HomeMy WebLinkAboutContract 21482148
PreferredOne Insurance Company
Group Master Contract
Employer: City of Columbia Heights Employer Group #: PCH10409
Address: as on file with PIC
Effective Date: January 1, 2009
This Group Master Contract ("GMC") is entered into by and between PreferredOne Insurance Company
("PIC") and the Employer. The GMC includes the Certificate of Coverage ("COC") and Exhibits A and
B, which are part of this GMC and incorporated by reference. The Employer accepts this GMC by
remitting the first pre~niu~n payment to PIC. In consideration of the monthly prerniurn paid by the
Employer PIC will arrange to provide the benefits described in the COC.
Once accepted, this GMC will be effective and all coverage under this GMC will begin at 12:01 a. m.
Central Time on the effective date noted above.
Words that are italicized in this GMC have a special meaning and are defined in the COC. PIC has
discretionary authority to determine eligibility for benefits and to interpret and construe terms, conditions,
limitations and exclusions of this GMC.
This GMC is delivered in and is governed by the laws of the State of Minnesota.
IN WITNESS WHEREOF, PIC has caused this GMC to be executed on this December 30, 2008 to take
effect on the effective date stated above.
PreferredOne Insurance Company
6105 Golden Hills Drive
Golden Valley, MN
(763) 847.4013
~'
°"
By: Paul Geiwitz
Executive Vice President and Chief Marketing Officer
Any person who knowingly and with intent to defraud makes a misstatement of material fact or
withholds or conceals material information, commits a fraudulent act, which is a crime.
PIC07-735-R2 I GMC (LG) (1/09)
SERVICES AND PAYMENT
Member Enrollment and Termination
The Employer will offer to all of its eligible employees the opportunity to become a secbscriber under this
GMC. Eligible employees and qualified dependents may enroll only at such times and under such
conditions as specified in the COC and Exhibit B.
The Employer will submit enrollment and termination information to PIC in a timely manner and in a
format acceptable to PIC. PIC must receive eligible employees' completed enrollment forms within 31
calendar days of the employees' eligibility date and notice of terminations of coverage within 90 calendar
days of the date of termination. Employer will also comply with PIC's request for information and/or
data regarding Employer's Plan and Employer, including but not limited to, information regarding Plan
participants for which PIC must provide reporting to regulatory authorities as required by state or federal
law, (such as Medicare reporting.) Employer agrees to compensate PIC for any fees or fines incurred by
PIC as a result of Employer's failure to comply with PIC's request.
When the Employer and PIC approve an application as to eligibility, the member's coverage is effective
on the date described in Exhibit B and is expressly subject to the conditions described in the COC. When
a member terminates coverage, the effective date of termination of coverage is determined in accordance
with the section entitled "Ending Your Coverage" in the COC.
Premium Billin
PIC will bill the Employer for each full month of coverage by multiplying the appropriate premiccm rate
set forth in Exhibit A by the number of persons enrolled. Full premium will be billed for persons who
become members between the first and fifteenth day of the month. No premium will. be billed for persons
who become members after the fifteenth day of the month. PIC will bill the Employer no more frequently
than once each month and the Employer agrees to pay the amount billed.
PIC will reflect additions and deletions in enrollment in the subsequent month's billing. For termination
of a person's coverage, the Employer will be eligible to receive a premium credit for a maximum period
of three months and in no event will any premium credit be given for a person during a month in which
the person received benefit(s) described in the COC.
For example, if the request to terminate a member effective May 31, 2009, is received and processed prior
to the scheduled September 2009 bill run (done in mid-August), the Employer will receive full premium
credit back to June 2009 (June, July, August). However, if this same request is received and processed
after the scheduled September bill run, the credit will be reflected on the subsequent month's billing
(October), and will only credit the Employer back to July (July, August, September), and thus the
Employer will forfeit the June premium credit.
PIC07-735-R2 2 GMC (LG) (1/09}
Amount and Timin og f Payments
PIC must receive prerniurn payment on or before the due date, which is the first day of each month. The
premium rate and scope of coverage provided are guaranteed fora 12 month period after the effective date
of this GMC.
The Employer has a 20-calendar day grace period to make its monthly premium payment. If all or a
portion of the premium remains unpaid at the end of the grace period, PIC may assess a finance charge of
18% per annum for the unpaid amount. If the Employer makes a premium payment after the due date, but
prior to expiration of the grace period, PIC, in its discretion, may require the Employer to authorize PIC
to make electronic fund transfers from the Employer's financial institution for subsequent premium
payments.
Commission Pavments to Brokers
PIC pays certain commissions and other payments to brokers for placement of the Employer's business
with PIC. The amount of commissions and other payments may vary from time to time depending on the
commission structure and the nature of the business placed with PIC. At the Employer's request and
without charge, PIC will furnish information regarding the actual commission and other payments (if any)
paid to brokers in connection with the Employer's contract with PIC.
Benefit Coverage
In consideration of the prerniurn paid, PIC will arrange for the provision of benefits described in the COC
to members. In so doing, PIC may enter into agreements with providers of health care, one or more
insurers and such other individuals and entities as may be necessary to enable PIC to fulfill its obligations
under this GMC.
By payment of the first premium owed PIC under this GMC, the Employer certifies to PIC that the COC
listed in Exhibit A and issued by PIC shall be used solely in connection with a health savings account
(HSA), within the meaning of Internal Revenue Code (Code) Section 223 and the regulations thereunder
and Minnesota law regarding health savings accounts, established by a subscriber or the Employer on
behalf of a subscriber covered under the terms of such COC.
NOTICE
The Employer will promptly notify PIC of the occurrence of any of the following events:
1. Material change of 10% or more in the number of its employees through merger, acquisition and/or
business unit changes;
2. Additional offerings of other carrier benefit plans to its employees;
3. Change in its contribution funding levels or contribution formulas for its employee coverage under
the COC; or
4. Disclosure of a Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA)
account offering.
Upon the occurrence of a listed event, PIC at its option may adjust the premium rate set forth in Exhibit
A, which change will be effective on the date the event occurred.
PIC07-735-R2 3 GMC (LG) (1/09)
TERMINATION OF GMC
This GMC may be terminated as follows:
By the Employer, on at least30-calendar days' advance written notice of termination to PIC. If the
30-calendar day notice period ends on a date other than the last day of the month, the effective date of
the termination will be delayed until the last day of that month. For example, if notice is given June
15, the 30-calendar day notice period will end July 15 and the termination will be effective July 31.
Premium will be charged through the effective date of termination of the GMC and the Employer is
responsible for its payment.
2. By PIC, on at least 30-calendar days' written notice of termination to the Employer and subscribers,
except that PIC may terminate this GMC effective the end of the month in which one of the following
events occurs:
a. Employer fails to pay premium in a timely manner under the terms of the GMC and subject to the
notice of termination described in the next paragraph;
b. Employer performs an act or practice that constitutes fraud or misrepresentation of material fact;
c. Employer fails to comply with a material provision relating to contributions or participation;
d. Employer ceases doing business; or
e. Upon renewal, Employer has less than two enrollees covered under this GMC.
If PIC terrrunates the GMC for nonpayment of the premium, it will send 30 calendar days' written
notice of termnation to the Employer and subscribers, specifying the date of cancellation of
coverage, which may be 60 calendar days before the effective date of the notice. Cancellation will be
effective at month end. For example, if notice of cancellation to the Employer and subscribers is
postmarked June 1, it may advise members that the notice is effective July 1 and that on that date their
coverage will be cancelled retroactively (60 calendar days) to April 30`".
Members whose coverage terminates for any of the reasons listed in items 2 and 3 above may be entitled
to conversion rights described in the COC.
DELIVERY OF NOTICES
All notices required to be given under this GMC will be written and personally delivered, effective on
delivery, or sent by United States mail, postage prepaid, effective on the day following the date deposited
in the mail. If PIC terminates the GMC for nonpayment of premium, the notice of cancellation it sends
subscribers will be effective 30 calendar days after the date postmarked by the United States Postal
Service. Coverage will terminate on the date as described in item " 3." of the "TERMINATION OF
GMC" provision. In mailing any notices to subscribers, PIC may rely upon the addresses supplied by the
Employer, which the Employer will update every 12 months while this GMC is in effect.
PIC07-735-R2 4 GMC (LG) (1/09)
RIGHTS AND OBLIGATIONS UPON TERMINATION.
Upon termination of this GMC, neither party has any further obligation to the other party, provided
however, that such termination will not release either party of its obligations with respect to obligations
including payment obligations accrued before and up to the termination date.
INCONTESTABILITY
Statements the Employer or a member makes relating to insurability will be considered a representation
and not a warranty. After the GMC has been in effect for two years, its validity cannot be contested,
except for nonpayment of premium or a fraudulent misrepresentation. After a member's coverage has
been in effect for two years, its validity cannot be contested except for a fraudulent misrepresentation..
P1C07-735-R2 5 GMC (LG) (1/09)
EXHIBIT A
Group Master Contract
By and Between
PreferredOne Insurance Company
and
City of Columbia Heights
The following terms and provisions are incorporated into and made a part of the above GMC:
1) MONTHLY PREMIUM RATE:
15.100.2. V 1500.75.2RxF. V
Employee $489.40 $322.71
Family $1,125.61 $742.23
The Monthly Premium Rates for subsequent renewals will be as shown on the Renewal Rate
Packet which will be sent to the Employer at least 30 days prior to the renewal date.
If an employee enrolls an eligible dependent under the COC who is not considered the
employee's tax dependent for health care benefits under the federal tax Code, then federal tax law
requires that the value of the coverage provided to such dependents be imputed as income to the
employee on the employee's W-2. It is the Employer's, and not PIC's responsibility to determine
the appropriate Employer tax treatment of, and fulfill all required Employer reporting
requirements for all employees and dependents covered under the COC.
PIC07-735-R2 6 GMC (LG) (1/09}
EXHIBIT B
Group Master Contract
By and Between
PreferredOne Insurance Company
and
City of Columbia Heights
The following terms and provisions are incorporated into and made a part of the above GMC:
1) PARTICIPATION REQUIREMENTS: At least 75% of all eligible employees and dependents
who have not waived coverage due to coverage under another plan, but no less than 50% of all
eligible employees must participate under this GMC or another group health plan sponsored by
Preferred One Insurance Company ("PIC"). Employees who have waived coverage must do so in
writing to the Employer and PIC has the right to review such waivers upon request.
2) CONTRIBUTION REQUIREMENTS: The Employer will contribute at least 50% of the
employee's total premium.
3) DEFINITION OF ELIGIBLE EMPLOYEES: All full-time employees of Employer defined as
working a minimum of 40 hours per week, and elected officials.
RETIRED: Retirees are eligible under Minnesota Statute 471..61.
4) WAITING PERIOD AND EFFECTIVE DATE OF COVERAGE: None.
Coverage begins first day of the calendar month following or coinciding with date of employment
and completion of required waiting period provided that application for coverage is received
within 31 days of the date of eligibility.
Late enrollees: First day of the calendar month following date PIC receives application for
coverage.
Note: Employees who moved from an ineligible to an eligible employment classification must
complete the waiting period designated above.
5) REHIRES: Treat as new employee, subject to the waiting period.
PIC07-735-R2 7 GMC (LG) (1/09)
j~referredQne °
INSURANCE COMPANY
READ YOUR CERTIFICATE CA,~tEFULLY
PIC07-760-R1 (1/09)
I'T~ t3F ~LUBI~ ~ICHTS
`I a. `I 00. Z..V
(PCH10409) 15.100.2.V
Questions? Our Customer Services staff is available to answer questions about your
coverage Monday through Friday, 7:00 a.m. - 7:00 p.m. Central Standard
Time (CST)
When contacting us, please have your member identification card available. If
your questions involve a bill, we will need to know the date of service, type of
service, the name of the licensed provider, and the charges involved.
Customer Service Telephone Monday through Friday 7:00 a.m.-7:00 p.m. CST 763.847.4477
Number Toll free 1.800.997.1750
Hearing impaired individuals 763.847.4013
Website www.preferredone.com
Office Mailing Address Claims, review requests, pre-certification, written inquiries may be mailed to:
Customer Services Department
PreferredOne Insurance Company
P.O. Box 59212
Minneapolis, MN 55459-0212
PIC07-760-R1 (1/09) (PCH10409) 15.100.2.V
TABLE 4F C®NTENTS
Important Member Information ..................................................................................................................1
Member Bill of Rights ...................................................................................................................................2
Disclosure of Provider Payment Methods ....................................................................................................2
Member Information for Non-Participating Provider Benefits .................................................................3
PreferredOne Insurance Company (PIC~ ...................................................................................................4
Introduction to Your Coverage ................................................................................................................4
Certificate of Coverage (COC) .................................................................................................................4
Services Received in a Participating Provider Facility from aNon-Participating Provider ..................4
Standing Referrals to Non-Participating Specialists :..............................................................................4
Continuity of Care ....................................................................................................................................4
Medical Entergency ...................................................................................................................................5
Group Master Contract (GMC) ...............................................................................................................5
Your Identification Card ..........................................................................................................................5
Provider Directory ...................................................................................................................................5
Changes in Coverage ................................................................................................................................5
Conflict with Existing Law .......................................................................................................................6
Privacy ......................................................................................................................................................6
Clerical Error ...........................................................................................................................................6
Assignment ...............................................................................................................................................6
Notice ........................................................................................................................................................b
Time Limit on Certain Defenses ..............................................................................................................6
Fraud ........................................................................................................................................................6
Medical Technology and Treatment Review ...........................................................................................7
Recommendations by Health Care Providers ..........................................................................................7
Legal Actions ............................................................................................................................................7
Eligibility and Enrollment ...........................................................................................................................8
Schedule of Payments ................................................................................................................................11
Pre-certification Reduirement and Prior Authorization ..........................................................................13
Description of Benefits ...............................................................................................................................17
Pre-existing Condition Limitation .............................................................................................................51
Exclusions ................................................................................................................................................... 51
Ending Your Coverage ...............................................................................................................................58
Leaves of Absence ......................................................................................................................................59
Family and Medical Leave Act (FMLA) ................................................................................................59
The Uniformed Services Employment and Reemployment Rights Act of 1994 (USE ) ................59
Continuation Coverage ..............................................................................................................................61
Your Right to Convert Coverage ...............................................................................................................70
Subrogation and Reimbursement ..............................................................................................................71
Coordination of Benefits ............................................................................................................................72
How to Submit a Bill if You Receive One for Covered Services ................................................................76
Initial Benefit Determinations ofPost-Service Claims ...............................................................................76
Complaint and Appeal Procedures ...........................................................................................................77
No Guarantee of Employment or Overall Benefits ...................................................................................79
Definitions ..................................................................................................................................................79
PIC07-760-R1 (1/09) (PCHI0409) 15.I00.2.V
Important Member Information
Covered Services: Services will be covered by PreferredOne Insurance Company (PIC). Your Certificate of
Coverage (COC) defines what services are covered and describes procedures you must follow to obtain coverage.
Providers: Enrolling in PIC does not guarantee services by a particular provider on the list of providers. When a
provider is no longer participating with PIC, you must choose among remaining PIC participating providers.
Contact Customer Service for the most recent listing of PIC providers.
Emergency Services: Emergencv services from nonparticipating providers will be covered only if proper
procedures are followed. Your COC explains the procedures and benefits associated with emergency care from
participating and non participating providers.
Exclusions: Certain services or medical supplies are not covered. You should read your COC for detailed
explanation of all exclusions.
Continuation: Yocr may convert to an individual contract or continue coverage under certain circumstances.
These continuation and conversion rights are explained in yozrr COC.
Termination: Your coverage may be terminated by you or PIC only under certain conditions. Your COC
describes all reasons for termination of coverage.
Prescription Drugs and Medical Equipment: Enrolling in PIC does not guarantee that any particular
prescription drug will be available nor that any particular piece of medical equipment will be available, even if
the drug or equipment is available at the start of the contract year.
Notice Applicable To Small Employer Groups: Minnesota law requires this disclosure. This plan of benefits
is expected to return on average 86 percent of your premium dollar in health care. The lowest percentage
permitted by state law for these benefits is 71 percent for small employer groups with fewer than 10 members,
and 75 percent for all other small employer groups.
According to state law, "small employer" is defined as an entity actively engaged in business, that employed an
average of no fewer than two nor more than 50 employees on business days during the preceding calendar year
and that employs at least two employees on the first calendar day of the calendar year.
Small employer plans are guaranteed renewable as long as the employer remains eligible for a small employer
plan.
PIC07-760-R1 (1/09) 1 (PCH10409) 15.100.2.V
Member Bill of Rights
The laws of the State of Minnesota grant members certain legal rights.
As a PIC member, you have the fallowing rights and responsibilities.
Members have the right to:
1. available and accessible services, including emergencv services 24 hours a day, 7 days a week;
2. be informed of health problems and receive information regarding treatment alternatives and risks that are
sufficient to assure informed choice;
3. refuse treatment recommended by PIC or any provider;
4. privacy of medical or dental and financial records maintained by PIC and its participating providers, in
accordance with existing law;
file a complaint with PIC and the Commissioner of Commerce and to initiate a legal proceeding when
experiencing a problem with PIC or its participating providers. For information, contact the Minnesota
Department of Commerce at 651.296.4026 or 1.800.657.3602 and request information.
Disclosure of Provider Payment Methods
PIC contracts with participating providers to provide health care services to members. Participating providers
submit claims for eligible charges to PIC with their usual charge for the health care services. At PIC, the
member benefits are determined for the service and the claims are paid according to the applicable fee schedule.
This may be based on various methodologies, depending on the provider type and contract (i.e. per service, per
event, per day, by diagnostic related group or percent of charge). The deductible and coinsurance amounts are
based on the fee schedule amount.
