . . . . . . . . . . . . . . . . . . . .  13
   Services provided under another plan . . . . .  14                                                           The UnitedHealthcare HRA plan encourages you to be more actively
   Transplants . . . . . . . . . . . . . . . . . . . . . . . . .  14
                                                                                                                involved in your health and wellness and gives you more financial
   Travel . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  14
   Vision and hearing  . . . . . . . . . . . . . . . . . . .  14                                                accountability for your health care choices. As always, you work with your
   All other exclusions . . . . . . . . . . . . . . . .  14–15                                                  physician to make health care decisions that are best for you.
Claims and appeals .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .                           16
                                                                                                                This guide provides a quick overview of this benefit option, along with many
Coordination of benefits .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .                                 16
Agent for legal processes  .  .  .  .  .  .  .  .  .  .  .  .  .  .                                     17      practical tips for taking advantage of everything the UnitedHealthcare HRA
Your rights as a plan participant .  .  .  .  .  .  .  .  .                                             18      plan has to offer, so you can take control of your health and well-being.
Privacy practices .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .                      18

UnitedHealthcare HRA Medical Plan Benefits | Centura Health
Unitedhealthcare HRA Medical Plan Benefits
Tiered Network Benefits                                          For the following non-physician-based services, you must
                                                                     use a Centura Health network provider or joint venture.
    Under the UnitedHealthcare HRA medical plan you have             Centura will pay 80 percent of covered expenses and you
    access to a two-tier level benefits structure. The tiers are     will pay the 20 percent coinsurance after the deductible has
    defined as Preferred Providers and Non-Preferred Providers.      been met:
    Both tier levels require you to cover the coinsurance costs
                                                                     ·   Hospitalization
    for provider visits, and the applicable deductible. Regardless
    of the tier level, you must access care from an in-network       ·   Outpatient surgery*
    provider. There are no out-of-network benefits under the plan.   ·   Outpatient facility services*
    Preferred Providers: This network is comprised of Primary        ·   MRIs, CT scans, PET scans*
    Care Preferred Provider network and a Preferred Specialty        ·   Diagnostic Testing
    Provider network.                                                ·   Physical and Occupational Therapy
    The Primary Care Preferred Provider network is now               ·   Durable Medical Equipment
    composed of those providers who are in the Centura               ·   Sleep study services*
    Health Physician Group and those who are affiliated with
                                                                     * If these services are provided at a non-Centura facility
    Colorado Health Neighborhoods. Also, all pediatricians in
                                                                        that is contracted with UnitedHealthcare there will be a
    UnitedHealthcare’s network are included in the Primary Care
                                                                        40 percent coinsurance after your deductible is met.
    Provider network.
    Under the Primary Care Preferred Provider network, Centura       Use your Primary Care Provider (PCP)
    pays 80 percent of covered expenses and you pay the
                                                                     Regardless of if your PCP is a Preferred or Non-Preferred
    remaining 20 percent coinsurance. When accessing care
                                                                     Provider, Centura recognizes the value of having a primary
    from a Primary Care Preferred Provider, your deductible
                                                                     care physician, and encourages you to find a PCP that you
    will be waived and you are responsible for the 20 percent
    coinsurance.                                                     can partner with to focus on your health.

    The Preferred Specialty Provider network in composed             By accessing care from a PCP, they can be your champion
    of specialists who are in the Centura Health Physician           for health and will assist you in making decisions when
    Group, Colorado Health Neighborhoods and designated              accessing care.
    UnitedHealthcare providers.                                      If you receive services from a PCP from the Preferred
    If you need to access care from a specialist and choose a        Provider network you are only responsible for your 20
    specialty physician within the Preferred Provider network,       percent coinsurance, and your deductible is waived.
    Centura will pay 80 percent of covered expenses and you          If you receive services from a Non-Preferred Provider PCP
    will pay the remaining 20 percent after your deductible is       your coinsurance is still 40 percent, and you must meet your
    met. All other covered services under the Preferred Provider     deductible first.
    network require that you meet the deductible (with the
    exception of mental health and substance abuse services)         You do not need to elect a PCP under the UnitedHealthcare
    before paying coinsurance.                                       HRA plan.

    Non-Preferred Providers: The Non-Preferred Provider              Pick your specialist
    network contains the remaining UnitedHealthcare Select
                                                                     Under the UnitedHealthcare HRA plan, you can see any
    providers that are not included in the Primary Care Preferred
                                                                     doctor or specialist without needing a referral from a
    Provider network or the Preferred Specialty Provider
                                                                     primary care doctor. You have access to specialists in both
    network. When utilizing services from a primary care provider
                                                                     the Preferred Provider and the Non-Preferred Provider
    (PCP) in the Non-Preferred Provider network you will be
                                                                     network. When accessing services from a specialist within
    subject to the deductible and Centura will pay 60 percent of
    covered expenses and you will pay the remaining 40 percent       the Preferred Provider network you will be responsible for a
    coinsurance. If you need to access care from a specialist and    lower amount of coinsurance after your deductible has been
    choose a specialty provider from the Non-Preferred Provider      met. When accessing care from a Non-Preferred Provider
    network you will be required to meet your deductible and         provider you will be responsible for a slightly higher amount
    Centura will pay 60 percent of covered expenses and you          of coinsurance after your deductible is met.
    will pay the remaining 40 percent coinsurance.

1    UnitedHealthcare HRA Medical Plan Benefits | Centura Health
Unitedhealthcare HRA Medical Plan Benefits
Choose your treatment                                          Use any Centura Health hospital or
    In most cases, your doctor does not need to notify or get      Joint Venture
    approval from UnitedHealthcare before providing treatment      You have your choice of Centura Health hospitals or joint
    or services that are covered under your plan. However,         ventures for hospital care. There is no out-of network
    certain prescription medications and procedures do require     coverage except for emergent or urgent care.
    advance notification from UnitedHealthcare. Online lists of
    medications and procedures requiring advance notification      Pediatric Care
    are available on myuhc.com or by calling UnitedHealthcare at
                                                                   Centura Health has formed an affiliation with Rocky Mountain
    1-866-234-8908.
                                                                   Hospital for Children to leverage their long-standing expertise
    Stay well                                                      in pediatrics with our own pediatric resources to increase
                                                                   the strengths and services that we bring to our communities.
    Take advantage of your preventive care benefits. The
    UnitedHealthcare HRA plan pays routine preventive care         Based upon this affiliation, your dependents can now access
    coverage from day one. There is no deductible applied          pediatric services at Rocky Mountain Hospital for Children.
    and there is no out-of-pocket cost to you. Here are some       In order to receive the highest level of benefits for pediatric
    examples of preventive care:                                   services, please contact UnitedHealthcare at 1-866-234-
       • routine physicals                                         8908 prior to services.
       • mammograms
       • annual adult health checkups                              Peace of mind for your out-of-area
       • child immunizations                                       dependents
                                                                   Out-of-area dependent coverage is available. Contact the
       • well-child checkups
                                                                   Centura Health Benefits Service Center if you have an out-of
    It makes sense. The better your health, the lower your
                                                                   area dependent you wish to cover under the medical plan.
    health care costs.