A participating provider may contractually agree to a risk allowance. The money withheld for the risk allowance
may or may not be returned to the provider, depending on various circumstances, such as quality of care,
efficiency, cost effectiveness, member satisfaction, and/or, the financial situation of PIC. The method by which
the risk allowance is repaid may differ by provider type/specialty and therefore may vary among participating
providers. Members are not responsible for payment of any risk allowance. Factors such as the quality,
efficiency and cost effectiveness of care that participating providers deliver may also affect future contract terms
between PIC and participating providers.
Post-service claims submitted to PIC for non participating provider benefits are paid on afee-for-service basis.
PIC determines member benefits based on the PIC Non-Participating Provider Reimbarrsement Value.
PIC does not specifically reward practitioners or other individuals for issuing denials of coverage or service care.
Financial incentives for utilization management decision makers do not encourage decisions that result in
underutilization. Utilization management decision making is based only on appropriateness of care and service
and existence of coverage.
PIC07-760-RI (1/09} 2 (PCH10409) 15.100.2.V
Member Information for Non-Participating Provider Benefits
Covered Services: PIC covers services from non participating providers, at varying levels of coverage.
Deductibles and maximum lifetime benefit restrictions may apply. Your COC lists the services available and
describes the procedures for receiving coverage through non participating providers.
Pre-Certification: There may be a reduction in the level of benefits available to you if you do not obtain pre-
certification. See section entitled "Pre-certification" in your COC for specific information about the need to
obtain pre-certification.
PIC07-760-R1 (1/09) 3 (PCH10409) 15.100.2.V
PreferredOne Insurance Company (PIC}
Introduction to Your Coverage
This COC describes your PIC health care coverage. PIC may not cover all of yozzr health care expenses. Read
this CDC carefully to determine which expenses are covered. Many provisions are interrelated; therefore,
reading just one or two provisions may not give yozz a complete understanding of the coverage described under
this COC. Italicized words used in this COC have special meanings and are defined at the back of this COC.
Certificate of Coverage (COC)
This COC describes the coverage under the GMC. PIC issues the GMC to your employer. The GMC provides
for the medical coverage described in this COC. It covers the subscriber and the enrolled dependents, if any, as
named on the subscriber's enrollment application.
Services Received in a Participating Provider Facility from aNon-Participating Provider
For services obtained through a participating provider facility, such as ancillary services, services from an x-ray
technician, and services of an emergency room physician, the participating provider level of benefits applies as
shown in the "Benefit Schedule". You will be responsible for any charges that may exceed the PIC Non-
Participating Provider Reimbursement Value.
Standing Referrals to Non-Participating Specialists:
Services provided by anon-participating specialist as a result of a standing referral will be covered as if a
participating specialist had provided the services, if a participating specialist is not reasonably available or
accessible to treat your condition. You may apply for, and if appropriate, receive a standing referral for treatment
of one of the following conditions:
1. a chronic health condition;
2. alife-threatening mental or physical illness;
3. a second or third trimester pregnancy;
4. a degenerative disease or disability; or
5. any other condition or disease of sufficient seriousness and complexity to require treatment by a specialist.
Continuity of Care
If the contract between PIC and your participating physician, participating hospital or participating specialist
terminates, and the termination was not for cause, PIC may, upon your written request to PIC, authorize
continued services from the terminating provider for up to 120 days for any of the following conditions:
1. An acute condition;
2. Life-threatening mental or physical illness;
3. Second or third trimester pregnancy;
4. Physical or mental disability defined as an inability to engage in one or more major life activities, provided
that the disability has lasted or can be expected to last for at least one year; or can be expected to result in
death; or
5. Disabling or chronic condition that is in an acute phase.
If the physician certifies that the member has an expected lifetime of 180 calendar days or less, services from the
terminating provider will be covered until the member's death. Continuity of care may also apply to members
who require an interpreter or are receiving culturally appropriate services and. the provider network does not have
such a provider or specialist in its network.
PIC07-760-R1 (1J09) 4 (PCH10409) 15.100.2.V
Continuity of care may also be extended to new members who meet the criteria described above and whose
employer changed health plans. However, in such situations, the non participating provider must agree to all of
the following:
1. Accept as payment in full the lesser of PIC's reimbursement rate for such services when provided by
participating providers or the nonparticipating provider's regular fee for such services;
2. Follow PIC's pre-certification requirements; and
3. Provide PIC with all necessary medical information related to the care provided to the member.
Requests for continuity of care will be denied if medical records and other supporting documentation are not
submitted to PIC. PIC's written policy regarding continuity of care is available upon request. Contact Customer
Service for assistance in obtaining a copy of PIC's written policy.
Medical Emergency
Yozz should be prepared for the possibility of a medical emergency by knowing your participating provider's
procedures for "on call" and after regular office hours before the need arises. Determine the telephone number to
call, which hospital your participating provider uses, and other information that will help yozz act quickly and
correctly. Keep this information in an accessible location in case a medical emergency arises.
If the situation is a medical emergency and if traveling to a participating provider would delay emergency care
and thus endanger yozrr health, you should go to the nearest medical facility. However, call PIC or your
participating provider within 48 hours or as soon as reasonably possible to discuss yozzr medical condition and to
coordinate any follow-up care. Yozz may authorize someone else to act on your behalf. If the situation is not a
medical emergency and if yozz seek care at a hospital emergency room, coverage for such services may be denied.
Group Master Contract (GMC)
PIC's Group Master Contract (GMC) combined with this COC, any amendments, the employer's application, the
individual applications of the subscribers and any other documents referenced in the GMC constitute the entire
contract between PIC and the employer. If you wish to see the GMC, contact your employer.
Your Identification Card
PIC issues an identification (ID) card containing coverage information. Please verify the information on the ID
card and notify PIC Customer Service if there are errors. If any ID card information is incorrect, post-service
claims or bills for your health care may be delayed or temporarily denied. Yozr will be asked to present yozrr ID
card whenever you receive services.
Provider Directory
Yazr may request from PIC a provider directory that lists facilities and individuals who are participating
providers and are available to yozz. You may also find participating providers on the designated website.
Coverage may vary according to yozrr provider selection.
The directory frequently changes and PIC does not guarantee that a listed pr•ovider• is a participating provider.
You may want to verify that a provider yotr choose is a participating provider by calling Customer Service.
Changes in Coverage
PIC may at any time modify the GMC so Long as such modification is consistent with applicable statute or
regulation and effective on a uniform basis among all individuals with the same type of coverage. Any change in
PIC07-760-RI (1/09) S (PCHI0409) I5.100.2.V
coverage is subject to PIC approval. If a change in coverage is requested by your employer, it is effective on the
date mutually agreed to by your employer and PIC. Only an officer of PIC has the authority to make or change
the GMC. Any change in coverage required by statute or regulation becomes effective according to statute or
regulation.
Conflict with Existing Law
If any provision of this COC conflicts with any applicable statute or regulation, only that provision is hereby
amended to conform to the minimum requirements of the statute or regulation.
Privacy
PIC is subject to the Health Insurance Portability and Accountability Act ("HIPAA") Privacy Rule. In
accordance with the HIPAA Privacy Rule, PIC maintains, uses, or discloses your Protected Health Information
for things like claims processing, utilization review, quality assessment, case management, and otherwise as
necessary to administer your PIC health care coverage. You will receive a copy of PIC's Notice of Privacy
Practices (which summarizes PIC's HIPAA Privacy Rule obligations, your HIPAA Privacy Rule rights, and how
PIC may use or disclose health information protected by the HIPAA Privacy Rule) with your enrollment packet.
You may also call Customer Service to receive one. Yozzr failure to provide authorization or requested information
may result in a denial of your claim.
Clerical Error
You will not be deprived of nor receive coverage under the GMC because of a clerical error by PIC. You will not
be eligible for coverage beyond the scheduled termination of your coverage because of a failure to record the
termination.
Assignment
FIC will have the right to assign any and all of ifs rights and responsibilities under the G1LIC to any affiliate of
PIC or to any other appropriate organization or entity.
Notice
Written notice given by PIC to a representative of the employer will be deemed notice to all affected in the
administration of the GMC, unless applicable laws and regulations require PIC to give direct notice to affected
members.
Time Limit on Certain Defenses
if there is any misstatement in the written application the employer completes, PIC cannot use the misstatement
to cancel coverage that has been in effect for two years or more. This time limit does not apply to fraudulent
misstatements.
Fraud
Coverage may be terminated, if a member falsifies their application for coverage; submits fraudulent, altered or
duplicate billings, for their or others personal gain; or allows another party not covered under this COC to use
their coverage.
PIC07-760-RI (1/09} 6 (PCH10409) 15.100.2.V
Medical Technology and Treatment Review
Depending on the focus of the technology or treatment, one of three committees (MedicaUSurgical Quality
Subcommittee, Behavioral Health Quality Subcommittee or the Pharmacy and Therapeutics Quality
Subcommittee) determines whether new and existing medical treatments and technology should be covered
benefits. These committees are made up of PIC staff and independent community physicians who represent a
variety of medical specialties. Their goal is to find the right balance between making improved treatments
available and guarding against unsafe or unproven approaches. These committees carefully examine the scientific
evidence and outcomes for each treatment/technology being considered. The decisions of the subcommittees are
overseen by the Quality Management Committee that is made up of independent community physicians, a
consumer representative and PIC staff.
Recommendations by Health Care Providers
In some cases, your provider may recommend or provide written authorization for services that are specifically
excluded by the COC. When these services are referred or recommended, a written authorization from your
provider does not override any specific COC exclusions.
Legal Actions
No legal action may be brought after the expiration of three years after the time written proof of loss is required
to be provided.
P1C07-760-R1 (1/09) 7 (PCH10409) 15.100.2.V
Eligibility and Enrollment
Eligibility
To be eligible to enroll for coverage, you must be a:
1. full-tune employee; or
2. dependent.
If the employer also sponsors and maintains a health reimbursement arrangement (HRA) plan, the employer may
require that eligibility, enrollment and coverage under this COC be coordinated with and conditioned upon
concurrent eligibility and enrollment for benefits under the HRA plan sponsored by the employer.
If concurrent eligibility and enrollment is required, then the eligibility requirements under this COC are also
applicable to the HRA plan and you must be concurrently enrolled under both programs (i. e., this COC and the
HRA plan) to participate in either program. If you are considered aself-employed individual within the meaning
of the HRA plan document and thus, ineligible for the HRA plan, you may enroll solely in this COC program and
will not be required to concurrently enroll in the HRA plan.
An employee must enroll for coverage as the subscriber in order to enroll his or her dependents. A spouse who is
covered as an employee of the employer is not an eligible dependent. A child who is covered as an employee of
the employer is not an eligible dependent. If both parents are covered as employees, children may be covered as
dependents of either parent, but not both.
Eligible dependents include a subscriber's:
1. lawful spouse as defined under Minnesota Statute 517.01;
2. unmarried children, from birth through age 24, including:
a. natural children;
b. legally adopted children or children placed with the subscriber for legal adoption (date of placement
means the assumption and retention by a person of a legal obligation for total or partial support of a child
in anticipation of adoption of the child. The child's placement with a person terminates upon the
termination of the legal obligation of total or partial support.);
c. stepchildren of the szzbscz•iber who reside in the subscriber's home in an on-going parent/child
relationship that is intended to continue to adulthood;
d. grandchildren} who reside in yozn• home after the initial discharge from the hospital due to birth and are
dependent on yozz for their financial support;
e. a child covered under a valid Qualified Medical Child Support Order, as defined under section 609 of the
Employee Retirement Income Security Act (ERISA) and its implementing regulations ("QMCSO"),
which is enforceable against a szbscriber. Yozzr employer is responsible for determining whether or not a
medical child support order is a valid QMCSO. Yozc may request a copy of the procedures used to make
such determinations from your employer.
f. a child for whom the subscriber has been appointed legal guardian by a court of law up to the age stated
in the court appointment if less than age 25.
3. Unmarried handicapped dependents, provided they are:
a. incapable ofself-sustaining emplo}nnent because of physical handicap, mental retardation, mental illness
or mental health disorder; and
b. dependent on the subscriber for a majority of financial support and maintenance.
Proof of incapacity must be provided with the subscriber's application for coverage.
After this initial proof, PIC may request proof again two years later, and each year after.
PIC07-760-R1 (1/09} 8 (PCH10409) 15.100.2.V
The handicapped dependent shall. be eligible for coverage as long as he or she continues to be handicapped
and dependent, unless coverage otherwise terminates under the GMC.
For purposes of this COC, a stepchild's address is considered to be the same as the subscriber's address when
attending an accredited school on a full-time basis, even though the stepchild may be located outside of the
service area.
Enrollment
Initial Enrollment. Eligible employees must make written application to enroll, and such application must be
received within 31 calendar days of the date the employee and any eligible dependent first becomes eligible
subject to the 12-month pre-existing condition limitation. The subscriber must make written application to enroll
a newly acquired dependent and that application and any required payments, if any, must be received within 31
calendar days of when the employee first acquires the dependent.
Late Enrollment. If the eligible employee and any eligible dependents do not enroll within 31 calendar days of
the date they first become eligible they may enroll at a later date subject to the 18-month pre-existing condition
limitation. Coverage will be effective the first of the month following the date PIC receives the application for
coverage.
There may be additional situations when employees are eligible to enroll themselves and any eligible dependents
after the first 31 calendar days of eligibility, in accordance with the Special Enrollment Period provisions listed
below.
Newborn Enrollment. Newborn infants, including the subscriber's newborn grandchildren and children newly
adopted or placed for adoption, who were born, adopted or placed for adoption while the subscriber is covered
under the COC, will be covered immediately from the date of birth, regardless of when notice is received by PIC.
If you submit an application more than 31 days after the date of birth, adoption or placement for adoption, the
newborn or adopted child will still be covered back to the date of birth, adoption or placement for adoption,
however, there may be claim delays until the application is received and any required premiums are paid in full.
PIC must receive required payments, if any, from the date of eligibility before benefits will be paid and the
suhscriber must be covered under this COC in order for the newborn infant to be covered.
Military Duty. Employees returning from active duty with the military and their eligible dependents will be
eligible for coverage as required by law. See USERRA section of this COC for specific requirements.
Special Enrollment Period for Employees and Dependents. If you are an eligible employee or an eligible
dependent of an eligible employee but not enrolled for coverage under PIC, you may enroll for coverage subject
to the 12-month pre-existing condition limitation under the terms of PIC if all of the following conditions are
met:
you were covered under a group health plan or had health insurance coverage at the time coverage was
previously offered to the employee or dependent;
the eligible employee stated in writing at the time of initial eligibility that coverage under a group health plan
or health insurance coverage was the reason for declining enrollment, but only if the Employer required a
statement at such time and provided the employee with notice of the requirement and the consequences of
such requirement at the time;
yocrr coverage described in 1. above was:
a. terminated under a COBRA or state continuation provision and the coverage under such provision was
exhausted; or
b. terminated as a result of Ioss of eligibility for the coverage (including as a result of legal separation,
divorce, death, termination of employment, or reduction in the number of hours of employment) or
employer contributions toward such coverage were terminated; and
PIC07-760-R1 (1/09) 9 (PCH10409) 15.100.2.V
4. the eligible employee requested such enrollment not later than 31 calendar days after the date of exhaustion
of coverage described in 3.a. above, or termination of coverage or employer contributions described in 3.b.
above.
Special Enrollment Period for New Dependefats Only. New dependents may enroll subject to the 12-month
pre-existing condition limitation if all the following conditions are met:
1. a group health plan makes coverage available to a dependent of an employee;
2. the employee is eligible for coverage under PIC;
3. they become dependents of the employee through marriage, birth, adoption, placement for adoption, or legal
guardianship. PIC shall provide a dependent special enrollment period during which the person may be
enrolled under PIC as a dependent of the employee, and in the case of birth, adoption, placement for adoption
or the legal guardianship of a child; the employee may enroll and the spouse of the employee maybe enrolled
as a dependent of the employee if such spouse is otherwise eligible for coverage. The eligible employee, if
not previously enrolled, is required to enroll when a dependent enrolls for coverage under PIC. In the case of
marriage: the employee, the spouse and any new dependents resulting from the marriage may be enrolled, if
otherwise eligible for coverage; and
4. application must be received within 31 calendar days of the date the employee first acquires the dependent
and coverage shall begin on the later of:
a. the date dependent coverage is made available under PIC; or
b. in the case of marriage, the date of the marriage as described in 3. above; or
c. in the case of a dependent's birth, the date of the birth as described in 3. above; or
d. in the case of a dependent's adoption, placement for adoption or legal guardianship, the date of the
adoption, placement for adoption or legal guardianship as described in 3. above.
The pre-existing condition limitation does not apply to newborns, adopted children, or children placed for
adoption.
NOTE: Other dependents (such as siblings of a newborn child) are not entitled to special enrollment rights upon
the birth or adoption of a child.
PIC07-760-Rt (i/09) IO (PCH10409) 15.100.2.V
Schedule of Payments
You are required to pay any deductible and coinsurance amount. Benefits listed in this Schedule of
Payments are according to what PIC pays. Any amount of coinsurance you must pay to the provider is
based on 100% of eligible charges less the percentage covered by PIC. PIC payment begins after you have
satisfied any applicable deductibles and coinsurance.
Discounts negotiated by PIC with providers may affect your coinsurance amount. PIC may pay higher
benefits if you choose participating providers. In addition to any copayrnents, coinsurance and deductible,
you also pay all charges that exceed the PIC non participating provider reimbursement valise when you use a
rton participating provider and receive rron participating provider benefits.
NOTE: Your coverage is either "subscriber only" or "family." Therefore, only one of the following sections
"Subscriber only" or "Family" applies to you. If yore have questions about which section applies to you, contact
PIC.
If yocc have subscriber only coverage, on the date that the coverage for yoccr eligible dependent(s) becomes
effective, you and yoccr new dependent(s) become subject to the terms and conditions of family coverage.
This is a Minnesota qualified plan.
Subscriber only
Deductible: The subscriber must first satisfy the deductible amount by incurring charges equal to that amount
for eligible services in a calendar year before PIC will pay benefits. PIC will not pay benefits for the eligible
charges applied toward the deductible. Any amount in excess of the PIC non participating provider
reimbursement valcee will not apply towards satisfaction of the deductible. The subscriber will not be required
to satisfy the deductible before PIC will pay benefits for the following: prenatal and child health services
received from a participating provider.
Out-of-Pocket Lintit: After the subscriber has met the out-of-pocket limit per calendar year for copayments,
coinsurance and deductibles, PIC covers 100% of charges incurred for all other eligible charges. The
subscriber pays any amounts greater than the out-of-pocket limit if any benefit maximums or the lifetime benefit
maximum are exceeded. It is the subscriber's responsibility to pay any amounts greater than the ocet-of-pocket
limits if any benefit maximums are exceeded. Expenses the subscriber pays for any amount in excess of the PIC
nan participating provider reimbursement value will not apply towards satisfaction of the out-of-pocket limit.
Subscriber only
Participating Provider Network
Non Participating Providers
Deductible
Out-of-Pocket Liznit
None.
$300 per calendar year for eligible
services of non participating
providers.
$1,500 per calendar year for eligible services of participating providers.
$3,000 per calendar year For eligible services of participating and non-
participating providers combined.
Lifetime Benefit Maximum $3,000,000 for all eligible services from participating and non participating
providers combined that the subscriber receives under this COC or any future
PIC COC or contract that has a lifetime benefit maximum.
PIC07-760-R1 (1/09) I1 (PCH10409) 15.100.2.V
Family (Subscriber and Enrolled Dependents}
Family Deductible: The family must first satisfy the family deductible amount by incurring charges equal to
that amount for eligible services in a calendar year before PIC will pay benefits. PIC will not pay benefits for
the eligible charges applied toward the family deductible. Any amount in excess of the PIC non participating
provider reimbursement value will not apply towards satisfaction of the family deductible. Members of the
family will not be required to satisfy the family deductible before PIC will pay benefits for the following:
prenatal and child health services received from a participating provider.
Family Out-of-Pocket Limit: After the family has met the family out-of-pocket limit per calendar year in
eligible charges in a calendar year for copayrnents, coinsurance and family deductibles, PIC covers 100% of
charges incurred for all other eligible charges. The family must pay any amounts greater than the family out-of-
pocket limit if any benefit maximums or the lifetime benefit maximum are exceeded. Expenses a member pays
for any amount in excess of the PIC non participating provider reimbursement valzze and will not apply towards
satisfaction of the family ozzt-of-pocket limit.
Family (Subscriber and
Dependents)
Family Deductible
Out-of-Pocket Limit
Participating Provider Network
None
Non-Participating Providers
$900 per calendar year for eligible
services of non participating
providers.
$5,000 per calendar your for eligible services of participating providers.
$6000 per calendar year for eligible services of participating and non-
participatingproviders combined.
No member ozzt-of-pocket limit within the family out-of-pocket limit amount.
Lifetime Benefit Maximum $3,000,000 for all eligible services from participating and non participating
providers combined that the member receives under this COC or any future
PIC COC or contract that has a lifetime benefit maximum.
Cost Sharing: The amount of the flat fee copayments is calculated on provider billed charges. The provider's
billed charge is the full amount that the provider bills, and does not include any discount that PIC negotiates with
the provider-.
The coinsurance percentage is calculated on the lesser of the provider's billed charge, or the fee schedule that
PIC has negotiated with the participating provider, or the PIC Non-Participating Provider Reimbursement Value
if PIC does not have an agreement with the provider. If you have a deductible, it is first subtracted from the
billed charge, fee schedule, or the PIC Non-Participating Provider Reimbursement Value, whichever is
applicable, then the coinsurance is applied to the remainder.
PIC07-'760-R1 (1/09} 12 (PCH10409) 15.100.2.V
Pre-certification Requirement and Prior Authorization
For pre-certification or prior authorization PIC will guarantee payment of services provided the services
are covered benefits, the member is eligible for coverage, the member has provided the appropriate
information for those services and the member has met all other terms of the COC. Please read the entire
COC to determine which other provisions may also affect benefits.
If your attending provider requests pre-certification or prior authorization on your behalf, the provider will
be treated as your authorized representative by PIC for purposes of such request and the submission of
your claim and associated appeals unless you specifically direct otherwise to PIC within ten (10) business
days from PIC's notification that an attending provider was acting as your authorized representative. Your
direction will apply to any remaining appeals.
Provision Participating Provider Benefit Non-Participating Provider
Benefit
Pre-certification Penalty None PIC will reduce the amount of
eligible charges by the lesser of
$500 or 25%.
Pre-Certification Requirement: Pre-certification is a screening process that permits early identification of
situations where case management would be beneficial or medical management is required. When a participating
provider renders services, the provider will notify PIC for you. It is your responsibility to ensure that PIC has
been notified when non ym~ticipating providers are used. You must call Customer Service during normal business
hours and before services are performed. Failure to obtain pre-certification may result in a reduction of non-
participatingprovider benefits.
Pre-certification is required for:
1. all inpatient admissions including skzlled nursing.facility, rehabilitation, hospital, etc.;
2. transplant services;
3. non-emergency ambulance and ambulance transfers; and
4. eating disorder treatment services provided by a participating designated eating disorder program.
If you have questions about pre-certification and when you are required to obtain it, please contact Customer
Service.
PIC07-760-RI (1/09) 13 (PCH10409) 15.100.2.V
Prior Authorization: It is recommended that you or your provider have certain services authorized in advance to
determine medical necessity, by PIC or its designee. When a participating provider renders services, the provider
will prior authorize with PIC for you. Tt is yoccr responsibility to prior authorize with PIC when non-
participating providers are used. If you have questions about prior authorization, please contact Customer
Service.
Prior authorization is recommended before the following medical services are received:
1. drugs or procedures that could be construed to be cosmetic;
2. home health care and hospice;
3. outpatient surgeries;
4. outpatient mental health or substance related services;
5. physical therapy, occupational therapy, speech therapy and other outpatient therapies;
6. pain therapy program services;
7. reconstructive surgery;
8. durable medical equipment (DME) and prosthesis that may exceed $5,000; and
9. physician directed weight loss programs when medically necessary to treat obesity as determined by PIC.
Certain prescription drugs may require prior authorization before you can have your prescription filled at the
pharmacy. These prescription drtcgs may include, but are not limited to:
10. prescription drugs, that are over:
a. $150 if a compound prescription;
b. $1,500 if a retail prescription; or
c. $2,500 if a mail order prescription;
11. weight loss medications;
12, oral antifungal drugs; and
13. specialty drugs.
PIC07-760-R1 (1/09) 14 (PCH10409) 15.100.2.V
When a participating provider renders services, the provider will notify PIC for you. It is your responsibility to
ensure that PIC has been notified when non participating providers are used. You or the provider must call
Customer Service during normal business hours and before services are performed. Failure to obtain pre-
certification may result in a reduction of benefits. For non participating providers yozc need to follow the
following procedures:
1. A phone call must be made to Customer Service no less than 15 calendar days prior to the date services are
scheduled. An expedited review is available if your prrovider believes it is warranted.
2. You and your attending provider will be notified of PIC's initial determination within 15 calendar days
following a request, but in no event later than the date on which the services are scheduled to be rendered,
provided PIC has all the necessary information. If you or your attending provider have not submitted the
request in accordance with these procedures, PIC will notify you within 5 calendar days. If PIC does not
have all information it needs to make a determination, this time period may be extended for an additional 15
calendar days upon written notice to you. You will then have at least 45 calendar days to provide the
requested information. PIC will notify you of its benefit determination within 15 calendar days after the
earlier of PIC's receipt of the requested information or the end of the time period specified for you to provide
requested information. The initial determination maybe made to your attending provider by telephone.
3. If the initial determination is that the service will not be covered, your attending provider will be promptly
notified by telephone within 1 business day after the decision has been made.
4. Written notification will then be provided to yozc and your attending provider explaining the principal reason
or reasons for the determination. The notification will also include the process to appeal the decision.
Note: If your request is denied, you may appeal that decision. Refer to the section entitled "Complaint and
Appeal Procedures" for details on how to appeal.
Should the state of Minnesota and/or the Minneapolis/St. Paul seven-county metropolitan area be declared subject
to a pandemic alert, PIC may suspend pre-certification requirements, prior authorization requirements, and other
services as may be determined by PIC.
How to Obtain an Expedited Review
Expedited Review: An expedited initial determination will be used if your attending provider believes it is
warranted. Acute care services, which can warrant expedited review, are medical care or treatment with respect
to which the application of the time periods for making non-expedited review determinations could seriously
jeopardize your life or health or your ability to regain maximum function, or in the opinion of your attending
provider would subject you to severe pain that cannot be adequately managed without the care or treatment that is
the subject of the pre-service claim.
An expedited initial determination will be provided to you and your attending provider as quickly as your medical
condition requires, but no later than 72 hours following the initial request. If PIC does not have all information it
needs to make a determination, you will be notified within 24 hours. You will then have at least 48 hours to
provide the requested information. You will be notified of the determination within 48 hours after the earlier of
PIC's receipt of the requested information or the end of the time period specified for you to provide the requested
information. If the initial determination would deny coverage, yozc or your attending provider will have the right
to submit an expedited appeal.
Nate: If your request is denied, you may appeal that decision. Refer to the section entitled "Complaint and
Appeal Procedures" for details on how to appeal.
P1C07-760-R1 (1/09) IS (PCH10409) 15.100.2.V
Case Management
In cases where the member's condition is expected to be or is of a serious nature, PIC may arrange for review
and/or case management services from a professional who understands both medical procedures and the PIC
health care coverage.
Under certain conditions, PIC will consider as eligible charges other treatments for a member's catastrophic
sickness or injury that would not normally be covered. PIC and the member's physician will determine whether
such treatments will be covered. Such care or treatment provided will not be considered as setting any precedent
or creating any future liability, with respect to that member or any other member.
Other treatments must meet both of these tests:
1. determined in advance by PIC to be medically appropriate and cost effective in meeting the long term or
intensive care needs of a member in connection with a catastrophic sickness or injury.
2. charges incurred for these services or supplies would not otherwise be payable or would be payable at a
lesser percentage.
PIC07-760-R1 (1/09} 16 (PCH10409) 15.100.2.V
Description of Benefits
1. Also refer to the Schedule of Payments to help determine your benefit level.
2. See the Pre-certification requirements for certain services.
3. Some rules for obtaining benefits are listed in your provider directory.
4. Be sure to review the list of Exclusions. A provider recommendation or performance of a service, even
if it is the only service available for your particular condition, does not mean it is a covered service.
Benefits are not available for medically necessary services, unless such services are also covered services,
and received while you are covered under this COC.
Benefit Participating Provider Benefit Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
Provider Reimbursement Value.
Ambulance Services
Ambulance services for an 80% of eligible charges. Same as participating provider benefit
emergency. Note: Non- for emergency services.
emergency transportation
must be pre-certified in 80% of eligible charges after the
advance by PIC. deductible for non-emergency
transportation.
Ambulance services for an emergency. PIC covers ambulance service to the nearest hospital or medical center
where initial care can be rendered for a medical emergency. Air ambulance is covered only when the condition
is an acute medical emergency and is authorized by a physician.
PIC covers emergency ambulance (air or ground) transfer from a hospital not able to render the medically
necessar)~ care to the nearest hospital or medical center able to render the medically necessary care only when
the condition is a critical medical situation and is ordered by a physician and coordinated with a receiving
physician.
Ambulance services for anon-e~rtergency. Non-emergency ambulance service, from hospital to hospital when
care for your condition is not available at the hospital where you were first admitted. Transfers from a hospital
to other facilities for subsequent covered care or from home to physician offices or other facilities for outpatient
treatment procedures or tests are covered if medical supervision is required enroute and when pre-certified.
PIC's medical director or designee must pre-certify non-emergency services in advance.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Non-emergency ambulance service from hospital to hospital such as transfers and admission to hospitals
performed only for convenience.
PIC07-760-R1 (1/09) 17 (PCH10409) 15.100.2.V
Benefit Participating Provider Benefit Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For non participating providers, in
addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
Provider Reimbursement Value.
Chiropractic Services 100% of eligible charges after a 80% of eligible charges after the
copayment of $15 per visit. deductible.
Limited to a maximum of 15 visits per
calendar year.
Coverage includes chiropractic services to treat acute musculoskeletal conditions, by manual manipulation
therapy. Diagnostic services are limited to medically necessary radiology. Treatment is limited to conditions
related to the spine or joints.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Services primarily educational in nature.
c. Vocational rehabilitation.
d. Self-care and self-help training (non-medacal).
e. Health clubs and spas.
f. Recreational therapy.
g. Rehabilitation services that are not expected to make measurable or sustainable improvement within 2
weeks to 3 months, depending on the physical and mental capacities of the individual.
h. Chiropractic therapy other than for treatment of acute musculoskeletal conditions.
i. Acupuncture, except for treatment in a chronic pain program and rendered by a provider licensed or
trained in acupuncture.
j. Blood, urine or hair analysis related to chiropractic services.
k. Ultrasound, MRI, EMG, waveform, and nuclear medicine diagnostic studies related to chiropractic
services.
1. Manipulation under anesthesia related to chiropractic services.
m. Homeopathic/holistic services related to chiropractic services.
PIC07-760-R1 (1/09) 18 (PCH10409) 15.100.2.V
Benefit Participati~zg Provider Benefit Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any deductibles and
coinsurance, yocc pay all charges that
exceed the PICNnn-Participating
Provider Reimbursement Value.
Dental Services
Accidental Dental 100% of eligible charges. 80% of eligible charges after the
Services deductible.
Note: Treatment and repair must be completed within twelve months of the
date of the injury.
Medically Necessary 100% of eligible charges. 80% of eligible charges after the
Outpatient Dental Services dedecctible.
and Hospitalization for
Dental Care
This provision does not provide coverage for preventive dental procedures. PIC considers dental procedures to
be services rendered by a dentist or dental specialist to treat the supporting soft tissue and bone structure.
PIC covers the following dental services:
1. Accidental Dental Services. PIC covers services to treat and restore damage done to sound, natural teeth as
a result of an accidental injcrrv. Coverage is for external trauma to the face and mouth only, not for cracked
or broken teeth that result from biting or chewing. A sound, natural tooth is a tooth without pathology
(including supporting structures) rendering it incapable of continued function for at least one year. Primary
(baby) teeth must have a life expectancy of one year before loss.
2. Medically Necessary Outpatient Dental Services: PIC covers outpatient dental services, limited to dental
services required for treatment of an underlying medical condition, e. g. removal of teeth to complete
radiation treatment for cancer of the jaw, cysts and lesions.
Medically Necessary Hospitalization for Dental Care: PIC covers hospitalization for dental care. This is
limited to charges incurred by a member who: (1) is a child under age 5; (2) is severely disabled; or (3) has
a medical condition, and requires hospitalization or general anesthesia for dental treatment. Coverage is
limited to facility and anesthesia charges. Oral surgeon/dentist or dental specialist professional fees are not
covered for dental services provided. The following are examples, though not all-inclusive, of medical
conditions that may require hospitalization for dental services: severe asthma, severe airway obstruction or
hemophilia. Care must be directed by a physician or by a dentist or dental specialist.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Dental services covered under your dental plan.
c. Preventive dental procedures.
d. Dental services and all associated expenses, except as stated in this section.
e. Orthodontia and all associated expenses, except as required by law.
PIC07-760-R1 (1/09) 19
(PCH10409) 15.100.2.V
£ Surgical extraction of impacted wisdom teeth.
g. Services for cracked or broken teeth that result from biting, chewing, disease or decay.
h. Dental implants.
i. Prescriptions written by a dentist unless in connection with dental procedures covered by PIC.
j. Denta] services related to periodontal disease.
P1C07-760-R1 (1/09} 20 (PCH10409) 15.100.2.V
Benefit Participating Provider Benefit Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
Provider Reimbursement Value.
Durable Medical Equipment ("DME") Services, Prosthetics, and Orthotics
Limited to a maximum PIC payment of
$1,500 per item and an aggregate
maximum PIC payment of $3,750 per
calendar year.
DME and Orthotics 80% of eligible charges. 80% of eligible charges after the
deductible.
Prosthetics 80% of eligible charges. 80% of eligible charges after the
deductible.
Hearing aids for members 80% of eligible charges. 80% of eligible charges after the
under age 19 for hearing deductible.
loss that is not correctable
by other covered
procedures.
Coverage limited to once
every three years.
Wigs for hair loss 80% of eligible charges. 80% of eligible charges after the
resulting from alopecia deductible.
areata are limited to a
maximum PIC payment of
$350 per calendar year-.
Special dietary treatment 80% of eligible charges. 80% of eligible charges after the
for phenylketonuria deductible.
(PKU}, and enteral
feedings
Diabetic supplies 80% of eligible charges. 80% of eligible charges after the
deductible.
Coverage includes over-
the-counter diabetic
supplies, including glucose
monitors, syringes, blood
and urine test strips, and
other diabetic supplies as
medically necessary, if
you have gestational
diabetes, type I diabetes,
or type II diabetes.