    Administrative information
    Plan year                                                      Acquisitions and mergers
    The plan year for the Centura Health Plan is July 1 through    Coverage begins on the first day of
    June 30.                                                       employment for individuals who become Centura Health
                                                                   associates by means of an acquisition or merger.
    Plan administrator & sponsor
       Centura Health                                              When coverage ends
       Associate Benefits                                          Your coverage under the Centura Health Plan will end on the
       188 Inverness Drive West, Suite 500                         last day of the month in which your employment terminates.
       Englewood, Colorado 80112
                                                                   Coverage under this plan will continue for up to six months
    When coverage begins                                           after an associate begins an active military leave.
    If you enroll in the Centura Health Plan, your coverage
    begins on the first day of the month after 30 days of active
    employment.

2    UnitedHealthcare HRA Medical Plan Benefits | Centura Health
Unitedhealthcare HRA Medical Plan Benefits
Eligibility                                                           •O
                                                                            utpatient Surgery, Diagnostic and Therapeutic
    Full-time and part-time associates scheduled to work at least          Services
    40 hours per pay period, and non-benefit eligible PRN and             •R
                                                                            econstructive Procedures
    part-time associates who have worked an average of 30                 • Rehabilitation Services — Outpatient Therapy
    hours per week between April 1, 2013 - March 31, 2014 are             •S
                                                                            killed Nursing Facility / Inpatient Rehabilitation Facility
    eligible to participate in the medical plan. You may enroll your       Services
    eligible dependents if you are also covered under the plan.
                                                                          • Transplantation Services
    Eligible dependents include:                                          •M
                                                                            RI, PET & CAT Scan Centura has Opted In to the
       • Your spouse, including your common-law spouse                     UnitedHealthcare provider radiology notification program.
       • Your civil union partner as recognized under Colorado            Providers must contact UnitedHealthcare to notify
          law.                                                             UnitedHealthcare of a radiology service.
       • Your child from birth, stepchild or legally adopted child    Filing a claim
          (from moment of placement in the home), or child of
                                                                       In-network care
          whom you have legal custody, until, in each case, the
          end of the month in which the child turns age 26             You do not need to file a claim when you receive care
                                                                       through a UnitedHealthcare participating provider. Your
       • Your child over age 26 who is:
                                                                       participating provider will do this for you.
          •M
            entally or physically disabled and unable to earn
           his or her own living and is dependent on you for           Out-of-network care
           a majority of support. Proof of incapacity must be          Out-of-network care is only considered if you receive
           provided to UnitedHealthcare within 31 days of the          emergency or urgent care outside of the Centura service
           date the child’s coverage would have ended due to           area. You may have to file a claim before any benefits will be
           age. The child must be covered under the plan on            paid. Follow these steps in the event that the out-of-network
           the date prior to the day coverage would have ended         provider does not file a claim for you:
           due to age except during an open enrollment period.
                                                                          • Request a claim form from UnitedHealthcare as soon as
                                                                             possible following the visit by calling 1-866-234-8908.
    Care coordination—notification
                                                                          • You can also download a UnitedHealthcare claim form
    Notification ensures that you receive medical care in the
                                                                             on www.myuhc.com
    most cost-effective and appropriate way possible.
                                                                          • Complete and sign the form. Return the completed form
    UnitedHealthcare works with you and your participating
                                                                             and original bills to UnitedHealthcare within 90 days
    provider to evaluate the medical necessity of health care
                                                                             after the charges are made.
    services and some prescription drugs, to make sure it is
                                                                          • Receive payment. UnitedHealthcare will send payment
    appropriate.
                                                                             to the appropriate parties (you and/or the provider.)
    The following services listed require you to call the Care
    Coordination staff for notification. Call: UHC 1-866-234-          Your benefits
    8908, Notification Option.                                         The following pages will summarize key Centura Health Plan
                                                                       provisions. This is only a general overview of the medical
       • Acupuncture Services
                                                                       insurance. For more detailed information regarding your
       • Dental Services – Accident only                               benefit plans, please review the Summary Plan Description
       • Durable Medical Equipment ($1,000 or more)                    located on My Virtual Workplace, Human Resources site.
       • Emergency Health Services                                     Should there be an inconsistency with any communications
       • Home Health Care                                              regarding these plans, the actual Summary Plan Description
                                                                       will govern.
       • Hospice Care
       • Hospital — Inpatient Stay                                     Any information contained herein may be subject to change.

       • Maternity Services

3    UnitedHealthcare HRA Medical Plan Benefits | Centura Health
Unitedhealthcare HRA Medical Plan Benefits
What makes up your UnitedHealthcare HRA plan?

         HEALTH
                                                              COMPREHENSIVE                   SAVINGS ON                  PREVENTIVE
     REIMBURSEMENT                     MEDICAL
        ACCOUNT              +        COVERAGE           +     HEALTH CARE            +      HEALTH CARE          +          CARE
                                                                RESOURCES                       COSTS                     COVERAGE
          (HRA)

    Centura-funded               Coverage for                Answers to                   More control                Centura helps you
    account that can             eligible expenses           many health care             over how your               pay for services
    help pay out-of-             after you reach             questions. You get           health care dollars         designed to keep
    pocket expenses.             your deductible.            the help you need,           are spent by                you well, including
                                 Catastrophic                when you need it,            taking advantage of         physicals, well-child
                                 coverage once               and delivered how            UnitedHealthcare’s          care, cancer
                                 you’ve fulfilled your       you want it — on the         purchasing power =          screenings and
                                 deductible and              phone or Web.                potential savings for       immunizations.
                                 reached your                                             you.
                                 out-of-pocket
                                 maximum.

    UnitedHealthcare gives you access to a large, high-quality network of physicians and health care professionals. And you have open access
    to specialists with no need for a referral.