PIC07-760-R1 (I/09) 21 (PCH10409} 15.100.2.V
PIC covers equipment and services ordered by a physician and provided by DME/prosthetic/orthotic vendors.
Por verification of eligible equipment and supplies, call Customer Service. Contact lenses are eligible for
coverage only when prescribed as medically necessary for treatment of keratoconus. Members must pay for
lens replacement. Coverage is provided for: (1) amino-acid based formulas, electrolyte substances to treat
PKU, and other inborn errors of metabolism when medically necessary; (2) enteral feedings and other oral
nutritional and electrolyte substances only as required to sustain life.
Payment is limited to the most cost effective and medically necessary alternative. When the member purchases
a model that is more expensive than what is considered medically necessary by the PIC medical director or its
designee, the member will be responsible for the difference in purchase and maintenance cost. PLC's payment
for rental shall not exceed the purchase price, unless PIC has determined that the item is appropriate for rental
only. PIC reserves the right for its medical director or designee to determine if an item will be approved for
rental or purchase.
If a member purchases new equipment or supplies when the PIC medical director or designee determines that
repair costs of the member's current equipment or supplies would be more cost effective, then the member will
be responsible for the difference in cost.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Any durable medical equipment or supplies not listed as eligible on PLC's durable medical equipment list,
or as determined by PIC.
c. Disposable supplies or non-durable supplies and appliances, including those associated with equipment
determined not to be eligible for coverage.
d. Revision of durable medical equipment and prosthetics, except when made necessary by normal wear or
e.
f.
g•
h.
k.
1.
m.
n.
o.
p•
q•
r.
s.
use.
Replacement or repair of items when: (1) damaged or destroyed by misuse, abuse or carelessness; (2) lost;
or (3) stolen.
Duplicate or similar items.
Items that are primarily educational in nature or for vocation, comfort, convenience or recreation.
Hearing aids, devices to improve hearing and related fittings (except as provided in the schedule above).
Communication aids or devices; equipment to create, replace or augment communication abilities
including, but not Limited to, speech processors, receivers, communication board, or computer or electronic
assisted communication.
Household equipment, household fixtures and modifications to the structure of the home, escalators or
elevators, ramps, swimming pools, whirlpools, hot tubs and saunas, wiring, plumbing or charges for
installation of equipment, exercise cycles, air purifiers, central or unit air conditioners, water purifiers,
hypoallergenic pillows, mattresses or waterbeds.
Vehicle/car or van modifications including, but not limited to, hand brakes, hydraulic lifts and car carrier.
Over-the-counter orthotics and appliances.
Orthopedic shoes and custom molded foot orthotics, except for members with diabetes or peripheral
vascular disease.
Charges for sales tax, mailing and delivery.
Durable equipment necessary for the operation of equipment determined not to be eligible for coverage.
Durable medical equipment, orthotics and prosthetics that are necessary for activities beyond activities of
daily living (ADCs).
Wigs for conditions other than alopecia areata.
Enteral feedings and other oral nutritional and electrolyte substances, except amino-acid based formulas
when medically necessary and electrolyte substances to treat PKU or otherwise required to sustain life.
Upgrades to or replacement of any items that are considered eligible charges and covered under this
section, unless the item is no longer functional and is not repairable.
PIC07-760-R1 (1/09) 22 (PCH10409) 15.100.2.V
Benefit Participating Provider Benefit Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
Provider Reimbursement Value.
Emergency Room Services 100% of eligible charges after a Sarne as the participating provider
copayment of $75 per visit. benefit.
You should be prepared for the possibility of a medical emergency by knowing your participating provider's
procedures for "on call" and after regular office hours before the need arises. Determine the telephone number
to call, which hospital your participating provider uses, and other information that will help you act quickly and
correctly. Keep this information in an accessible location in case a medical emergency arises.
If you have an emergency situation that requires immediate treatment, call 911 or go to the nearest emergency
facility. If possible under the circumstances, you should telephone your physician or the participating clinic
where you normally receive care. A physician will advise you how, when and where to obtain the appropriate
treatment.
Note: Non-emergency services received in an emergency room are not covered. If yozz choose to receive non-
emergency health services in an emergency room, you are solely responsible for the cost of these services. See
emergency under "Definitions".
Covered hospital services are subject to all of the benefit limitations set forth in this COC. To receive
maximum coverage under this part, you or your representative must notify PIC of admittance within 48 hours or
as soon as reasonably possible, if medically stable.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Non-emergency services received in an emergency room.
PIC07-760-R1 (1/09) 23 (PCH10409) 15.100.2.V
Benefit Participating Provider Benefit Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For norr participating providers,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PICNnn-Participating
Provider Reimbursement Value.
Home Health Services Note: For norzparticipatingprovider
services, coverage of all home health
services is limited to a maximum PIC
payment of $3,750 per calendar year.
Note: Coverage for all home health services is limited to a maximum PIC
payment of $25,000 per member per calendar year.
Home health care as an 100% of eligible charges. 80% of eligible charges after the
alternative to hospital deductible.
confinement or skilled
nursing facility care.
One well-baby home visit 100% of eligible charges. 80% of eligible charges after the
by a registered nurse fora deductible.
mother and newborn child
if the inpatient hospital
stay for the birth of the
newborn was less than 48
hours following a vaginal
delivery or less than 96
hours following a
caesarean section. This
visit must occur within 4
days after the date of
discharge from the
hos ital.
PIC covers skilled nursing services, physical therapy, occupational therapy, speech therapy, respiratory therapy,
and other therapeutic services, laboratory services, equipment, supplies and drugs, as appropriate, and other
eligible home health services prescribed by a physician for the care and treatment of the member's sickness or
injury and rendered in the member's home.
You must be homebound for care to be received in your home, or PIC or its designee must deem the care
medically appropriate and/or that the care is more cost effective than care in a hospital or clinic.
A service shall not be considered a skilled nursing service merely because it is performed by, or under the direct
supervision of, a licensed, registered nurse. Where a service (such as a tracheotomy suctioning or ventilator
monitoring or like services) can be safely and effectively performed by anon-medical person, or self-
administered, without the direct supervision of a licensed, registered nurse, the service shall not be regarded as a
skilled nursing service, whether or not a skilled nurse actually provides the service. The unavailability of a
competent person to provide anon-skilled service shall not make it a skilled. service when a skilled nurse
provides it. Only the skilled nursing component of so-called "blended" services (i. e., service, that include
skilled and non-skilled components) are covered under PIC.
P1C07-760-R1 (1/09) 24 (PCH10409) 15.100.2.V
Exclusions:
a. Please see the section entitled "Exclusions."
b. Companion and home care services, unskilled nursing services, services provided by your family or a person
who shares your legal residence.
c. Services provided as a substitute for a primary caregiver in the home.
d. Services that can beperformed by anon-medical person or self-administered.
e. Home health aides.
£ Services provided in your home for convenience.
g. Services provided in your home due to lack of transportation.
h. Custodial care.
i. Services at any site other than your home.
j. Recreational therapy.
PIC07-760-R1 (1/09) 25 (PCH10409) 15.100.2.V
Benefit Participating Provider Benefit Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any deductibles and
coinsurance, yozz pay all charges that
exceed the PIC Non-Participating
Provider Reimbursement Value.
Hospice Care 100°/0 of eligible charges. 80% of eligible charges after the
deductible.
PIC covers hospice services for members who are terminally ill patients and accepted as home hospice program
participants. Members must meet the eligibility requirements of the program, and elect to receive services
through the home hospice program. The services will be provided in the patient's home, with inpatient care
available when medically necessazy as described below. Members who elect to receive hospice services do so
in lieu of curative or restorative treatment for their terminal illness for the period they are enrolled in the home
hospice program.
Eligibility. In order to be eligible to be enrolled in the home hospice program, a member must:
a. be a terminally-ill patient with physician certification of 6 months or less to live; and
b. have chosen a palliative treatment focus (i.e., emphasizing comfort and supportive services rather than
restorative treatment or treatment attempting to cure the disease or condition).
A member may withdraw from the home hospice program at any time.
2. Covered Services. Hospice services include the following services, provided in accordance with an
approved hospice treatment plan:
a. part-time (defined as up to two hours of service per calendar day) care in the member's home by an
interdisciplinary hospice team (which may include a physician, nurse, social worker, and spiritual
counselor) and home health aide services, if prior authorized by PIC's medical director or its designee.
b. one or more periods of continuous care in the meznbez°'s home or in a setting that provides day care for
pain or symptom management, when medically necessazy, as determined by PIC's medical director or
designee. Continuous care is defined as two to twelve hours of service per calendar day provided by a
registered nurse, licensed practical nurse, or home health aide, during a period of crisis in order to
maintain a terminally ill patient at home.
c. medically necessazy inpatient services, when pre-certified by PIC's medical director or designee.
d. respite care for caregivers in the member's home or in an appropriate setting. Respite care should be
prior authorized by PIC's medical director or designee, to give the patient's primary caregivers (i.e.,
family mezzzbers or friends) rest and/or relief when necessary in order to maintain a terminally ill patient
at home. The period of respite care is limited to 30 calendar days while enrolled in the hospice
program.
e. medically necessazy medications for pain and symptom management, if prior authorized by PIC's
medical director or designee.
f. hospital beds and other durable medical equipment when medically necessazy and should be prior
authorized by PIC's medical director or its designee.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Services provided by your family or a person who shares your legal residence.
c. Respite or rest care except as specifically described in this section.
PICO'7-760-R1 (1/09) 26 (PCH10409) 15.100.2.V
Benefit Participating Provider Benefit Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
Provider Reimbccrsement Value.
Hospital Services Notify PIC upon admission to a non participating provider hospital as soon as medically
ossible.
Inpatient Hospital 100% of eligible charges. 80% of eligible charges after the
Services deductible.
Note: Each member's Coverage for confinements in non-
confinement, including participating hospitals and skilled
that of a newborn child, is nccrsing facilities are limited to a
separate and distinct from combined maximum of 120 calendar
the confinement of any days per calendar year.
other member.
If you have sc{bscriber
only coverage, on the date
of birth of a newborn, you
and your new dependent(s)
become subject to the
terms and conditions of
family coverage.
Outpatient Hospital 100% of eligible charges. 80% of eligible charges after the
Services, Ambulatory Care deductible.
or Surgical Facility
Services
Rehabilitation Services in 100% of eligible charges. 80% of eligible charges after the
a Day Hospital Program deductible.
Injectable drugs that are 100% of eligible charges. 80% of eligible charges after the
not specialty drugs, deductible.
excluding insulin.
Eating Disorder Treatment 100% of eligible charges. 80% of eligible charges after the
Program deductible.
Services must be provided
by a PIC designated
participating eating
disorder treatment
programs and pre-certified
by the PIC medical
director or its designee.
PIC07-760-R1 (1/09) 27 (PCH10409) 15.100.2.V
_--
Medically necessary genetic
testing determined by PIC to
be covered ser-r~ices, as
described below:
• Prenatal fetal or maternal
genetic testing (e.g.,
amniocentesis, chorionic
vinous sampling) done as
a component of care of
the member's pregnancy.
• Genetic testing services if
you are diagnosed with a
specific sickness by a
physician.
• Genetic testing services if
you are considered to be
high risk for a specific
sickness as determined by
100% of eligible charges. 80% of eligible charges after the
deductible.
When anon-participating hospital is used, notify PIC of an admission to the non-participating hospital within
48 hours or as soon as reasonably possible after an emergency. For non-emergencies, a phone call must be
made to Customer Service no less than 15 calendar days prior to the date of services.
1. Inpatient Hospital Services. PIC covers services and supplies for the treatment of acute sickness or injury,
that requires the level of care only available in an acute care facility. Inpatient hospital services include, but
are not limited to:
a. room and board;
b. the use of operating rooms, intensive care facilities; newborn nursery facilities;
c. general nursing care, anesthesia, radiation therapy, physical, speech and occupational therapy,
prescription drugs or other medications administered during treatment, blood and blood plasma and
other diagnostic or treatment related hospital services;
d. physician and other professional medical and surgical services;
e. laboratory tests, pathology and radiology;
f. for a ventilator-dependent patient, up to 120 hours of services, provided by a private-duty nurse or
personal care assistant, solely for the purpose of communication or interpretation for the patient; and
g. professional medical and surgical services provided by an assistant surgeon, which is defined as a
certified phrysician assistant (PA-C), nurse practitioner (NP), clinical nurse specialist (CNS), RN first
assistant, certified registered nurse first assistants (CRNFA), certified nurse midwives (CNM), or a
physician.
PIC covers asemi-private room, unless a pltvsiciarz recommends that a private room is medically necessary
and so orders. In the event a member chooses to receive care in a private roam. under circumstances in
which it is not medically necessary, PIC's payment toward the cost of the room shall be based on the
average semi-private room rate in that facility. PIC's medical director or designee will determine if a
private room meets medically necessary criteria.
2. Outpatient Hospital, Ambulatory Care or Surgical Facility Services. PIC covers the fallowing services
and supplies, for diagnosis or treatment of sickness or injury on an outpatient basis:
a. use of operating rooms or other outpatient departments, rooms or facilities;
PIC07-760-R1 (1/09) 28 (PCH10409) 15.100.2.V
b. the following outpatient services: general nursing care, anesthesia, radiation therapy, prescription
drugs or other medications administered during treatment, blood and blood plasma, and other
diagnostic or treatment related outpatient services;
c. laboratory tests, pathology and radiology;
d. physician and other professional medical and surgical services rendered while an outpatient;
e. physician directed weight loss programs only when medically necessary to treat obesity as determined
by PIC; and
f. professional medical and surgical services provided by an assistant surgeon, which is defined as a
certified physician assistant (PA-C), nurse practitioner (NP), clinical nurse specialist (CNS), RN first
assistant, certified registered nurse first assistants (CRNFA}, certified nurse midwives (CNM), or a
physician.
PIC also covers preventive health services performed in an outpatient hospital setting. These preventive
services will be covered as listed in the Office Visits and Urgent Care Center Visits section.
3. Rehabilitation Services in a Day Hospital Program. PIC covers rehabilitation services in a day hospital
program. Coverage is limited to services for rehabilitative care in connection with a sickness or injury.
4. Eating Disorder Treatment Program. PIC covers the treatment of eating disorders provided by a PIC
designated participating eating disorder treatment program.
Emergency Services at a Hospital that leads to an Inpatient Admission
You need to provide notice to PIC of an emergency hospital admission. However, if you are incapacitated in a
manner that prevents you from providing notice of the admission within 48 hours or as soon as reasonably
possible, or if you are a minor and your parent (or guardian) was not aware of your admission, then the 48 hour
time period begins when the incapacity is removed, or when your parent (or guardian) is made aware of the
admission. You are considered incapacitated only when: (1) you are physically or mentally unable to provide
the required notice; and (2) you are unable to provide the notice through another person.
Statement of Rights Under the Newborns' and Mothers' Health Protection Act
Under state law, group health plans and health insurance issuers offering group health insurance coverage as
specified below may not restrict benefits for any hospital length of stay in connection with childbirth for the
mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a
delivery by cesarean section. However, the group health plan or health issuer may pay for a shorter stay if the
attending provider (e.g., your physician, nurse midwife, or physician assistant), after consultation with and
mutual agreement by the mother, discharges the mother or newborn earlier.
Also, under federal law, group health plans and health issuers may not set the level of benefits or out-of-pocket
costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother
or newborn than any earlier portion of the stay.
In addition, a group health plan or health issuer may not, under federal law, require that a physician or other
health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours).
However, to use certain providers or facilities, or to reduce yozzr out-of-pocket costs, you may be required to
obtain pre-certification as described in the pre-certification provisions of the Schedule of Payments
PIC07-760-R1 (1/09) 29 (PCH10409) 15.100.2.V
Exclusions:
a. Please see the section entitled "Exclusions."
b. Travel, transportation, other than ambulance transportation, or living expenses.
c. Hospitalization, transportation, supplies, or medical services, including physicians' services furnished by
the United States Government or by an institution operated by the United States Government, unless
payment is required in accordance with applicable law.
d. Private room, except when medically necessary or if it is the only option available at the admitted facility.
e. Non-emergency ambulance service from hospital to hospital, such as transfers and admissions to hospitals
performed only for convenience.
f. Services and/or drugs to treat conditions that are cosmetic in nature.
g. Orthoptics and refractive surgery (i.e. lasik) for opthalmic conditions that are correctable by contacts or
glasses.
h. Services and/or surgery and associated expenses for gender reassignment unless determined to be medically
necessary. These services and associated expenses will be reviewed on a case by case basis and, if
determined to be medically necessary, services must be received at a PIC designated treatment center.
i. Genetic testing and associated services when done as a screening test to predict whether you may be a
carrier of a specific sickness when you are not diagnosed with the specific sickness by a plrysician or yoit are
not at high risk for the specific sickness as confirmed by a physician.
j. Homeopathic medicine; hypnosis; chelation therapy, except chelation therapy will be covered when
medically necessary for the treatment of heavy metal poisoning.
k. Acupuncture, except for treatment in a chronic pain program and rendered by a provider licensed or trained
in acupuncture.
1. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease.
m. Autopsies.
n. Bariatric surgeries.
o. Services for items for personal convenience, such as television rental.
p. Commercial weight loss programs.
q. Nutritional counseling, except when:
1. provided during a confinement;
2. for the diagnosis and treatment of diabetes or an eating disorder; or
3. a member has been diagnosed with a chronic medical condition by a physician.
4. In all cases, except confinement, nutritional counseling must be provided in a physician's office, clinic
system or hospital setting.
r. Treatment of eating disorders, except as shown in the Eating Disorders Treatment Program benefit.
PIC07-760-R1 (1/09} 30 (PCHI0409} 15.I06.2.V
Benefit Participating Provider Be~aefit Non-Participating Provider Benefzt
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any deda~ctibles and
coinsa~rance, yogi pay all charges that
exceed the PIC Non-Participating
Provider Reimbursement Vahre.
Infertility Services 100% of eligible charges. Same as participating provider benefit.
Note: Limited to diagnostic
services only.
PlC covers professional services for the diagnosis of infertility and treatment of an underlying medical
condition, tests, facility charges and laboratory work related to covered services (such as, but not limited to,
diagnostic radiology, laboratory services, semen analysis and diagnostic ultrasounds}.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Reversal of voluntary sterilization.
c. Adoption costs.
d. In vitro fertilization.
e. Gamete and zygote intrafallopian transfer (GIFT and ZIFT) procedures.
f. Surrogate pregnancy.
g. Sperm banking.
h. Embryo and egg storage.
i. Artificially assisted technology, such as, but not limited to, artificial
insemination (IUI).
j. Donor sperm.
k. Oral and injectable drugs for infertility.
insemination (AI) and intrauterine
PIC07-760-R1 (1/09) 31 (PCH10409) 15.1002.V
Benefit Participating Provider Benefit Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any deductibles and
coinszu~ance, you pay all charges that
exceed the PIC Non-Participating
Provider Reimbursement ti'alue.
Mental and Substance-Related Disorder Services
Office Visits 100% of eligible charges after a &0% of eligible charges after the
copayment of $15 per visit. deductible.
Inpatient Services 100% of eligible charges. 80% of eligible charges after the
deductible.
Coverage for confinements in non-
participating hospitals and skilled
nursing facilities is limited to a
combined maximum of 120 calendar
days per calendar year.
Outpatient Hospital, 100% of eligible charges. 80% of eligible charges after the
Partial Hospital and Day dedz~ctible.
Treatment Services
Each two calendar days of partial
hospital or day treatment services will
be considered equal to one calendar day
of treatment in a hospital. These days
are part of the 120 calendar day
maximum limit listed under "Inpatient
Services."
PIC covers services performed by providers for a mental and/or substance abuse related diagnosis that is
defined in the most current edition of the Diagnostic and Statistical Manual of Mental Disorders ("DSM"), leads
to significant disruption of function in your life situation, and has a recognized effective treatment. PIC's
medical director or designee determines when there is a serious or persistent mental or nervous disorder that
meets criteria for coverage.
Coverage is available as follows:
1. Horne Care. PIC's medical director or designee must authorize in advance any services received in your
home.
2. Office Visits. PIC covers:
a. Outpatient professional services for evaluation, diagnosis, crisis intervention, therapy including
rrredically necessary' group therapy, psychiatric services, treatment of a minor (and/or family therapy
but only for treatment on the minor), treatment of mental and nervous disorders, and
b. Diagnosis and treatment of substance-related disorders, including evaluation, diagnosis, therapy and
psychiatric services,
PIC07-760-R1 (1/09) 32 (PCH10409) 15.100.2.V
The results of a comprehensive diagnostic assessment will be used by a mental health professional to
evaluate the appropriate treatment modality and the extent of services that are medically necessary. These
services may have to be authorized by a provider who is a mental health professional or his or her designee.
Inpatient Services. PIC covers inpatient services in a hospital or licensed residential treatment facility and
professional services. These services must bepre-certified by PIC's medical director or designee.
PIC covers asemi-private room, unless a phvsician recommends that a private room is medically necessary
and so orders. Benefits for a private room are available only when the private room is medically necessary
for a sickness or injury or it is the only option available at the admitted facility. If you choose a private
room when it is not medically necessary, PIC's payment toward the cost of the room shall be based on the
average semi-private room rate in that facility. PIC's medical director or designee will determine if a
private room meets medically necessary criteria.
4. Outpatient Hospital, Partial Hospital, and Day Treatment Services. PIC covers such services in a hospital
or licensed treatment facility. These services must bepre-certified by PIC's medical director or designee.
Hospital or Residential Treatment Facility Care for Emotionally Handicapped Children. PIC covers
medically necessary inpatient treatment for emotionally handicapped children as diagnosed by a physician
under the Minnesota Department of Human Services criteria. This care must be authorized by and arranged
through a mental health professional. For treatment provided by a hospital or residential treatment center
licensed by the Minnesota Commissioner of Human Services, inpatient coverage for emotionally
handicapped children is the same as the inpatient benefit. The child through age 18 years of age must be an
eligible dependent according to the terms of the COC.
Court-Ordered Services. PIC covers mental health and/or substance related evaluations and treatment ordered
by a Minnesota court under a valid court order when the services ordered are covered under this COC and:
l . The court-ordered behavioral care evaluation is performed by a participating provider or other pr-ovider• as
required by law and the provider is a licensed psychiatrist, licensed chemical dependency counselor, or
doctoral level licensed psychologist.
2. The treatment is provided by a participating provider or other provider as required by law and is based on a
behavioral care evaluation that meets the criteria of (1) above and includes a diagnosis and an individual
treatment plan for care in the most appropriate and least restrictive environment.
PIC must receive a copy of any court order and evaluation. PIC or its designee may make a motion to modify a
court ordered plan and may request a new behavioral care evaluation.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Counseling, studies, services or confinements ordered by a court or law enforcement officer that are not
determined to be medically necessary by PIC, except as specifically covered above.
c. Marital counseling, relationship counseling, family counseling except as described in this COC, or other
similar counseling or training services.
d. Substance or mental health related conditions that according to generally accepted professional standards
cannot be improved with treatment, except as stated in this COC.
e. Services to hold or confine a member under chemical influence when no medically necessary services are
required, regardless of where the services are received (e. g. detoxification centers).
f. Early behavioral interventions for children including but not limited to Lovaas therapy, applied behavioral
analysis, discrete trial training, and intensive intervention programs.
g. Private room, except when medically necessa~~ or if it is the only option available at the admitted facility.
PIC07-760-RI (1/09} 33 (PCH10409) 15.100.2.V
h. Home-based mental or behavioral health services.
i. Biofeedback.
j. Mental retardation or mental conditions that, according to generally accepted professional standards, are not
amenable to favorable modification, except for initial evaluation, diagnosis or crisis intervention.
PIC07-760-R1 (1/09) 34 (PCH10409) IS.I00.2.V
Benefit Participating Provider Benefit Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
ProviderReimbu~sement Value.
Office Visits and Urgent Care Center Visits
Sickness or injztrv -office 100% of eligible charges after a 80% of eligible charges after the
and urgent care center copayment of $15 per visit. deductible.
visits related to diagnosis,
care or treatment of a
condition, sickness or
injury.
Electronic/online 100% of eligible charges. 80% of eligible charges after the
evaluation of chronic deductible.
conditions; limited to 6
evaluations per member
per calendar year.
(In order to be covered, the
evaluation must be
conducted by a designated
electronic/online
participating provider only
for established patients
with specific chronic
diseases, such as diabetes
or heart disease, as
determined by PIC or its
designee.)
PICO'7-760-R1 (1/09) 35 (PCH10409) I5.100.2.V
Medically necessaYV genetic 100% of eligible charges. 80% of eligible charges a$er the
testing determined by PIC to deductible.
be covered services, as
described below:
• Prenatal fetal or maternal
genetic testing (e.g.,
amniocentesis, chorionic
vinous sampling) done as
a component of care of
the member's pregnancy.
• Genetic testing services if
you are diagnosed with a
specific sickness by a
physician.
• Genetic testing services if
you are considered to be
high risk for a specific
sickness as determined by
a physician.
Implantable and insertable 100% of eligible charges. 80% of eligible charges after the
drug delivery devices for deductible.
birth control. Implantable
drug delivery devices far
contraceptive therapy are
limited to one device
every 5 years.
Allergy injections 100% of eligible charges. 60% of eligible charges after the
deductible.
Port wine stain -treatment 100% of eligible charges. 80% of eligible charges after the
to lighten or remove the deductible.
discoloration
Postnatal care 100% of eligible charges. 80% of eligible charges after the
deductible.
PIC07-760-R1 (1/09} 36 (PCH10409) 15.100.2.V
Preventive Health Care 100% of eligible charges. 80% of eligible charges after the
Services deductible.
Immunizations (over
age 6)
Laboratory tests,
pathology and
radiology
Preventive health
physicals
Cancer screening
(including routine
PSA tests, pap
smears, colorectal
tests, and
mammograms)
Routine preventive eye
examinations, limited
to one exam per
member per calendar
year.
Well-baby/child health 100% of eligible charges. 80% of eligible charges after the
services (up to age 6 deductible.
including
immunizations)
Prenatal care
Injectable drugs that are 100% of eligible charges after a 80% of eligible charges after the
not specialty drugs, copavment of $15 per visit. deductible.
excluding insulin,
PIC covers the professional medical and surgical services of licensed: physicians, health care providers and
nurses.
1. Services are provided for the following:
a. Office and arrgent care center visits relating to the diagnosis, care or treatment of a condition, sickness
or injury.
b. Treatment of diagnosed Lyme disease.
c. Contact lenses prescribed as nzedicall}~ necessary for the treatment of keratoconus, the lenses and fitting
are eligible charges under the DME benefit. Members must pay for lens replacement.
d. Laboratory tests, pathology and radiology.
2. a. Implantable and insertable drug delivery devices. This is limited to one device every five years for
contraceptive therapy, unless services are medically necessary earlier due to complications of the
device. Includes associated physician charges.
b. Contraceptive devices and delivery methods, other than implantable drug delivery devices, available in
the physician's office.
3. Port wine stain treatment to lighten or remove the discoloration.
4. Postnatal exams.
5. Allergy injections.
6. Preventive health care services, as defined by PIC when submitted by the provider with a routine
preventive health care exam diagnosis.
a. Routine screening procedures for cancer, including mammograms, pap smears, colorectal tests and
prostate specific antigen (PSA}.
PIC07-760-R1 (l/09) 37 (PCH10409) 15.100.2.V
b. Immunizations as recommended by yoazn• physician.
c. Laboratory tests, pathology and radiology.
d. Preventive care exams and periodic health supervision services provided during an office visit,
including evaluation and follow-up, when there is no existing condition or complaint about your health.
A physician will counsel yozz as to how often health assessments are needed based on your age, sex and
health status.
e. Prenatal care.
£ Well baby and child health supervision services including pediatric preventive health care services,
routine immunizations, developmental assessments and laboratory services.
g. Routine eye screening and exam.
7. Surgical services performed in the office, including but not limited to:
a. Oral surgery for: (1) treatment of oral neoplasms and non-dental cysts; (2) fracture of the jaws; (3)
trauma of the mouth and jaws; and (4) any other oral surgery procedures provided as medically
nzecessary dental services.
b. Surgical and non-surgical treatment of confirmed, existing temporomandibular disorder (TMD) and
craniomandibular disorder (CMD), that is medically necessany. TMD splints and adjustments are
covered if your primary diagnosis is TMD. Dental services required to directly treat TMD or CMD are
eligible.
8. Treatment of cleft lip and cleft palate for a covered dependent child. Treatment must be scheduled or have
started prior to the covered dependent child reaching age 19. Treatment includes orthodontic treatment and
oral surgery directly related to the cleft. Dental services required for the treatment of cleft lip or cleft palate
are covered. If a covered dependent child is also covered under a dental plan, which includes orthodontic
services, that dental plan shall be considered primary for the necessary orthodontic services. Oral
appliances are subject to the same conditions and limitations as durable medical equipment.
9. Treatment of diagnosed diethylstilbestrol (DES).
10. Diabetic outpatient self-management training and education.
11. An emergency examination of a child ordered by judicial authorities.
12. Prenatal screening for Cystic Fibrosis when a pregnancy is considered at high risk.
13. Smoking cessation programs covered through a smoking cessation provider designated by PIC. Limited to
participation in one program in a I2-month period.
14. OB/GYN services for a pregnancy. Female members may obtain the obstetric and gynecologic services
from obstetricians and gynecologists in the participating provider network without a referral from, or prior
approval through, another physician, PIC, or its designees.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Services, seminars, or programs that are primarily educational in nature.
c. Health education, except when provided during an office visit.
d. Smoking cessation programs, except as provided in this COC.
e. Weight loss programs, including, but not limited to, consultations, laboratory services, testing, nutritional
and food supplements, and weight loss drugs when not being treated for obesity, except when medically
necessary as determined by PIC's medical director or designee.
f. Nutritional counseling, except when:
1. provided during a confinement;
2. for the diagnosis and treatment of diabetes, or an eating disorder; or
3. a mennber has been diagnosed with a chronic medical condition by a physician.
In all cases, except confinement, nutritional counseling must be provided in a physician's office, clinic
system or hospital setting.
g. Recreational therapy.
h, Professional sign language and foreign language interpreter services in a provider's office, except as
provided in the Continuity of Care provision.
PIC07-760-RI (1/09) 38 (PCH10409) 15.100.2.V
i. Exams, other evaluations and/or services for employment, insurance, licensure, judicial or administrative
proceedings or research, except as otherwise covered under this section or as part of a routine preventive
health examination.
j. Charges for duplicating and obtaining medical records from non participating providers unless requested
by PIC.
k. Genetic testing and associated services when done as a screening test to predict whether yots may be a
carrier of a specific sickness when you are not diagnosed with a specific sickness by a physician or yocs are
not at high risk for the specific sickness as confirmed by a physician.
1. Homeopathic medicine; hypnosis; chelation therapy, except chelation therapy will be covered when
medically necessary for the treatment of heavy metal poisoning.
m. Acupuncture, except for treatment in a chronic pain program and rendered by a provider licensed or trained
in acupuncture.
n. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease.
o. Treatment of cleft lip and cleft palate, except as otherwise provided in this CDC.
p. Vision therapy/orthoptics.
q. Services provided by an audiologist that are not provided in an office setting.
r. Biofeedback.
s. Routine hearing exams.
PIC07-760-R1 (1/09) 39 (PCH10409) 15.100.2.V
Benefit Designated Transplant Non-Designated Transplant
Network Provider Network Provider
Organ and Bone Marrow Office visits: 100% of eligible Office visits: 80% of eligible
Transplant Services charges after a copayment of $15 per charges after the deductible.
visit.
Hospital Services: 100% of eligible I Hospital Services: 80% of eligible
charges. charges after the deductible.
PIC covers eli ig ble transplant services that PIC's medical director or designee pre-certifies and determines in
advance to be medically necessary and not investigative. If the transplant is medically necessary, but is part of a
clinical trial, then benefits are available only for the transplant services that are not part of the clinical trial and
therefore not investigative. It is recommended that transplant services be received at a designated transplant
network provider.
Coverage for organ transplants, bone marrow transplants and bone marrow rescue services is subject to periodic
review. PIC evaluates transplant services for therapeutic treatment and safety. This evaluation continues at
least annually or as new information becomes available and it results in specific guidelines about benefits for
transplant services. Yon may call PIC at the telephone number listed inside the cover of this COC for
information about these guidelines.
Benefits, if the transplant meets the definition of an eligible charge, is medically necessary, and not
investigative, are available for the following eli ig~ble transplants:
1. Bone marrow transplants and peripheral stem cell transplants.
2. Heart transplants.
3. Heart/lung transplants.
4. Lung transplants.
5. Kidney transplants.
6. Kidney/pancreas transplants.
7. Liver transplants.
8. Pancreas transplants.
9. Small bowel transplants.
Transplant coverage includes a private room and all related post-surgical treatment and drugs. The transplant-
related treatment provided shall be subject to and in accordance with the provisions, limitations and other terms
of this COC.
Medical and hospital expenses of the donor are covered only when the recipient is a member and the transplant
has been pre-certified in advance by the medical director or designee. Treatment of medical complications that
may occur to the donor are not covered.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Services related to organ, tissue and bone marrow transplants and stem cell support procedures or peripheral
stem cell support procedures for a condition that is investigative.
c. Services, chemotherapy, supplies, drugs and aftercare for or related to human organ transplants not
specifically approved as medically raecessazy by PIC.
d. Services, chemotherapy, radiation therapy or any therapy that damages the bone marrow, except in cases
involving a bone marrow or stem cell transplant.
PIC07-760-R1 (1/09) 40 (PCH10409) 15.1002.V
e. Non-emergency ambulance service from hospital to hospital such as transfers and admission to hospitals
performed only for convenience.
f. Treatment of medical complications to a donor after procurement of a transplanted organ.
g. Computer search for donors,
h. Private collection and storage of blood and umbilical cord/umbilical cord blood.
io Travel expenses related to a covered transplant.
PIC07-760-R1 (1/09) 41 (PCH10409} 15.100.2.V
Benefit Participating Provider Benefit Non-Participati~zg Provider Be~zefit
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
Provider Reimbairsement Value.
Physical Therapy, 100% of eligible charges after a 80% of eligible charges after the
Occupational Therapy And copavment of $15 per visit. deductible.
Speech Therapy
Sensory integration therapy Coverage is limited to a maximum of 8 visits
for the treatment of feeding per member per calendar yem~.
disorders
100% of eligible charges after a 80% of eligible charges after the
copavment of $15 per visit. deductible.