    How does the UnitedHealthcare
    HRA work?
    Centura Health funds your Health Reimbursement Account.                   copays. Preventive care is 100%
    When you receive covered health care services (including                  Centura paid and does not come
    mental health and substance abuse services), the provider                 out of your HRA.
    sends the bill to UnitedHealthcare for discounts and
                                                                              If you don’t use all of the money in your HRA, and you
    payment. The claim is paid directly to the provider with funds
                                                                              decide to stay with UnitedHealthcare HRA plan for another
    from your HRA account. You will receive a statement in the
                                                                              year, your remaining balance will carry forward to next year.
    mail so that you can keep track of your HRA balance.
                                                                              That means more money in your HRA next year and even
    If you spend your entire HRA, you’ll pay 100 percent of all               less that you might have to pay from your own pocket. The
    medical services until you’ve reached your deductible.                    maximum balance allowed in your HRA is equal to two times
    Once you reach your deductible, the plan pays 80 percent                  your annual contribution.
    of your qualified medical expenses and you pay the
    remaining 20 percent for Preferred Provider services, up to
    your out-of-pocket maximum. If you reach the out-of-pocket
    maximum, Centura pays 100 percent of all other allowable
    charges incurred during the plan year, including prescription

4    UnitedHealthcare HRA Medical Plan Benefits | Centura Health
Unitedhealthcare HRA Medical Plan Benefits
UnitedHealthcare HRA details for the 2014–15 plan year
        Coverage             HRA funds             Total deductible                     Out-of-pocket max             Most you’ll pay
        Single                $1,000*                   $1,500                                $3,500                     $2,500
        Two-Party              $1,500*                   $3,000**                                $7,000***                $5,500
        Family                 $2,000*                   $4,500**                                $10,500***               $8,500
        *Your HRA contributes to the total deductible. **$1,500 per person maximum. *** $3,500 per person out-of-pocket maximum

      A picture is worth                                        COINSURANCE                                   Counts toward your
      a thousand words                               (Your share of cost if deductible is met)                Out-of-pocket Maximum

                                         YOUR CONTRIBUTION TO REACH DEDUCTIBLE
                                                        (If HRA is depleted)
        Counts toward your
             Deductible
                                            HEALTH REIMBURSEMENT ACCOUNT                                      Responsibility
                                                       (Funded by Centura)
                                                                                                                    You
                                                                                                                    Centura
                                                       PREVENTIVE CARE COVERAGE
                                                                                                                    Your medical benefit

    Terms you need to know                                                     Out-of-pocket maximum
                                                                               This is the maximum amount out-of-pocket you pay, including
    The structure of UnitedHealthcare HRA plan creates some slight
                                                                               your deductible, coinsurance and prescription copays.
    variations in the meanings of some traditional insurance terms.
                                                                               Regardless of the tier that your provider is covered under,
    Please read the definitions below to become familiar with what
                                                                               no person will ever pay more than $3,500. The maximum
    these words mean for the Centura UnitedHealthcare HRA plan.
                                                                               for two-party coverage is $7,000 and the family maximum is
    Deductible                                                                 $10,500. If you reach the out-of-pocket maximum, Centura
                                                                               Health pays 100 percent of all other allowable charges incurred
    This is a fixed amount of health care expenses that you must
                                                                               during the plan year, including prescriptions.
    pay before health benefits begin.
    Under Centura’s medical plan, preventive care, pharmacy                    Meeting your deductible
    expenses, mental health care and substance abuse benefits and              The plan will pay 80 percent of covered Preferred Provider
    Preferred Provider PCP services, are not subject to and do not             benefits and Non-Preferred Provider PCP expenses, and 60
    contribute to the deductible.                                              percent of covered Non-Preferred speciality provider expenses
                                                                               after you have met your deductible. For two-party coverage, the
    Coinsurance
                                                                               deductible operates as though each person has single coverage.
    This is the percentage of the covered medical expenses that
                                                                               For families of three or more people, no individual will be
    you pay once the deductible has been met. Under the Preferred
                                                                               required to pay more than $1,500 toward the deductible. Once
    Provider network, Centura pays 80 percent of the allowable
                                                                               an individual family member has reached the $1,500 deductible,
    charges and the associate pays the remaining 20 percent. Under
                                                                               the plan will pay 80 percent of allowable charges under the
    the Non-Preferred Provider network, Centura pays 60 percent of
                                                                               Preferred Provider network and 60 percent of allowable
    the allowable charges and the associate pays the remaining 40
                                                                               Non-Preferred Primary Care and speciality provider charges
    percent for speciality services. Please note that mental health and
                                                                               under the Non-Preferred Provider network for that person.
    substance abuse services are subject to the coinsurance, without
                                                                               Once three or more family members together incur $4,500
    meeting your deductible.
                                                                               of allowable medical expenses, the plan pays 80 percent of
    For ancillary services, such as outpatient surgery, outpatient             covered Preferred Provider expenses and 60 percent of covered
    facility services, MRIs, CT scans, PET scans, and sleep study              Non-Preferred Primary Care Provider and speciality provider
    services, you must use a Centura Health network provider or joint          expenses for the entire family.
    venture. If these services are provided at a non-Centura facility
                                                                               If you have questions about how the deductible works, please
    that is contracted with UnitedHealthcare there will be a 40 percent
                                                                               contact the Benefits Service Center by calling 1-888-622-1111.
    coinsurance after your deductible is met.

5      UnitedHealthcare HRA Medical Plan Benefits | Centura Health
Unitedhealthcare HRA Medical Plan Benefits
Prescription benefits
    UnitedHealthcare/OptumRx administers your prescription            Use Centura’s retail pharmacies or
    drug coverage. Most prescriptions can be filled at a              UnitedHealthcare’s mail order for
    retail outlet. However, maintenance medications can be            maintenance drugs
    purchased more economically through a Centura retail              You will receive a 90-day supply for two copays, instead of
    pharmacy or via mail order. In both cases, you can purchase       three copays. Many of the hospital campuses have Centura
    a 90-day supply for two copays, instead of three. There are a     retail pharmacies on site. The participating pharmacies are
    limited number of drugs that require advance approval from        listed here:
    UnitedHealthcare. A list of drugs requiring approval can be
    found on www.myuhc.com.                                              • ApotheCare Porter Pharmacy

    Call 1-866-234-8908 to speak with a UnitedHealthcare                 • Medical Arts Pharmacy — St. Mary Corwin
    representative for advance approval or mail-order drug service.         Medical Center

    Drug copayments are as follows:                                      • Penrose Professional Pharmacy

                                                                         • St. Anthony Hospital Pharmacy
               Retail outlets, 30-day        Mail order, 90-day
                 supply, (1 copay)           supply,(2 copays)

     Tier 1             $15                          $30
     Tier 2             $30                          $60
     Tier 3             $60                         $120

    UnitedHealthcare HRA plan is easy to use —
    the rest is up to you!
    Take advantage of your preventive care                            See your primary care doctor before going
    coverage                                                          to a specialist
    No matter what tier your provider is covered under, Centura       Your PCP may be able to resolve the issue at a much lower
    covers 100% of preventive care coverage. You and your             cost to you. In addition, if you access care from a primary
    family can stay healthy or detect problems early with routine     care doctor under the Preferred Provider benefit network,
    physicals, regular screenings and immunizations.                  Centura will waive your deductible and you only pay the
                                                                      applicable coinsurance.
    Be prepared when you make, and arrive for,
    medical appointments                                              Try to work toward the healthiest lifestyle
    Have your UnitedHealthcare medical ID card handy. Your            possible
    doctor’s staff may ask for your plan information, subscriber      Change can take time, but the rewards can be wonderful
    and group numbers when you call and copy your card when           There are dozens of small things that can add up to
    you arrive for your appointment. You also may want to bring       significant changes that can improve your health and your
    a few prepared questions for your doctor to get the most          ability to enjoy life. Set small goals and work with your health
    from your visit.                                                  care providers, family and friends to accomplish them.