PIC covers outpatient physical therapy (PT}, occupational therapy (OT) and speech therapy (ST) for
rehabilitative care rendered to treat a medical condition, siclrness or injury. PIC also covers outpatient PT, OT
and ST habilitative therapy for medically diagnosed conditions that have significantly limited the successful
initiation of normal motor or speech development. Therapy must be ordered by a physician, plrysician's assistant
or certified nurse practitioner and the therapy must be provided by or under the direct supervision of a licensed
physical therapist, occupational therapist or speech therapist for appropriate services within their scope of
practice. Coverage is limited to rehabilitative care or habilitative therapy that demonstrates measurable and
sustainable improvement within 2 weeks to 3 months, depending on the physical and mental capacities of the
individual.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Custodial care or maintenance care.
c. Recreational, educational, or self-help therapy (such as, but not limited to, health club memberships or
exercise equipment).
d. Therapy provided in your home far convenience.
e. Rehabilitation services that are not expected to make measurable or sustainable improvement within 2
weeks to 3 months, depending on the physical and mental. capacities of the individual.
f. Therapy for conditions that are self-correcting.
g. Voice training and voice therapy absent of a medical condition.
h. Investigative therapies for the treatment of autism, such as secretin infusion therapies.
i. Sensory integration therapy when used for a reason other than the treatment of feeding disorders.
j. Group therapy for PT, OT and ST.
PIC07-760-R1 (1./09) 42 (PCH10409} 15.100.2.V
Benefits* Drugs obtained at a pharmacy Drugs obtained at a pharmacy that is
that is a participating provider. not a participa6zzg provider. PIC pays:
PIC a s: See "Pre-certification" section.
NOTE: Benefits for specialty drugs are as described in this section,
regardless of the place of service where the specialty drug is dispensed or
administered.
Prescription Drug Services Generic drugs: 100% of eligible Fornzulazy and non formulazy
charges after a copayment of $10 60% of eligible charges after the
1. Prescription drags that per prescription or refill. deductible.
can beself-administered
for up to a 31-calendar Formulary brand drugs: 100%
day supply. of eligible charges after a
2. Up to a 31-day supply for copayment of $25 per prescription
one type of insulin. or refill.
3. Oral contraceptives for
a 1-month supply. Non fornzulazy brand drugs:
4. Contraceptive devices 100% of eligible charges after a
and delivery methods, copayment of $50 per prescription
other than oral or refill.
contraceptives and
injectable contraceptives,
available from a
pharmacy.
5. Compounded drugs.
® Mail order prescription Generic drugs: 100% of eligible Not covered.
drugs for up to a 93 charges after a copayment of $20
calendar day supply. per prescription or refill.
Formulazy brand drugs: 100%
of eligible charges after a
copayment of $50 per prescription
or refill.
Non forizzulazy brand drugs:
100% of eligible charges after a
eopavment of $100 per
prescription or refill.
PIC07-760-R1 (1/09) 43 (PCH10409) 15.100.2.V
Diabetic supplies
Coverage includes over-
the-counter diabetic
supplies, including glucose
monitors, syringes, blood
and urine test strips, and
other diabetic supplies as
medically necessary, if
you have gestational
diabetes, type I diabetes,
or type II diabetes. 80% of eligible charges. 60% of eligible charges after the
deductible.
PrescriptiocT drugs and Generic drugs: 100% of eligible Formulary and non formulary
over-the-counter (OTC) charges after a copayment of $10 60% of eligible charges after the
items used in connection per prescription or refill. deductible.
with smoking cessation for
up to 31 calendar days per Formulary brand drugs: 100%
prescription and limited to of eligible charges after a
a 93 calendar day supply copayment of $25 per prescription
per calendar year. or refill.
Non formulary brand drugs:
100% of eligible charges after a
copayment of $50 per prescription
or refill.
Specialty drugs 80% of eligible charges up to a 60% of eligible charges after the
a. Up to a 31 day $200 maximum per prescription deductible.
Supply. or refill.
b. Specialty drugs may
be oral or injectable.
c. Must be purchased
through a specialty
pharmacy. A list of
the specialty
pharmacies maybe
obtained on the PIC
website or calling
Customer Service.
d. A list of these
specialty drugs may
be obtained on the
PIC website or by
calling PIC Customer
Service.
e. The list of specialty
drugs may be revised
from time to time
without notice.
PIC07-760-R1 (1/09) 44 (PCH10409) 15.100.2.V
Injectable drugs that are
not specialty dnrgs,
excluding insulin. 80% of eligible charges. 60% of eligible charges after the
deductible.
Over-the-Counter (OTC) 100% of eligible charges after a copayment of $10 per prescription or refill.
Drags
Not subject to the deductible.
(Only includes OTC
drugs on the PIC OTC
drug list).
Limited up to a 30
calendar day supply per
prescription.
PIC uses its drug formulary and the preference of dispensing to determine which prescription dc~crgs, including
their generic equivalents are covered. A list of these drugs may be obtained on the PIC website or by calling
PIC Customer Service.
For certain medical conditions, there is a need to manage the use of specific drugs before alternative (second
line) drugs are prescribed for the same medical condition. This is known as step therapy. Members in a step
therapy program will need to meet the requirements of that program prior to receiving the second line drug.
Step therapy can apply to formulary or non formulary drugs and brand or generic drugs. The Step Therapy List
is subject to periodic review and modification by PIC.
Some dispensed prescrzptiorc drugs require the use of quantity limits, which ensure that the quantity of each
prescription remains consistent with clinical guidelines. Quantity limits can apply to formulary or non-
formulary drugs and brand or generic drugs. A list of those prescription dnrgs with quantity limits is available
upon request. The quantity limits list is subject to periodic review and modification by PIC. Requests for
quantities in excess of the established limits will not be reviewed. You will be responsible for additional
coinsurance for quantities received that are in excess of the quantity limit.
Certain drugs available over-the-counter (OTC) are covered by PIC as determined by the PreferredOne
Pharmacy and Therapeutics Committee. A list of such OTC drugs is available upon request. Those OTC drugs
that are covered by PIC will require a physician's prescription. To receive PIC's payment toward your OTC
drug you must present yocn• prescription at a participating pharmacy counter. You will still be responsible for
applicable coinsurance or deductible amounts.
You or your provider may request an exception to the drug formulary. If an exception applies, the non-
formcrlary drugs that are approved as an exception will be covered at the same level as formulary drugs.
Exceptions to the drug.formularv are available as follows:
1. When a plrysicicm designates that the prescription for an antipsychotic drug must be dispensed as
communicated and certifies in writing to PIC that the physician has considered all equivalent drugs in the
formulary and has determined that the drug prescribed will best treat your condition.
2. If yocr received a prescription drug to treat a diagnosed mental illness or emotional disturbance PIC will
continue to cover the drug, as though it were a formular~~ drug, for up to one year after it is removed from
the for-mulur2,~ or you change health plans and become covered under this COC, provided the drug has been
shown to effectively treat yocrr illness or disturbance and the following conditions are met:
a. You were treated with the drug for 90 calendar days before a change in PIC's formulary or a change in
your health plan,
b. Yocrr- physician designates that the prescription must be dispensed as communicated, and
P1C07-760-R1 (1/09) 45 (PCH10409) 15.100.2.V
a Your plzvsician certifies in writing to PIC that the prescription drug will best treat your condition.
An exception is valid for up to one year. Your physician may request the exception annually, following the
procedure described above. The exception does not apply if PIC removed the drug from the formulary for
safety reasons. Contact Customer Service for a copy of the written guidelines and procedures or for assistance
in requesting an exception.
When prescription drugs from a nonparticipating provider pharmacy are covered, eligible charges include
only the PIC nonparticipating provider reimbursement value. The PIC non participating provider
reimbursement value is the cost of the generic equivalent of the prescription drug and the dispensing fee, or if a
generic equivalent does not exist, the charge that PIC determines is to be customary for such prescription drug.
If the member- requests a brand name drug when a generic drug alternative is available, the member will be
required to pay the applicable copavmertt or coinsurance plus the difference in cost between the brand name and
the generic drug. The difference in cost between the brand name drug and the generic drug will not apply to any
applicable copayment, deductible or coinsurance costs the member incurs. When the member has reached the
otrt-of-pocket limit, the member still pays the difference in the allowed amount between the brand name and the
generic drug, even though the member is no longer responsible for the prescription drug copayment or
coinsurance.
Compounded drttgs will be covered provided that at least one active ingredient is a prescription drug. Payment
for a compounded drug that has a commercially prepared product available that is identical to or similar to the
compounded product, will be considered for coverage after documented failure of the commercially prepared
product(s). A commercially prepared product is one that is available at the pharmacy in its final, usable form
and does not need to be compounded at the pharmacy. The applicable benefit level will be applied.
Compounded drugs containing any product that is excluded by PIC will not be covered, including dosages and
route of administration that have not been approved by the FDA.
Compounded drugs will be covered according to the member's pharmacy network benefits. If a non-
participating provider pharmacy is used to obtain the compounded prescription, the non participating provider
benefit level will apply, without exception.
Off-label uses of drugs for cancer treatment are covered when the drug is recognized for cancer treatment in the
standard reference compendium, or in an article in medical literature from a major peer reviewed medical
journal. The article must use generally acceptable scientific standards other than case reports. Off-label uses of
specialty dr~trgs are not covered.
Prior Authorization. Certain prescription drugs may require prior authorization before yotr can have your
prescription filled at the pharmacy. For information, yotr may call PIC at the phone number listed on the inside
front cover of this COC. These prescription drugs may include, but are not limited to:
1. prescription drugs, that are over:
a. $150 if a compound prescription;
b. $1,500 if a retail prescription; or
c. $2,500 if a mail order prescription;
2. specialty drugs;
3. weight loss drugs to treat obesity; and
4. oral antifungal drugs.
Exclusions®
a. Please see the section entitled `Exclusions."
b. Replacement of a prescription drug due to loss, damage, or theft.
PIC07-760-R1 (1/09} 46 (PCH10409) 15.100.2.V
c. Drugs available over-the-counter (OTC) that by applicable law do not require a prescription, except as
provided in this COC.
d. Prescription drugs that are equivalent or similar to OTC dz•tzgs, except as provided in this COC.
e. OTC home testing products, except as provided in this COC.
f. Drugs not approved by the FDA.
g. Take home drugs when dispensed by a physician.
h. Weight loss drugs, except when medically necessary to treat obesity.
i. Prescription drugs and OTC drzzgs for smoking cessation, except as provided in this COC.
j. Prescriptions written by a dentist unless in connection with dental procedures covered under this Plan.
k. Drugs used for cosmetic purposes.
1. Unit dose packaging.
m. Homeopathic medicine, including dietary supplements.
n. Prescriptian drugs for the treatment of infertility.
o. Topical or oral acne treatments for members age 19 and over.
p. Non-FDA approved route of administration (e.g., drug that is FDA approved for oral use, but is being
applied topically).
q. Drugs that are given or administered as part of a drug manufacturer's study.
r. Prescription drugs if purchased by mail order through a program not administered by PIC's pharmacy
vendor.
s. Prescription drugs for the treatment of erectile dysfunction.
t. Prescription drugs are excluded that have a similar OTC drug (on the PIC OTC list) which has an identical
strength, identical route of administration, identical active chemical ingredient(s), and identical dosage
form.
u. Off-label use of specialty drugs.
v. Certain combination drugs and other drugs, regardless of formulary status, will not be covered according to
the PIC pharmacy policy titled "Cost Benefit Program." Contact Customer Service for a copy of this policy
or a list of the affected drugs. This policy is subject to change.
PIC07-760-R1 (1/09) 47 (PCH10409} 15.100.2.V
Benefit Participating Provider Benefit Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any dedzzctibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
Provider Reimbursement Value.
Reconstructive Surgery 100% of eligible charges. 80% of eligible charges after the
deductible.
PIC covers reconstructive surgery due to sickness, accident or congenital anomaly. Eligible charges include
eligible hospital, physician, laboratory, pathology, radiology and facility charges. Contact Customer Service to
determine if a specific procedure is covered.
Reconstructive surgery following a mastectomy includes the following:
1. reconstruction of the breast on which the mastectomy has been performed;
2. surgery and reconstruction of the other breast to produce symmetrical appearance;
3. prostheses; and
4. treatment of physical complications at alI stages of mastectomy, including lymphedemas.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Services and/or drugs to treat conditions that are cosmetic in nature.
PIC07-760-RI (1/09) 48 (PCHI0409) 15.100.2.V
Benefit Participating Provider Benefit Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
Provider Reimbursement Value.
Skilled Nursing Facility Care
Skilled rehabilitation, 80% of eligible charges. 80% of eligible charges after the
including room and board deductible.
Coverage for confinements in non-
participating hospitals and skilled nursin
facilities is limited to a combined
maximum of 120 calendar days per
calendar year.
Daily skilled care as an 100% of eligible charges. 80% of eligible charges after the
alternative to hospital deductible.
confinements
PIC covers the eligible skilled nursing facility services for post-acute treatment and rehabilitative care of
sickness or injury. These services must be directed or referred by a physician and pre-certified by PIC's
medical director or designee.
Skilled nursing.facility services include room and board, daily skilled nursing and related ancillary services.
PIC covers asemi-private room unless a physician recommends that a private room is medically necessary and
so orders. PIC's medical director or designee determines if a private room is medically necessary. In the event
a member chooses to receive care in a private room under circumstances in which it is not medically necessary,
PIC's payment toward the cost of the room shall be based on the average semi-private room rate in that facility.
Only services that qualify as reimbursable under Medicare are covered benefits, and coverage is limited to the
maximum number of calendar days per calendar year if the services would qualify as reimbursable under
Medicare.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Hospitalization, transportation, supplies, or medical services, including physicians' services furnished by
the United States Government or by an institution operated by the United States Government, unless
payment is requip-ed in accordance with applicable law.
c. Private room, except when medically necessary or if it is the only option available at the admitted facility.
d. Respite or custodial care.
PIC07-760-R1 (1/09} 49 (PCH10409) 15.100.2.V
Specified Non-Participating Provider Services
The services listed below are covered at the same benefit level as the type of service benefit shown in the
schedule above for participating provider benefits. Yau are not required to receive these services from a
participating provider. For example, an office visit, (whether by a participating provider or a non-
participatingprovider) for the services listed below will be covered at the participating provider benefit level.
1. Voluntary family planning of the conception and bearing of children.
2. The provider visit(s) and test(s) necessary to make a diagnosis of infertility.
3. Testing for sexually transmitted diseases, AIDS, and other HIV-related conditions.
4. Treatment of sexually transmitted diseases, except AIDS and other HIV-related conditions.
Exclusions:
a. Please see the section entitled "Exclusions."
PIC07-760-R1 (I/09} 50 (PCHI0409) I5.100.2.V
Pre-existing Condition Limitation
Pre-Existing Condition Any condition, regardless of the cause of the condition, for which medical advice,
diagnosis, care or treatment was recommended or received, during the 6 month
period immediately preceding the member's enrollment date under PIC. Genetic
information or pregnancy will not be considered apre-existing condition.
In the case of a lttte enrollee, apre-existing condition is excluded from coverage until the end of 18 months
from the effective date. For eligible employees and any eligible dependents when first eligible for coverage, a
preexisting condition is excluded from coverage until the end of 12 months from the enrollment date. For those
that enroll under the Special Enrollment provision, apre-existing condition is excluded from coverage until the
end of 12 months from the enrollment date.
The pre-existing condition limitation is reduced by any period of time during which the member had continuous
and. creditable coverage prior to his or her enrollment under the GMC. This limitation does not apply to
newborns, adopted children, or children placed for adoption.
Exclusions
In addition to any other exclusions or limitations specified in this COC, PIC will not cover charges
iaacarrr•ecl for any of the following servicesa
1. Services or supplies that PIC determines are not medically necessary.
2. Investigative procedures and associated expenses.
3. Charges for services determined to be duplicate services by PIC.
4. Personal comfort or convenience items.
5. Procedures that are always cosmetic, or for convenience or comfort reasons, as listed on PIC's Cosmetic
Procedures Policy. This policy maybe obtained by calling PIC Customer Service.
5. rJrthognathic surgery.
7. Services received before coverage under PIC begins or after your coverage under PIC ends.
8. Services or supplies not directly related to your care.
9. Services or supplies through a provider ordered or rendered by providers that are unlicensed or not certified
by the appropriate state regulatory agency.
10. PIC or the member are not liable for services, drugs or supplies not rendered in the most cost-efficient
setting or methodology appropriate for the condition based on medical standards and accepted practice
parameters of the community, or provided at a frequency other than that accepted by the medical
community as medically appropriate.
11. Charges that exceed the PIC Non-Participating Provider Reimbursement Value for services or supplies
received from non ~ar•ticipating providers, including non-participating pharmacies.
12. Services prohibited by law or regulation, or illegal under applicable laws.
PIC07-760-R1 (1/09} 51 (PCH10409) 15.100.2.V
13. Charges for services that are eligible for payment under any insurance policy, including auto insurance, or
under Workers' Compensation law, employer liability law or any similar law.
14. Services under this plan that are paid under Medicare Part B but only to the extent: (i) you are eligible to be
covered under Medicare Part B; (ii) you and/ or PIC are not subject to Medicare secondary rules; and (iii)
such an exclusion is permitted by applicable state and federal law.
15. Charges incurred outside the United States if the member traveled to such a location for the primary
purpose of obtaining medical services, drugs or supplies.
16. Eyeglasses, frames and their related fittings.
17. Contact lenses and their related fittings, except when prescribed as medically necessary for the treatment of
keratoconus.
18. Any service, drug or supply provided by a relative (i.e., a spouse, parent, brother, sister or child of the
subscriber or of the subscriber's spouse) or anyone who customarily lives in the subscriber's household.
19. PIC or the member are not liable for charges for services performed by certified surgical technicians,
surgical technicians or certified operating room technicians.
20. All services, except emergency services, for members when outside the United States.
21. Services provided by massage therapists, doulas, and personal trainers.
22. Sexual devices, services; or supplies or prescription dr~r{gs for the treatment of sexual dysfunction.
23. Charges that are paid under medical payment, automobile or other coverage that is payable without regard
to fault, including charges that are applied toward any coir~sur•ance requirement of such a policy.