    Buy generic drugs whenever possible                               Use Walgreens Clinics
    When you need a prescription, ask your doctor if a generic        The Healthcare Clinic at select Walgreens provides 100%
    equivalent is available. A generic medication has the same        coverage for preventive services and the Preferred
    active ingredients as a brand name drug and, in most cases,       Provider benefit level for all other offered services. Visit
    you’ll pay less.                                                  www.Walgreens.com/Clinic for a list of services and locations
                                                                      and hours.
6    UnitedHealthcare HRA Medical Plan Benefits | Centura Health
Unitedhealthcare HRA Medical Plan Benefits
Free Health and Disease
    Management Programs
    Numerous programs are available to you and your family to
    give you the support and tools you need to maintain good
    health, have a healthy pregnancy, or manage a chronic
    health condition.
    To find out more about what’s available, call
    UnitedHealthcare at 1-866-234-8908, or if you work for
    Penrose-St. Francis Health Services, St. Mary-Corwin or
    St. Thomas More, call 1-855-385-5943 or 719-776-7983.
    You may also visit My Virtual Workplace, select the 2020
    tab at the top of the page, select Code You from the drop
    down menu and select well-being benefits.

      How to find a health care provider
      Use the links in the My Virtual Workplace, Associates
      Services, Human Resources site                               Take advantage of everything
         • Call UnitedHealthcare toll-free: 1-866-234-8908.        myuhc.com® has to offer
                                                                   This includes advice, claims history, account information
                                                                   and tools to help you manage your health care dollars.

      Got a question?                                              Myuhc.com gives you easy access to health and
      If you need an answer or want more information about         medical information, as well as personalized benefit
      your benefits, help is on the way:                           claims and account information. You’ll also find great
                                                                   tools to help you make informed, economical and
         •C
           all the Benefits Service Center toll-free at           healthful decisions.
          1-888-622-1111 or in Denver at 303-770-4750.
         •E
           -mail the Benefits Service Center at                   Finding fast answers on myuhc.com
          benefits@centura.org.                                    You can:
         •R
           eview the Summary Plan Descriptions on My                 • Verify eligibility, deductible or copayments
          Virtual Workplace, Human Resources site for more            • Confirm that a claim is in process or was paid
          detailed information.
                                                                      • Verify what is covered by your benefits
                                                                      • Order a replacement ID card
                                                                      • Find a network physician in your area
                                                                      • Order prescriptions and refills
                                                                      • Research the cost of a medical treatment
                                                                      • Learn more about your coverage
                                                                      • Find which treatments the experts recommend

7    UnitedHealthcare HRA Medical Plan Benefits | Centura Health
Unitedhealthcare HRA Medical Plan Benefits
Centura UnitedHealthcare HRA Plan Summary
    UnitedHealthcare HRA medical plan fundamentals
    Deductible			                                                                                                         HRA funds
    Associate Only                                                                $1,500		                                $1,000
    Associate + One                                                               $3,000 ($1,500 per person)              $1,500
    Associate + Two or More                                                       $4,500 ($1,500 max. per person)         $2,000

    Out-of-pocket maximum (includes deductibles, coinsurance and prescription copays)
    Associate Only                                                                $3,500
    Associate + One                                                               $7,000 ($3,500 per person)
    Associate + Two or More                                                       $10,500 ($3,500 max. per person)

    Preferred Provider Coinsurance after deductible                               20%
    Non-Preferred Provider Coinsurance after deductible                           40%

    Covered outpatient services at a non-Centura facility                         40%

    Life-time maximum                                                             None

    Pre-existing conditions                                                       None

    Preventive care benefit: UnitedHealthcare HRA
    Preventive medical care
    Example: Routine man and woman well-exam,                                    100% covered per participant
     baby/well-child, routine mammogram

    Prescription benefit: UnitedHealthcare / OptumRx
    Outpatient prescription drugs
    Tier 1:                                                                       $15
    Tier 2:                                                                       $30
    Tier 3:                                                                       $60

    Mail order Rx & Centura retail pharmacies	2 copays for a 90-day supply

    Medical services: UnitedHealthcare HRA                                        You pay
    Office visit Services
    Preferred Provider Primary Care Physician (PCP) office visits                 20% Coinsurance, deductible waived
    Non-Preferred Provider Primary Care Physician (PCP) office visits             40% Coinsurance after deductible
    Preferred Provider Specialist office visits                                   20% Coinsurance after deductible
    Non-Preferred Provider Specialist office visits                               40% Coinsurance after deductible

    Hospital and emergency services
    Inpatient (Centura facilities only)                                           20% Coinsurance after deductible
    Emergency care                                                                20% Coinsurance after deductible
    Ambulance (Ground and air)                                                    20% Coinsurance after deductible
    Urgent care                                                                   20% Coinsurance after deductible
    Outpatient surgery* (Centura facilities and Joint ventures only)              20% Coinsurance after deductible*
    * Covered services provided at a non-Centura facility that is contracted with UnitedHealthcare have a 40 % coinsurance after your deductible is met.
    Home health care                                                              20% Coinsurance after deductible

    Hospice care                                                                  20% Coinsurance after deductible

8    UnitedHealthcare HRA Medical Plan Benefits | Centura Health
Medical services: UnitedHealthcare HRA                                     You pay
    Therapies (Centura facilities only)
    Physical, occupational or speech	20% Coinsurance after deductible, up to 60 visits per plan year combined
    Cardiac rehabilitation                                                     20% C
                                                                                    oinsurance after deductible, up to 20 visits per plan year
    Pulmonary rehabilitation                                                   20% C
                                                                                    oinsurance after deductible, up to 20 visits per plan year

    Durable medical equipment or prosthetics	20% Coinsurance after deductible

    Maternity
    Initial visit - Preferred Provider                                        20% Coinsurance after deductible
    After initial visit - Preferred Provider                                   20% Coinsurance of global fee after deductible
    Initial visit - Non-Preferred Provider                                     40% Coinsurance after deductible
    After initial visit - Non-Preferred Provider                               40% Coinsurance of global fee after deductible

    Nutritional services (certain conditions apply)                            100% covered

    Other health care services
    Acupuncture (pain management for approved diagnosis)                       20% Coinsurance after deductible, up to 20 visits per plan year
    Chiropractic services                                                      20% Coinsurance after deductible, up to 20 visits per plan year
    Hearing exam (diagnostic injury or illness)                                20% Coinsurance after deductible
    Lab and X-Ray (MRI,* PET* and CT* scans must                               20% Coinsurance after deductible*
    be performed at a Centura Health facility,
    joint venture, or Denver MRI)
    * Covered services provided at a non-Centura facility that is contracted with UnitedHealthcare have a 40 % coinsurance after your deductible is met.
    Mammography testing                                                        20% Coinsurance after deductible
    Skilled nursing/Inpatient rehabilitation                                   20% Coinsurance after deductible, 60-day max per plan year, combined
    (Centura facilities only)                                                  with inpatient rehabilitation*

    Reconstructive procedures
    Medically necessary                                                        20% Coinsurance after deductible

    Transplantation services
    Specific Centura facilities must be utilized                               20% Coinsurance after deductible
    Bone marrow/Stem cell search                                               $25,000 maximum benefit
    Transportation, meal and lodging	$50 for one person / $100 for two people, up to $10,000 Lifetime

    Roux-en-Y, Lap band and Sleeve gastrectomy
    bariatric surgery                                                          20% Coinsurance after deductible
    Penrose-St. Francis Hospital, Parker Adventist Hospital, and
    St. Thomas More Hospital only

    Mental health and substance abuse services: United Behavioral Health*
    *All inpatient mental health and substance abuse services must be pre-authorized, call 1-877-384-2266.
    Mental health services
    Inpatient                                                                  20% Coinsurance, no deductible
    Partial hospitalization                                                   20% Coinsurance, no deductible
    Outpatient visit                                                           20% Coinsurance, no deductible

    Substance abuse
    Inpatient                                                                  20% Coinsurance, no deductible
    Inpatient detoxification                                                  20% C
                                                                                    oinsurance, no deductible
    Partial hospitalization                                                    20% Coinsurance, no deductible
    Outpatient detoxification                                                  20% Coinsurance, no deductible
    Intensive outpatient program                                              20% Coinsurance, no deductible

9       UnitedHealthcare HRA Medical Plan Benefits | Centura Health
UnitedHealthcare HRA Medical Plan examples1
Services                                                     Deductible                                Coinsurance
                                                          $1,500 Per Person        Preferred Provider: 20% Non-Preferred Provider: 40%     1
                                                                                                                                                 or illustrative
                                                                                                                                                F
                                                            $4,500 Family                 Up to $2,000 Per Person, $6,000 Family                purposes, it
Routine Physical – Preferred Provider or                                                                                                        is assumed
                                                                 None                                        None
Non-Preferred Provider                                                                                                                          that claims are
PCP Office Visit – Preferred Provider                            Waived                               20% No Deductible                         processed by
PCP Office Visit – Non-Preferred Provider                         Yes                                40% After Deductible                       UnitedHealthcare
                                                                                                                                                in the order in
Specialist Office Visit – Preferred Provider                      Yes                                20% After Deductible
                                                                                                                                                which services
Specialist Office Visit – Non-Preferred Provider                  Yes                                40% After Deductible                       are listed.
Cast & Minor Surgery                                              Yes                                20% After Deductible

       Single Example                     Services                Cost      Amount you           Coinsurance      Paid from   UnitedHealthcare         HRA
                                                                            pay to meet            you pay          HRA       HRA plan benefit        balance
          Dedcutible: $1,500                                                 deductible
                 HRA: $1,000        Associate
               Coinsurance:          Routine Physical –           $230                $0                $0             $0                $230           $1,000
    Preferred Provider – 20%         Preferred Provider
Non-Preferred Provider – 40%         or Non-Preferred
                                          Provider
   Out-of-pocket maximum:
                                     PCP Office Visit –           $120                $0               $24            $24                 $96             $976
                    $3,500
                                     Preferred Provider
        Total cost of medical         Specialist Office           $140             $140                 $0           $140                  $0             $836
             services: $2,630              Visit –                          (paid by HRA)
            Total amount the         Preferred Provider
            HRA paid: $1,000             Cast & Minor         $2,000             $1360                $128           $836                $512               $0
                                           Surgery                            ($836 paid
      UnitedHealthcare HRA                                                      by HRA)
            plan paid: $922           Specialist Office           $140                $0               $56             $0                 $84               $0
      Total amount you paid:              Visit -
                       $708            Non-Preferred
                                         Provider
                                    Totals                    $2,630             $1,500               $208          $1,000               $922               $0

 Two Party Example                             Services              Cost       Amount you         Coinsurance Paid from       UnitedHealthcare         HRA
                                                                                pay to meet          you pay     HRA           HRA plan benefit        balance
           Dedcutible: $3,000                                                    deductible
       ($1,500 per person max)
                                    Associate
                  HRA: $1,500         Routine Physical –             $210                   $0               $0          $0               $210          $1,500
      Coinsurance: Preferred         Preferred Provider or
Provider – 20% Non-Preferred        Non-Preferred Provider
              Provider – 40%            PCP Office Visit –           $120                   $0            $24           $24                $96          $1,476
                                        Preferred Provider
    Out-of-pocket maximum:
                       $7,000        Specialist Office Visit –       $140              $140                  $0        $140                    $0       $1,336
       ($3,500 per person max)         Preferred Provider                      (paid by HRA)