24. Massage therapy.
25. Telephone consultations.
26. Electronic mail consultations except as covered in Office Visits and Urgent Care Center Visits of this COC.
27. Preventive medical services, such as but not limited to, flu shots, cholesterol testing, glucose testing and
mammograms, that are not ordered by a physician.
28. Financial or legal counseling services.
29. Light-based treatments for acne.
30. Elective abortions.
31. PIC shall not be liable for any loss to which a contributing cause was the member's commission of or
attempt to commit a felony or to which a contributing cause was the member's being engaged in an illegal
occupation.
32. Travel> transportation or living expenses.
PIC07-760-R1 (I/09) 52 (PCH10409) 15.100.2.V
The following exclusions are repeated from the "Schedule of Payment" section":
'~ For ease of reference, some exclusions may contain headings for categories of benefit services and
supplies. Please note that, exclusions listed under all categories of benefit services and supplies shall
apply to all services and supplies, regardless of the heading under which they are listed.
33. Ambulance Services:
a. See all exclusions.*
b. Non-emergency ambulance service from hospital to hospital such as transfers and admission to
hospitals performed only for convenience.
34. Chiropractic Services:
a. See all exclusions.*
b. Services primarily educational in nature.
c. Vocational rehabilitation.
d. Self-care and self-help training (non-medical).
e. Health clubs and spas.
f. Recreational therapy.
g. Rehabilitation services that are not expected to make measurable or sustainable improvement within 2
weeks to 3 months, depending on the physical and mental capacities of the individual.
h. Chiropractic therapy other than for treatment of acute musculoskeletal conditions.
i. Acupuncture, except for treatment in a chronic pain program and rendered by a provider licensed or
trained in acupuncture.
j. Blood, urine or hair analysis related to chiropractic services.
k. Ultrasound, MRI, EMG, waveform, and nuclear medicine diagnostic studies related to chiropractic
services.
1. Manipulation under anesthesia related to chiropractic services.
m. Homeopathic/holistic services related to chiropractic services.
35. Dental Services:
a. See all exclusions. *
b. Dental services covered under your dental plan.
c. Preventive dental procedures.
d. Dental services and all associated expenses, except as stated in this section.
e. Orthodontia and all associated expenses, except as required by law.
f. Surgical extraction of impacted wisdom teeth.
g. Services far cracked or broken teeth that result from biting, chewing, disease or decay.
h. Dental implants.
i. Prescriptions written by a dentist unless in connection with dental procedures covered by PIC.
j. Dental services related to periodontal disease.
36. Durable Medical Equipment (DME), Services and Prosthetics:
a. See all exclusions.*
b. Any durable medical equipment or supplies not listed as eligible on PIC's durable medical list, or as
determined by PIC.
c. Disposable supplies or non-durable supplies and appliances, including those associated with equipment
determined not to be eligible for coverage.
d. Revision of durable medical equipment and prosthetics, except when made necessary by normal wear
or use.
e. Replacement or repair of items when: (1) damaged or destroyed by misuse, abuse or carelessness; (2)
lost; or (3) stolen.
f. Duplicate or similar items.
g. Items that are primarily educational in nature or for vocation, comfort, convenience or recreation.
PIC07-760-R1 (1/09) 53 (PCH10409) 15.100.2.V
h. Hearing aids, devices to improve hearing and related fittings (except as provided in the Durable
Medical Equipment (DME), Services and Prosthetics provision).
i. Communication aids or devices; equipment to create, replace or augment communication abilities
including, but not limited to, speech processors, receivers, communication board, or computer or
electronic assisted communication.
j. Household equipment, household fixtures and modifications to the structure of the home, escalators or
elevators, ramps, swimming pools, whirlpools, hot tubs and saunas, wiring, plumbing or charges for
installation of equipment, exercise cycles, air purifiers, central or unit air conditioners, water purifiers,
hypoallergenic pillows, mattresses or waterbeds.
k. Vehicle/car or van modifications including, but not limited to, hand brakes, hydraulic lifts and car
carrier.
1. Over-the-counter orthotics and appliances.
m. Orthopedic shoes and custom molded foot orthotics, except for members with diabetes or peripheral
vascular disease.
n. Charges for sales tax, mailing and delivery.
o. Durable equipment necessary for the operation of equipment determined not to be eligible for coverage.
p. Durable medical equipment, orthotics and prosthetics that are necessary for activities beyond activities
of daily living (ADCs).
q. Wigs for conditions other than alopecia areata.
r. Enteral feedings and other oral nutritional and electrolyte substances, except amino-acid based formulas
when medically necessary and electrolyte substances to treat PKU or otherwise required to sustain life.
s. Upgrades to or replacement of any items that are considered eligible charges and covered under this
section, unless the item is no longer functional and is not repairable.
37. Emergency Room Services:
a. See all exclusions.
b. Non-emergency services received in an emergency room.
38. Home Health Services:
a. See all exclusions.*
b. Companion and home care services, unskilled nursing services, services provided by yozzr family or a
person who shares your legal residence.
c. Services provided as a substitute for a primary caregiver in the home.
d. Services that can beperformed by anon-medical person or self-administered.
e. Home health aides.
f. Services provided in your home for convenience.
g. Services provided in your home due to lack of transportation.
h. Custodial care.
i. Services at any site other than yozzr home.
j. Recreational therapy.
39, Hospice Care:
a. See all exclusions.*
b. Services provided by your family or a person who shares yozzr legal residence.
c. Respite or rest care except as specifically described in this section.
40. Hospital Services:
a. See all exclusions.
b. Travel, transportation, other than ambulance transportation, or living expenses.
c. Hospitalization, transportation, supplies, or medical services, including physicians' services furnished
by the United States Government or by an institution operated by the United States Government, unless
payment is required in accordance with applicable law.
d. Private room, except when medically necessary or if it is the only option available at the admitted
facility.
PIC07-760-R1 (1/09) 54 (PCH10409) 15.100.2.V
e. Non-emergency ambulance service from hospital to hospital, such as transfers and admissions to
hospitals performed only for convenience.
f. Services and/or drugs to treat conditions that are cosmetic in nature.
g. Orthoptics and refractive surgery (i. e. lasik) for opthalmic conditions that are correctable by contacts or
glasses.
h. Services and/or surgery and associated expenses for gender reassignment unless determined to be
medically necessary. These services and associated expenses will be reviewed on a case by case basis
and, if determined to be medically necessary, services must be received at a PIC designated treatment
center.
i. Genetic testing and associated services when done as a screening test to predict whether you may be a
carrier of a specific sickness when you are not diagnosed with the specific sickness by a physician or
you are not at high risk for the specific sickness as confirmed by a physician.
j. Homeopathic medicine; hypnosis; chelation therapy, except chelation therapy will be covered when
medically necessary for the treatment of heavy metal poisoning.
k. Acupuncture, except for treatment in a chronic pain program and rendered by a provider licensed or
trained in acupuncture.
1. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease.
m. Autopsies.
n. Bariatric szrrgeries.
o. Services for items for personal convenience, such as television rental.
p. Commercial weight loss programs.
q. Nutritional counseling, except when:
1. provided during a confinement;
2. for the diagnosis and treatment of diabetes or an eating disorder; or
3. a member has been diagnosed with a chronic medical condition by a physician.
In all cases, except confinement, nutritional counseling must be provided in a physician's office, clinic
system or hospital setting.
r. Treatment of eating disorders, except as shown in the Eating Disorders Treatment Program benefit.
41. Infertility Services:
a. See all exclusions.*
b. Reversal of voluntary sterilization.
c. Adoption costs.
d. In vitro fertilization.
e. Gamete and zygote intrafallopian transfer (GIFT and ZIFT) procedures.
f. Surrogate pregnancy.
g. Sperm banking.
h. Embryo and egg storage.
i. Artificially assisted technology, such as, but not limited to, artificial insemination (AI) and intrauterine
insemination (IUI).
j. Donor sperm.
k. Oral and injectable drugs for infertility.
42. Mental and Substance-Related Disorder Services:
a. See all exclusions.
b. Counseling, studies, services or confinements ordered by a court or law enforcement officer that are not
determined to be medically necessary by PIC, except as specifically covered above.
c. Marital counseling, relationship counseling, family counseling except as described in this COC, or other
similar counseling or training services.
d. Substance or mental health related conditions that according to generally accepted professional
standards cannot be improved with treatment, except as stated in this COC.
e. Services to hold. or confine a member under chemical influence when no medically necessary services
are required, regardless of where the sei-vices are received (e.g. detoxification centers).
PIC07-760-R1 (1./09) 55 (PCH10409) LS.t00.2.V
f. Early behavioral. interventions for children including but not limited to Lovaas therapy, applied
behavioral analysis, discrete trial training, and intensive intervention programs.
g. Private room, except when medically necessary or if it is the only option available at the admitted
facility.
h. Home-based mental or behavioral health services.
i. Biofeedback.
j. Mental retardation or mental conditions that, according to generally accepted professional standards, are
not amenable to favorable modification, except for initial evaluation, diagnosis or crisis intervention.
43. Office Visits and Urgent Care Center Visits:
a. See all exclusions. *
b. Services, seminars, or programs that are primarily educational in nature.
c. Health education.
d. Smoking cessation programs, except as provided in this COC.
e. Weight loss programs, including, but not limited to, consultations, laboratory services, testing,
nutritional and food supplements, and weight loss drugs when not being treated for obesity, except
when medically necessary as determined by PIC's medical director or designee.
f. Nutritional counseling, except when:
1. provided during a confinement;
2. for the diagnosis and treatment of diabetes or an eating disorder; or
3. a member has been diagnosed with a chronic medical condition by a plzvsician.
In all cases, except confinement, nutritional counseling must be provided in a physician's office, clinic
system or hospital setting.
g. Recreational therapy.
h. Professional sign language and foreign language interpreter services in a provider's office, except as
provided in the Continuity of Care provision.
i. Exams, other evaluations and/or services for employment, insurance, licensure, judicial or
administrative proceedings or research, except as otherwise covered under this section or as part of a
routine preventive health examination.
j. Charges for duplicating and obtaining medical records from non participating providers unless
requested by PIC.
k. Genetic testing and associated services when done as a screening test to predict whether you may be a
carrier of a specific sickness when you are not diagnosed with a specific sickness by a physician or you
are not at high risk for the specific sickness as confirmed by a physician.
1. Homeopathic medicine; hypnosis; chelation therapy, except chelation therapy will be covered when
medically necessary for the treatment of heavy metal poisoning.
m. Acupuncture, except for treatment in a chronic pain program and rendered by a provider licensed or
trained in acupuncture.
n. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease.
o. Treatment of cleft lip and cleft palate, except as otherwise provided in this COC.
p. Vision therapy/orthoptics.
q. Services provided by an audiologist that are not provided in an office setting.
r. Biofeedback.
s. Routine hearing exams.
44. Organ and Bone Marrow Transplant Services:
a. See all exclusions.*
b. Services related to organ, tissue and bone marrow transplants and stem cell support procedures or
peripheral stem cell support procedures for a condition that is investigative.
c. Services, chemotherapy, supplies, drugs and aftercare for or related to human organ transplants not
specifically approved as medically necessary by PIC.
d. Services, chemotherapy, radiation therapy or any therapy that damages the bone marrow, except in
cases involving a bone marrow or stem cell transplant.
PICO'7-'760-R1 (1/09} 56 (PCH10409) 15.100.2.V
e. Non-emergency ambulance service from hospital to hospital such as transfers and admission to
hospitals performed only for convenience.
f. Treatment of medical complications to a donor after procurement of a transplanted organ.
g. Computer search for donors.
h. Private collection and storage of blood and umbilical cord/umbilical cord blood.
i. Travel expenses related to a covered transplant.
45. Physical Therapy, Occupational Therapy and Speech Therapy:
a. See all exclusions.
b. Custodial care or maintenance care.
c. Recreational, educational, or self-help therapy (such as, but not limited to, health club memberships or
exercise equipment).
d. Therapy provided in your home for convenience.
e. Rehabilitation services that are not expected to make measurable or sustainable improvement within 2
weeks to 3 months, depending on the physical and mental capacities of the individual.
f. Therapy for conditions that are self-correcting.
g. Voice training and voice therapy absent of a medical condition.
h. Investigative therapies for the treatment of autism, such as secretin infusion therapies.
i. Sensory integration therapy when used for a reason other than the treatment of feeding disorders.
j. Group therapy for PT, OT and ST.
46. Prescription 17rug Services:
a. See all exclusions.
b. Replacement of a prescription drug due to loss, damage, or theft.
c. Drugs available over-the-counter (OTC) that by applicable law do not require a prescription, except as
provided in this COC.
d. Prescription dra4gs that are equivalent or similar to OTC drugs, except as provided in this COC.
e. OTC home testing products, except as provided in this COC.
f. Drugs not approved by the FDA.
g. Take home drugs when dispensed by a physician.
h. Weight loss drugs except when medically necessary to treat obesity.
i. Prescription drugs and OTC drugs for smoking cessation, except as provided in this COC.
j. Prescriptions written by a dentist unless in connection with dental procedures covered under this Plan.
k. Drugs used for cosmetic purposes.
1. Unit dose packaging.
m. Homeopathic medicine, including dietary supplements.
n. Prescription drugs for the treatment of infertility.
o. Topical or oral acne treatments for members age 19 and over.
p. Non-FDA approved route of administration (e.g., drug that is FDA approved for oral use, but is being
applied topically),
q. Drugs that are given or administered as part of a drug manufacturer's study.
r. Prescription drugs if purchased by mail order through a program not administered by PIC's pharmacy
vendor.
s. Prescription drugs for the treatment of erectile dysfunction.
t. Prescriptio~a drugs are excluded that have a similar OTC dr-acg (on the PIC OTC list} which has an
identical strength, identical route of administration, identical active chemical ingredient(s), and identical
dosage form.
u. Off-label use of specialty drugs.
v. Certain combination drugs and other drugs, regardless of formulary status, will not be covered
according to the PIC pharmacy policy titled "Cost Benefit Program." Contact Customer Service for a
copy of this policy or a list of the affected dings. This policy is subject to change.
P1C07-760-R1 (1/09) 57 (PCH10409) 15.100.2.V
47, Reconstructive Surgery:
a. See all exclusions. *
b. Services and/or drugs to treat conditions that are cosmetic in nature.
48. Skilled NursingFacility Care:
a. See all exclusions.*
b. Hospitalization, transportation, supplies, or medical services, including physicians' services furnished
by the United States Government or by an institution operated by the United States Government, unless
payment is required in accordance with applicable law.
c. Private room, except when medically necessary or if it is the only option available at the admitted
facility.
d. Respite or custodial care.
49. Specified Non-Participating Provider Services:
a. See all exclusions.*
Ending Your Coverage
Coverage of the subscriber and/or his or her dependents will terminate on the earliest of the following dates,
except that coverage may be continued or converted in some instances as specified in the "Continuation of
Coverage" and "Your Right to Convert Coverage" sections:
1. For the subscriber and dependents, the end of the month in which PIC terminates the GMC.
2. For the subscriber and dependents, the end of the month in which the subscriber retires, unless PIC and the
employer have agreed to provide coverage for retirees under the GMC.
3. For the subscriber and dependents, the end of the month in which the subscriber's eligibility under the GMC
ends.
4. For the subscriber and dependents, the end of the month following the receipt of a written request from the
subscriber to cancel coverage.
5. For a child covered as a dependent, the end of the month in which the child is no longer eligible as a
dependent, unless the eligible dependent is handicapped.
6. For the subscriber and dependents, termination will be retroactive to the last calendar day for which the
subscriber's contribution towards premium has been received.
7. For the subscriber and dependents, the date you have preformed an act or practice that constitutes fraud or
made an intentional misrepresentation or material fact under the terms of the GMC.
8. For the covered spouse of the subscriber, the end of the month in which the covered spouse is no longer
eligible as a covered spouse.
9. For COCs that are coordinated with a health reimbursement arrangement (HRA) plan sponsored by the
employer, for the subscriber and dependents including those enrolled for continuation coverage (COBRA),
the date the subscriber ceases to be enrolled as a participant (including the date the applicable member ceases
to be enrolled for continuation coverage (COBRA) in a HRA plan.
PIC07-760-R1 (1/09) 58 (PCH10409) 15.100.2.V
Extension of Benefit:
An extension will be provided to a member who is confined in a hospital or skilled nursing facility on the date of
termination of the GMC. PIC will pay benefits during the confinement, until discharge, upon receipt of due proof
of the following:
1. the member incurred eligible charges during the confinement;
2. the eligible charges are related to the sickness or injury causing the confinement; and
3. the eligible charges would have resulted in a valid post-service claim if this benefit had been in effect at the
time expenses were incurred.
Leaves of Absence
Family and Medical Leave Act (FMLA)
If you are absent from work due to an approved family or medical leave under the Family and Medical Leave
Act of 1993 (FMLA), coverage may be continued for the duration of the approved leave of absence as if there
was no interruption in employment. Such coverage will continue until the earlier of the expiration of such leave
or the date you notify the employer that you do not intend to return to work. You are responsible for all required
contribzztions.
If yozz do not return after an approved leave of absence, coverage may be continued under the "Continuation
Coverage" section, provided you elect to continue under that provision. If the member returns to work
immediately following his or her approved FMLA leave, no waiting periods or pre-existing condition
limitations will apply.
The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA)
Continuation of Benefits. Subscribers who are absent due to service in the uniformed services and/or their
covered dependents may continue coverage pursuant to USERRA for up to 24 months after the date the
subscriber is first absent due to uniformed service duty.