        Total cost of medical       Dependent
             services: $2,380         Routine Physical –             $250                   $0               $0          $0               $250          $1,336
                                     Preferred Provider or
 Total amount the HRA paid:
                                    Non-Preferred Provider
                    $1,500
                                      PCP Office Visit –             $120                   $0               $0        $120                    $0       $1,216
 UnitedHealthcare HRA plan          Non-Preferred Provider
                 paid: $640
                                        Outpatient Surgery         $1,400            $1,380               $20            $0                    $0           $0
Total amount you paid: $264                                                      ($1,216 paid
                                                                                     by HRA)
        Total cost of medical
                                    Specialist Office Visit –        $140                   $0            $56            $0                $84              $0
             services: $2,380
                                    Non-Preferred Provider
                                    Totals                         $2,380            $1,640              $100          $284               $640              $0
 10    UnitedHealthcare HRA Medical Plan Benefits | Centura Health
UnitedHealthcare HRA Medical Plan examples1
Family Example                     Services            Cost     Amount you      Coinsurance    Paid    UnitedHealthcare   HRA balance
                                                                pay to meet       you pay      from    HRA plan benefit
  Dedcutible: $4,500                                             deductible                    HRA
  ($1,500 per person
                          Associate
                max)
                            Routine Physical –          $250              $0           $0        $0              $250         $2,000
         HRA: $2,000       Preferred Provider or
         Coinsurance:     Non-Preferred Provider
     Preferred Provider     Specialist In-Office        $500           $500            $0      $500                $0         $1,500
                – 20%          Procedure –                      (paid by HRA)
                            Preferred Provider
Non-Preferred Provider
               – 40%      Spouse
                            Routine Physical –          $250              $0           $0        $0              $250         $1,500
      Out-of-pocket
                           Preferred Provider or
  maximum: $10,500
                          Non-Preferred Provider
  ($3,500 per person
                max)        PCP Office Visit –          $120           $120            $0      $120                $0         $1,380
                          Non-Preferred Provider                (paid by HRA)
Total cost of medical
   services: $29,995        Outpatient Surgery         $1,600        $1,380           $44     $1,380             $176            $0
                                                                (paid by HRA)
     Total amount the
     HRA paid: $2,000     Specialist Office Visit –     $150              $0          $45        $0               $90            $0
                          Non-Preferred Provider
     UnitedHealthcare     Dependent
       HRA plan paid:
             $23,316      Well-Child Check-Up –         $175              $0           $0        $0              $175            $0
                           Preferred Provider or
     Total amount you     Non-Preferred Provider
          paid: $4,604
                          Specialist Office Visit –     $140           $140            $0        $0                $0            $0
Total cost of medical     Non-Preferred Provider
   services: $29,995      Dependent
     Total amount the     Well-Child Check-Up –         $175              $0           $0        $0              $175            $0
     HRA paid: $2,000      Preferred Provider or
                          Non-Preferred Provider
                             PCP Office Visit –         $120           $120            $0        $0                $0            $0
                             Preferred Provider
                            Outpatient Surgery         $1,200        $1,200            $0        $0                $0            $0
                          Dependent
                          Well-Child Check-Up –         $175              $0           $0        $0              $175            $0
                           Preferred Provider or
                          Non-Preferred Provider
                          Specialist Office Visit –     $140           $140            $0        $0                $0            $0
                          Non-Preferred Provider
                             Inpatient Surgery        $25,000          $900        $2,000        $0           $22,100            $0
                          Totals                      $29,995        $4,500        $2,089     $2,000          $23,316

11    UnitedHealthcare HRA Medical Plan Benefits | Centura Health
General plan limitations
     We will not pay benefits for any of the services, treatments,      2.	Preventive care, diagnosis, treatment of or related to
     items, or supplies described in this section, even if either of        the teeth, jawbones or gums. Examples include all of the
     the following is true:                                                 following:

        • It is recommended or prescribed by a Physician.                    • Extraction, restoration, and replacement of teeth.
        • It is the only available treatment for your condition.             • Medical or surgical treatments of dental conditions.

     Alternative treatments                                                   • Services to improve dental clinical outcomes.
     1. Acupressure.                                                    3. Dental implants.
     2. Aroma therapy.                                                  4. Dental braces.
     3. Hypnotism.                                                      5.	Dental x-rays, supplies, and appliances and all
                                                                            associated expenses, including hospitalization and
     4. Massage Therapy.
                                                                            anesthesia. The only exceptions to this are for any of the
     5. Rolfing.                                                            following:

     6.	Other forms of alternative treatment as defined by the               • Transplant preparation.
         Office of Alternative Medicine of the National Institutes of
                                                                              • Initiation of immunosuppressives.
         Health.
                                                                              • The direct treatment of acute traumatic injury, cancer
     Comfort or convenience                                                      or cleft palate.
     1. Television.                                                     6.	Treatment of congenitally missing, malpositioned,
     2. Telephone.                                                          or super numerary teeth, even if part of a congenital
                                                                            anomaly.
     3. Beauty/Barber service.

     4. Guest service.                                                   xperimental or investigational services or
                                                                        E
                                                                        unproven services
     5.	Supplies, equipment, and similar incidental services and
                                                                        Experimental or investigational services and unproven services
         supplies for personal comfort. Examples include:
                                                                        are excluded. The fact that an experimental or investigational
           • Air conditioner.                                           service or an unproven service, treatment, device or
           • Air purifiers and filters.                                 pharmacological regimen is the only available treatment for a
                                                                        particular condition will not result in benefits if the procedure is
           • Batteries.                                                 considered to be experimental or investigational or unproven
           • Battery chargers.                                          in the treatment of that particular condition.

           • Dehumidifier.                                              Foot care
           • Humidifiers.                                               1.	Except when needed for severe systemic disease:
                                                                             Routine foot care (including the cutting or removal of
     6.	Devices and computers to assist in communication and
                                                                             corns and calluses.) Nail trimming, cutting, or debriding.
         speech.
                                                                        2.	Hygienic and preventive maintenance foot care. Examples
     7.	Home remodeling to accommodate a health need (such
                                                                            include the following:
         as, but not limited to, ramps and swimming pools.)
                                                                              • Cleaning and soaking the feet.
     Dental                                                                   • Applying skin creams in order to maintain skin tone.
     1.	Dental care except as described in the SPD, (Section
                                                                              • Other services that are performed when there is not
         1: What’s Covered – Benefits) under the heading Dental
                                                                                a localized illness, injury or symptom involving the
         Services — Accident Only.
                                                                                foot.

12    UnitedHealthcare HRA Medical Plan Benefits | Centura Health
3. Treatment of flat feet.                                             •S
                                                                              kin abrasion procedures performed as a treatment
     4. Treatment of subluxation of the foot.                                for acne.

     5. Shoe orthotics.                                               2.	Replacement of an existing breast implant if the earlier
                                                                          breast implant was performed as a cosmetic procedure.
     Medical supplies and appliances                                      Note: Replacement of an existing breast implant is
     1.	Devices used specifically as safety items or to affect           considered reconstructive if the initial breast implant
         performance in sports-related activities.                        followed mastectomy.
     2.	Prescribed or non-prescribed medical supplies and            3.	Physical conditioning programs such as athletic training,
         disposable supplies. Examples include:                           body-building, exercise, fitness, flexibility, and diversion
           • Elastic stockings (Job stockings are not excluded.)         or general motivation.

           • Ace bandages.                                            4.	Weight loss programs whether or not they are under
                                                                          medical supervision. Weight loss programs for medical
           • Gauze and dressings.                                         reasons are also excluded.
           • Syringes.                                                5. Wigs regardless of the reason for the hair loss.
           • Diabetic test strips.
                                                                      Providers
     3.	Orthotic appliances that straighten or re-shape a body
                                                                      1.	Services performed by a provider who is a family
         part (including some types of braces.)
                                                                          member by birth or marriage, including spouse, brother,
     4.	Tubing, nasal cannulas, connectors and masks are                 sister, parent or child. This includes any service the
         not covered except when used with Durable Medical                provider may perform on himself or herself.
         Equipment (see Summary Plan Description.)
                                                                      2.	Services performed by a provider with your same legal
                                                                          residence.
     Nutrition
     1.	Megavitamin and nutrition based therapy.                     3.	Services provided at a free-standing or hospital-based
                                                                          diagnostic facility without an order written by a physician
     2.	Except as described in the SPD (Section 1: What’s
                                                                          or other provider. Services that are self-directed to a free-
         Covered — Benefits) under Nutritional Counseling,
                                                                          standing or hospitalbased diagnostic facility. Services
         nutritional counseling for either individuals or groups,
                                                                          ordered by a physician or other provider who is an
         including weight loss programs, health clubs, and spa
                                                                          associate or representative of a free-standing or hospital-
         programs.
                                                                          based diagnostic facility, when that physician or other
     3.	Enteral feedings and other nutritional and electrolyte           provider:
         supplements, including infant formula, donor breast milk,          •H
                                                                              as not been actively involved in your medical care
         nutritional supplements, dietary supplements, electrolyte           prior to ordering the service, or
         supplements, diets for weight control or treatment of
         obesity (including liquid diets or food), food of any kind         • Is not actively involved in your medical care after the
         (diabetic, low fat, cholesterol), oral vitamins, and oral            service is received.
         minerals except when sole source of nutrition.                     This exclusion does not apply to mammography testing.

     Physical appearance                                              Reproduction
     1.	Cosmetic Procedures. See the definition in the SPD           1.	Surrogate parenting.
         (Section 10: Glossary of Defined Terms.) Examples include:   2.	The reversal of voluntary sterilization.
           • Pharmacological regimens, nutritional procedures, or    3.	Fees or direct payment to a donor for sperm or ovum
              treatments.                                                 donations.
           • Scar or tattoo removal or revision procedures (such     4.	Monthly fees for maintenance and/ or storage of frozen
              as salabrasion, chemosurgery and other such skin            embryos.
              abrasion procedures.)                                   5.	Health services and associated expenses for abortion.

13    UnitedHealthcare HRA Medical Plan Benefits | Centura Health
6.	Fetal reduction surgery.
     7.	Health services associated with the use of non-surgical
         or drug-induced pregnancy termination.

     Services provided under another plan
     1.	Health services for which other coverage is required by
         federal, state or local law to be purchased or provided
         through other arrangements. This includes, but is not
         limited to, coverage required by workers’ compensation,
         no-fault auto insurance, or similar legislation. If coverage
         under workers’ compensation or similar legislation is
         optional for you because you could elect it, or could have
         it elected for you, benefits will not be paid for any injury,
                                                                         Vision and hearing
         sickness or mental illness that would have been covered
                                                                         1.	Purchase cost of eye glasses or contact lenses, (charges
         under workers’ compensation or similar legislation had
                                                                              are covered for eyeglasses that are a result of cataract
         that coverage been elected.
                                                                              surgery.)
     2.	Health services for treatment of military service-related
                                                                         2.	Fitting charge for eye glasses or contact lenses.
         disabilities, when you are legally entitled to other
         coverage and facilities are reasonably available to you.        3.	Eye exercise therapy.

     3.	Health services while on active military duty.                  4.	Surgery that is intended to allow you to see better
                                                                              without glasses or other vision correction including radial
     Transplants                                                              keratotomy, laser, and other refractive eye surgery.
     1.	Health services for organ and tissue transplants, except
         those described in the Summary Plan Description.                All other exclusions
                                                                         1.	Health services and supplies that do not meet the
     2.	Health services connected with the removal of an organ
                                                                              definition of a Covered Health Service (see the definition in
         or tissue from you for purposes of a transplant to another
                                                                              the SPD Section 10: Glossary of Defined Terms.)
         person. (Donor costs for removal are payable for a
         transplant through the organ recipient’s benefits under         2.	Physical, psychiatric or psychological exam, testing,
         the plan.)                                                           vaccinations, immunizations, or treatments that are
                                                                              otherwise covered under the Plan when:
     3.	Health services for transplants involving mechanical or
         animal organs.                                                        •R
                                                                                 equired solely for purposes of career, education,
                                                                                sports or camp, travel, employment, insurance,
     4.	Any multiple organ transplant not listed as a covered                  marriage or adoption.
         health service under the heading Transplantation Health
         Services in the Summary Plan Description.                             •R
                                                                                 elated to judicial or administrative proceedings or
                                                                                order.
     Travel                                                                    •C
                                                                                 onducted for purposes of medical research.
     1.	Health services provided in a foreign country, unless
                                                                               •R
                                                                                 equired to obtain or maintain a license of any type.
          required as Emergency Health Services.
                                                                         3.	Health services received as a result of war or any act of
     2.	Travel or transportation expenses, even though
                                                                              war, whether declared or undeclared or caused during
          prescribed by a physician. Some travel expenses
                                                                              service in the armed forces of any country.
          related to covered services rendered at United Resource
          Networks participating programs or Designated Facilities       4.	Health services received after the date your coverage
          may be reimbursed at our discretion.                                under the Plan ends, including health services for
                                                                              medical conditions arising before the date your coverage
                                                                              under the Plan ends.

14    UnitedHealthcare HRA Medical Plan Benefits | Centura Health
5.	Health services for which you have no legal responsibility   24.	Any charges higher than the actual charge. The actual
          to pay, or for which a charge would not ordinarily be            charge is defined as the provider’s lowest routine charge
          made in the absence of coverage under the Plan.                  for the service, supply or equipment.

     6.	Charges in excess of eligible expenses or in excess of any   25.	Any charge for services, supplies or equipment advertised
          specified limitation.                                            by the provider as free.

     7.	Services for the evaluation and treatment of                 26.	Any charges by a provider sanctioned under a
          temporomandibular joint syndrome (TMJ), when the                 federal program for reason of fraud, abuse or medical
          services are considered to be medical or dental in nature,       competency.
          including oral appliances.
                                                                       27.	Any charges prohibited by federal anti-kickback or self-
     8.	Upper and lower jawbone surgery except as required for           referral statutes.
          direct treatment of acute traumatic Injury or cancer. Jaw
                                                                       28.	Any additional charges submitted after payment has been
          alignment and treatment for the temporomandibular joint,
                                                                           made and your account balance is zero.
          except as a treatment of obstructive sleep apnea.
          Ortho­gnathic jawbone surgery is a covered service.          29.	Any outpatient facility charge in excess of payable
                                                                           amounts under Medicare.
     9.	Speech therapy except as required for treatment of a
          speech impediment or speech dysfunction that results         30.	Any charges by a resident in a teaching Hospital where a
          from injury, stroke, or a congenital anomaly.                    faculty Physician did not supervise services.

     10.	Non-surgical treatment of obesity, including morbid         31.	Outpatient rehabilitation services, spinal treatment or
         obesity.                                                          supplies including, but not limited to spinal manipulations
                                                                           by a chiropractor or other doctor, for the treatment of a
     11.	Surgical treatment of obesity, except Roux-en-Y, Lap
                                                                           condition which ceases to be therapeutic treatment and
         band and Sleeve gastrectomy bariatric surgery at
                                                                           is instead administered to maintain a level of functioning
         Penrose-St. Francis Hospital or Parker Adventist Hospital.
                                                                           or to prevent a medical problem from occurring or
     12. Sex transformation operations.                                    reoccurring.

     13. Custodial Care.                                               32.	Spinal treatment, including chiropractic and osteopathic
                                                                           manipulative treatment, to treat an illness, such as asthma
     14. Domiciliary care.
                                                                           or allergies.
     15. Private duty nursing.
                                                                       33.	Speech therapy to treat stuttering, stammering, or other
     16. Respite care.                                                     articulation disorders.
     17. Rest cures.                                                   34.	Liposuction.
     18. Psychosurgery.                                                35.	Chelation therapy, except to treat heavy metal positioning
     19.	Treatment of benign gynecomastia (abnormal breast            36.	Cosmetic or reconstructive surgery (except as specified
         enlargement in males).                                            above.)
     20.	Medical and surgical treatment of excessive sweating        37.	Personal trainer.
         (hyperhidrosis).
                                                                       38.	Naturalist.
     21.	Medical and surgical treatment for snoring, except when
                                                                       39.	Holistic or
         provided as a part of treatment for documented obstructive
                                                                            homeopathic care.
         sleep apnea.
                                                                       40.	Pulmonary
     22.	Appliances for snoring.
                                                                            rehabilitation
     23.	Any charges for missed appointments, room or facility             therapy.
         reservations, completion of claim forms or record
         processing.

15    UnitedHealthcare HRA Medical Plan Benefits | Centura Health
Claims and appeals
     If any claim for benefits is denied, you will be given the        For more information about the claims and appeals process,
     reason for denial in writing usually within 30 days after         call UnitedHealthcare directly at 1-866-234-8908.
     the receipt of the claim by UnitedHealthcare. The Claims
                                                                       Claims submittal:
     Administrator will notify you within this 30 day period if
     additional information is needed to process the claim. You        UnitedHealthcare Insurance Company
     may request a one time extension within 15 days and pend          P.O. Box 30555
     your claim until all information is received.                     Salt Lake City, Utah 84130-0555

     Once notified of the extension you then have 45 days to           Requests for review of denied claims & notice of
     provide this information. If you don’t provide the needed         complaints:
     information within the 45 day period, your claim will be          UnitedHealthcare Insurance Company
     denied. If you provide the information within the 45 day          P.O. Box 30432
     extension, a decision will be made within 15 days after the       Salt Lake City, Utah 84130-0432
     information is received.

     Coordination of benefits
     If you and your dependents have coverage under another
     medical plan (such as your spouse’s employer’s plan),
                                                                          Example
     benefits are coordinated between the two plans. The primary
                                                                          Suppose your spouse incurs $1,000 in medical
     plan pays your benefits first. Then the secondary plan pays
                                                                          expenses and his or her plan pays $500. If the Centura
     any additional benefits that may be due.                             Health Plan would have paid $650 as the primary, it
                                                                          will consider paying up to $150 ($650 – $500 = $150),
     For you                                                              subject to plan provisions, toward your spouse’s
     The Centura Health Plan is always considered primary for             expenses.
     you, the associate. If you are also covered as a dependent           If your spouse’s plan pays $750, more than the Centura
     on your spouse’s plan, that plan will be secondary. If the           Health Plan would have paid as the primary, then no
     other plan does not have a coordination of benefits provision,       benefit would be paid by the Centura Health Plan.
     that plan will always pay first.

     For your spouse
     If your spouse is covered under his or her employer’s plan,       For your children
     that plan will be considered primary for your spouse, and the     If your dependent children are covered by your plan and your
     Centura Health Plan will be secondary. The Centura Health         spouse’s plan, the primary payer will be determined by the
     Plan will pay expenses not paid by the primary plan, up to        “birthday rule.” Under this rule, the plan of the parent whose
     the amount that would have been payable under the terms           birthday falls first during the calendar year (regardless of year
     of the Centura Health Plan had it been the primary plan.          of birth) will pay primary (If birthdays of both parents are the
     If the other plan does not have a coordination of benefits        same, the plan that has covered either of the parents longer
     provision, that plan will always pay first. If none of the        is primary.) This rule does not apply in the case of separation
     circumstances already described apply, the plan that has          or divorce. Instead, determination may be based on which
     covered your spouse for a longer period of time will pay first.   parent has legal custody of the child. If a court decree has

16    UnitedHealthcare HRA Medical Plan Benefits | Centura Health
been issued, the primary plan is determined by which parent      individuals who are covered by the Centura Health Plan
     the court decree obligates to cover the health care expenses     due to “current employment status” and who are covered
     of the child. Otherwise, if the parents are not married or are   by Medicare due to age or disability. The Centura Health
     separated or divorced, the order of benefit payment for the      Plan is primary payer for the first 30 months that a covered
     child is:                                                        individual is entitled to Medicare because of end-stage renal
                                                                      disease (ESRD.)
        • The plan of the custodial parent
        • The plan of the spouse of the custodial parent              Right of recovery
        • The plan of the non-custodial parent                        Centura Health is entitled to receive reimbursement from
        • The plan of the spouse of the non-custodial parent.         participants who receive compensation from any third party,
     If the other plan does not have a coordination of benefits       other than family members, for expenses that have been
     provision, that plan will always pay first. If none of the       paid for by the plan.
     circumstances already described apply, the plan that has         In some situations, a third party, such as another person
     covered your dependents for a longer period of time will pay     or insurance company can be legally responsible for your
     first.                                                           medical expenses. A car accident is an example of such
                                                                      a situation. In these cases, the Health Plan is entitled to
     Filing coordination claims                                       repayment for all medical expenses paid. When you accept
     If you are covered under two plans, it is important that you     payment from UnitedHealthcare, you agree to provide any
     file full and complete claims with both claim administrators.    documents that would help the company recover payments
     You should file your claim with the primary plan first. Then,    it makes on your behalf. The legal term for the company’s
     when you receive the explanation of benefits, you should         right of recovery is subrogation.
     forward it along with your claim to the secondary plan.
                                                                      If you do receive payment from a third party and do
     If you have any questions about which plan is primary            not promptly refund the company the full amount,
     or secondary, please contact UnitedHealthcare at                 UnitedHealthcare has the right to reduce future benefits
     1-866- 234-8908.                                                 that are payable under the Centura Health Plan. The
                                                                      reductions will equal the amount of the required refund.
     Medicare secondary payer                                         UnitedHealthcare may have other rights in addition to the
     The Centura Health Plan pays primary to Medicare for             right to reduce future benefits.

     Agent for legal processes
           Plan Administrator
           Centura Health
           188 Inverness Drive West, Suite 500
           Englewood, Colorado 80112

17    UnitedHealthcare HRA Medical Plan Benefits | Centura Health
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