Eligibility. A subscriber is eligible for continuation under USERRA if he or she is absent from employment
because of voluntary or involuntary performance of duty in the Armed Forces, Army National Guard, Air
National Guard or the commissioned corps of the Public Health Service. Duty includes absence for active duty,
active duty for training, initial active duty for training, inactive duty training and for the purpose of an
examination to determine fitness for duty.
Covered dependents who have coverage under PIC immediately prior to the date of the subscriber's covered
absence are eligible to elect continuation under USERRA.
Upon the subscriber's return to work immediately following his or her leave under USERRA, no waiting
periods or pre-existing condition limitations will apply.
Contribution Payment. If continuation of coverage is elected under USERRA, the subscriber or covered
dependent is responsible for payment of the applicable cost of coverage. If the szzbscriber is absent for not
longer than 31 calendar days, the cost will be the amount the szzbscriber would otherwise pay for coverage. For
absences exceeding 31 calendar days, the cost may be up to 102% of the cost of coverage under PIC. This
includes the subscriber's share and any portion previously paid by the employer.
PIC07-760-R1 (1/09} 59 (PCH10409) 15.100.2.V
Duration of Coverage. Elected continuation of coverage under USERRA will continue until the earlier of:
1. 24 months, beginning the first day of absence from employment due to service in the uniformed services;
2. the day after the subscriber fails to apply for or return to employment as required by USERRA, after
completion of a period of service;
3. the early termination of USERRA continuation coverage due to the subscriber's court-martial or
dishonorable discharge from the uniformed services; or
4. the date on which the GMC is terminated.
The continuation available under USERRA runs concurrently with continuation available under "Continuation
Coverage." Subscriber's should contact their employer with any questions regarding coverage normally
available during a military leave of absence or continuation coverage and notify the employer of any changes in
marital status or a change of address.
Return to Work Requirements. Under USERRA a service member is entitled to return to work following an
honorable discharge as follows:
1. Less than 31 days service: By the beginning of the first regularly scheduled work period after the end of
the calendar day of duty, plus time required to return home safely and an eight hour rest period.
2. 31 to 180 days: The employee must apply for reemployment no later than 14 days after completion of
military service.
3. 181 days or more: The employee must apply for reemployment no later than 90 days after completion of
military service.
4. Service-connected injury or illness: Reporting or application deadlines are extended for up to two years
for persons who are hospitalized or convalescing.
PIC07-760-R1 (1/09) 60 (PCH10409) 15.100.2.V
Continuation Coverage
Important Note if Employer also Sponsors HRA Program: If coverage under this COC is paired with benefits
offered under a health reimbursement arrangement or HRA (within the meaning of IRS Revenue Ruling 2002-41)
established and maintained by the employer, then your right to continue coverage under this COC is not
conditioned upon your concurrent enrollment for continuation coverage (COBRA) under the employer's HRA
program. Thus, to enroll for continuation coverage (COBRA) under this COC, an otherwise eligible subscriber
and/or covered member is not required to elect, enroll or be enrolled for, or maintain continuation coverage under
the employer's HRA program. Notwithstanding the foregoing, the employer's HRA program may condition the
right to continue coverage under such HRA program upon the subscriber's and/or covered member's election,
concurrent enrollment for, and maintenance of continuation coverage (COBRA) under this COC. A failure to
elect and maintain continuation coverage under this COC may terminate your right to continue coverage under the
employer's HRA program. Termination of continuation coverage (COBRA) under this COC before expiration of
the maximum continuation period may terminate continuation coverage (COBRA) under the employer's HRA
program. To enroll for continuation coverage under this COC, you must make a timely separate election to
continue coverage under this COC and timely pay separate continuation premiums for such coverage as required
under this COC. To also enroll for continuation coverage under the employer's HRA program, you must make a
timely separate election to continue such coverage and timely pay separate continuation premiums for such
coverage as required under the employer's HRA program.
Notwithstanding the foregoing paragraph relating to continuation coverage, coverage for an otherwise (active)
eligible employee and his/her dependents under this COC that is non-continuation coverage shall be coordinated
with and conditioned upon enrollment and coverage under the HRA program offered and maintained by the
employer.
PIC shall not be required to establish, maintain or contribute to a HRA on behalf of an eligible member or the
employer.
The subscriber, his or her covered spouse and covered dependent children may continue coverage under PIC
when a qualifying event occurs. Yozz may elect continuation coverage for yourself regardless of whether the
subscriber or other eligible dependents in yozzr family elect continuation coverage. A subscriber and a covered
spouse may elect continuation coverage on behalf of each other and/or their covered dependent children. Only
the subscriber, his or her covered spouse and covered dependent children are eligible for continuation coverage.
Other individuals, even though eligible to enroll for coverage under this COC, are ineligible for Continuation
Coverage under this COC.
If a loss of coverage qualifying event occurs:
1. In certain cases, the subscriber may continue his or her coverage and may also continue coverage for his or
her covered spouse and covered dependent children when coverage would normally end;
2. In certain cases, the covered spouse and covered dependezzt children may continue coverage when coverage
would normally end;
3. Coverage will be the same as that for other similar members; and
4. Continuation coverage with PIC ends when the GMC terminates or as explained in detail on the following
Continuation Chart. The subscriber, his or her covered spouse and covered dependent children may,
however, be entitled to continuation coverage under another group health plan offered by the employer. You
should contact the employer for details about other continuation coverage. Also refer to the "Youz- Right to
Convert Coverage" section following this "Continuation Coverage" section for your conversion rights.
For additional information about your rights and obligations under the GMC and/or state or federal COBRA
continuation law, you should contact the employer.
PIC07-760-R1 (1/09} 61 (PCH10409) 15.100.2.V
Qualifying Events
1. Loss of coverage under the GMC by the subscriber due to one of these events:
a. Voluntary or involuntary termination of employment of the subscriber for reasons other than "gross
misconduct."
b. Reduction in the hours of employment of the subscriber.
c. Layoff of the subscriber.
d. Leave of absence of the subscriber.
e. Early retirement of the subscriber.
f. Total disability of the subscriber while employed by the employer.
2. Loss of coverage under the GMC by the covered spouse and/or covered dependent children due to one of
these events:
a. Voluntary or involuntary termination of employment of the subscriber for reasons other than "gross
misconduct."
b. Reduction in the hours of employment of the subscriber.
c. Layoff of the subscriber.
d. Leave of absence of the subscriber.
e. Early retirement of the subscriber.
f. Total disability of the subscriber while employed by the employer.
g. Subscriber becoming enrolled in Medicare.
h. Divorce or legal separation of the subscriber.
i. Death of the subscriber.
3. Loss of coverage under the GMC by the covered dependent child due to his or her loss of "dependent child"
status under the GMC.
4. Loss of coverage under the GMC due to the bankruptcy of the employer under Title XI of the United States
Code. For purposes of this qualifying event (bankruptcy), a loss of coverage includes a substantial
elimination of coverage that occurs within one year before or after commencement of the bankruptcy
proceeding. Applies to the covered retiree, his or her covered spouse and covered dependent children.
Throughout the rest of this section, "Employer" or "Continuation Administrator" is referenced based on the entity
responsible for administering Minnesota Continuation.
Required Procedures
When the initial qualifying event is death, termination of employment or reduction in hours (including leave of
absence, layoff, or retirement), total disability while employed, or Medicare enrollment of the subscriber, the
employer will offer continuation coverage to qualified memhers. Yozz do not need to notify the employer of these
qualifying events. However, for other qualifying events including divorce or legal separation of the subscriber
and loss of dependent child status, continuation is available anly if you provide timely, written notice to the
employer. Yott must also provide timely, written notice to the employer of other events, such as a Social Security
disability determination or second qualifying events, in order to be eligible for an extension of continuation
coverage as required below by the employer. To elect continuation coverage, you must make a timely, written
election as required below by the employer.
What the employer must do:
1, Provide initial gene~•al continuation notices as required by law; determine if the member is eligible to
continue coverage according to applicable laws;
PIC07-760-R1 (1/09} 62 (PCHI0409) I5.100.2.V
2. Notify persons of the unavailability of continuation coverage;
3. Notify the member of his or her rights to continue coverage provided that all required notice and notification
procedures have been followed by the subscriber, covered spouse and/or covered dependent children;
4. Inform the member of the premium contribution required to continue coverage and how to pay the premium
contribution; and
5. Notify the member when he or she is no longer entitled to continuation coverage or when his or her
continuation coverage is ending before expiration of the maximum (18-, 29-, 36-month) continuation period.
What you must do:
1. You must notify the employer in writing of a divorce or legal separation within 60 calendar days after the date
of the qualifying event, or the date coverage would end due to the qualifying event, whichever is later;
2. Yorr must notify the employer in writing of a covered dependent child ceasing to be eligible within 60
calendar days after the date of the qualifying event, or the date coverage would end due to the qualifying
event, whichever is later;
You must submit your written notice of a qualifying event within the 60 day timeframe, as explained
previously in Item #1 and #2, using the employer's approved notice form. (Yorr may obtain a copy of the
approved form from the employer.) This notice must be submitted to the employer in writing and must
include the following:
a. the name of the employer;
b. the name and address of the subscriber or former subscriber ;
c. the names and addresses of ail applicable dependents;
d. the description and date of the qualifying event;
e. documentation pertaining to the qualifying event such as: decree of divorce or legal separation, marriage
certificate for child, student transcript showing last day of student enrollment for child etc.; and
f. the name, address, and telephone number of the individual submitting the notice. This individual can be
a subscriber, former subscriber, or his or her dependents}; nr a representative acting on behalf of the
employee or dependents}.
If you do not supply all notice requirements in writing as previously described, then you must follow the
employer's requirements and specified time period for submitting, in writing, all required information and
supporting documentation.
All written notices as described previously in 1, 2, and 3, under "What you must do," must be sent to
the employer.
4. To elect continuation, you must notify the employer of your election in writing within 60 calendar days after
the date the member's coverage ends, or the date the employer notifies the member of continuation rights,
whichever is later. To elect continuation coverage, you must complete and submit your written election
within the 60-day timeframe using the employer's approved election form. (Yorr may obtain a copy of the
approved form from the employer.) This election must be submitted in writing to the employer; and
5. You must pay continuation premium contributions:
a. The premium contribution to continue coverage is the combined employer plus subscriber rate charged
under the GMC, plus the employer may charge an additional 2% of that rate (rate also applies if the
qualifying event is the total disability of the subscriber while employed). For a member° receiving an
PIC07-760-R1 (1/09) 63 (PCH10409) 15.100.2.V
additional 11 months of coverage after the initial 18 months due to a continuation extension for Social
Security disability, the premium contribution for those additional months may be increased to 150% of
the employer's total cost of coverage. The continuation election form will set forth yozrr continuation
premium contribution rate(s).
b. The first pz°emizvn contribution must be paid by check within 45 calendar days after electing to continue
the coverage or such longer period as required by law. Thereafter, the member's monthly payments are
due and payable by check at the beginning of each month for which coverage is continued.
c. The member must pay subsequent premium contributions by check on or before the required due date,
plus the 30-calendar day grace period required by law, and if authorized by PIGS such longer period
allowed by the employer or required by law.
What you must do to apply for continuation extension:
A. Social. Security Disability:
If you are currently enrolled in continuation coverage under the GMC, and it is determined that you are
totally disabled by the Social Security Administration within the first 60 calendar days of your current
continuation coverage, then you may request an extension of coverage provided that your current
continuation coverage resulted from the subscriber's leave of absence, retirement, reduction in hours,
layoff, or his or her termination of employment for reasons other than gross misconduct. To request an
extension of continuation, yozr must notify the employer in writing of the Social Security Administration's
determination within 60 calendar days after the latest of:
a. the date of the Social Security Administration's disability determination;
b. the date of the subscriber's termination of employment, reduction of hours, leave of absence,
retirement, or layoff; or
c. the date on which yozz would lose coverage under the GMC as a result of the subscriber's
termination, reduction of hours, leave of absence, retirement, or layoff.
2. You must submit your^ written notice of total disability within the 60 day timeframe, as described
previously in Item #1, and before the end of the 18`" month of your initial continuation coverage using the
employer's approved disability notice form. (You may obtain a copy of the approved form from the
employer.) This notice must be submitted, in writing, to the employer and must include the following:
a. the name of the employer;
b. the name and address of the subscriber or former subscriber;
c. the names and addresses of all applicable dependents currently on continuation coverage;
d. the description and date of the initial qualifying event that started yozzr continuation coverage;
e. the name of the disabled member;
f. the date the member became disabled;
g. the date the Social Security Administration made its determination of disability;
h. a copy of the Social Security Administration's determination of disability; and
i. the name, address, and telephone number of the individual submitting the notice. This
j. individual can be a subscriber, former subscriber, or his or her dependent(s); or a representative
acting on behalf of the employee or dependents}.
If you do not supply all notice requirements in writing as previously described, then you must follow the
employer's requirements and specified time period for submitting, in writing, all required information
and supporting documentation.
3. To elect an extension of continuation, you must notify the employer of the Social Security
Administration's determination, in writing, within the 60 calendar day and the initial 18-month
continuation period timeframes, by following the notification procedure as previously explained in Item
#1 and #2, and submitting the employer's approved form; and
PIC07-760-R1 (1/09} 64 (PCH10409) 15.100.2.V
4. Yoca must pay continuation premium contributions:
a. The premium contribution to continue coverage is the combined employer plus subscriber rate
charged under the GMC, plus the employer may charge an additional 2% of that rate. For a member
receiving an additional 11 months of coverage after the initial 18 months due to a continuation
extension for Social Security disability, the premium contribution for those additional months maybe
increased to 150% of the employer's total cost of coverage. The disability notice form will set forth
your continuation premium contribution rate(s).
b. The first premium contribution must be paid by check within 45 calendar days after electing to
continue the coverage. Thereafter, the member's monthly payments are due and payable by check at
the beginning of each month for which coverage is continued.
c. The member must pay subsequent premiarm contributions by check on or before the required due
date, plus the 30-calendar day grace period required by law, and if authorized by PIC, such longer
period allowed by the employer.
B. Second OualifvinE Events for Covered Dependents Only:
If you are currently enrolled in continuation coverage under this GMC and the subscriber dies, or in the
case of divorce or a legal separation of the subscriber, or a covered dependent child loses eligibility, then
you may request an extension of coverage provided that your current continuation coverage resulted from
the sc~bscf•iber's leave of absence, retirement, reduction in hours, layoff or his/her termination of
employment for reasons other than gross misconduct or resulted from a Social Security Administration
disability determination. To request an extension of continuation, you must notify the employer in
writing within 60 calendar days after the later of:
a. the date of the second qualifying event (death, divorce, legal separation, loss of dependent child
status); or
b. the date on which the covered dependents} would lose coverage as a result of the second qualifying
event.
Note: This extension is only available to a covered spouse and covered dependent children. This
extension is not available when a subscriber becomes enrolled in Medicare.
2. You must submit your written notice of a second qualifying event within the 60 day timeframe, as
previously described in Item #l, using the employer's approved second event notice form. (You may
obtain a copy of the approved form from the employer.) This notice must be submitted to the employer
in writing and must include the following:
a. the name of the employer;
b. the name and address of the subscriber or former subscriber;
c, the names and addresses of all applicable dependents currently on continuation;
d. the description and date of the initial qualifying event that started your continuation coverage;
e. the description and date of the second qualifying event;
f. documentation pertaining to the second qualifying event such as: a decree of divorce or legal
separation, death certificate, marriage certificate for child, student transcript showing last day of
student enrollment, etc.; and
g. the name, address, and telephone number of the individual submitting the notice. This individual can
be a subscriber, former subscriber, or his or her dependent(s); or a representative acting on behalf of
the employee or dependent(s}.
If you do not supply all notice requirements in writing as previously described, then you must follow the
employer's requirements and specified. time period for submitting, in writing, all required information
and supporting documentation.
PIC07-760-R1 (1/09) 65 (PCH10409} 15.100.2.V
3. To elect an extension of continuation coverage, you must notify the employer of the second qualifying
event in writing within the 60 calendar day timeframe, by following the notification procedure as
previously explained in Item #1 and #2, and submitting the employer's approved form; and
4. Yocz must pay continuation premiazm contributions:
a. The premium contribution to continue coverage is the combined employer plus subscriber rate
charged under the GMC, plus the employer may charge an additional 2% of that rate. For a member
receiving an additional 11 months of coverage after the initial 18 months due to a continuation
extension for Social Security disability, the premium contribution for those additional months maybe
increased to 150% of the employer's total cost of coverage. The election form will set forth yozzr
continuation premium contribution rates.
b. The first premium contribution must be paid by check within 45 calendar days after electing to
continue the coverage or such longer period as required by law. Thereafter, the member's monthly
payments are due and payable by check at the beginning of each month for which coverage is
continued.
c. The member must pay subsequent pz-emizzm contributions by check on or before the required due
date, plus the 30-calendar day grace period required by law, and if authorized by PIG such longer
period allowed by the employer or as required by law.
Additional Notices You Must Provide: Other Coverages, Medicare Enrollment and Cessation of
Disability
You must also provide written notice of (1) your other group coverage that begins after continuation is elected
under the GMC; (2) yoczz- Medicare enrollment (Part A, Part B or both parts) that begins after continuation is
elected under the GMC; and (3) the member, whose disability resulted in a continuation extension due to
disability, being determined to be no longer disabled by the Social Security Administration.
Your written notice must be submitted using the employer's approved notification form within 30 calendar days
of the events requiring additional notices as previously described. The notification form can be obtained from the
employer and must be completed by you and timely submitted to the employer. In addition to providing all
required information requested on the employer's approved notification form, yozzr written notice must also
include the following:
If providing notification of other coverage that began after continuation was elected, the name of the member
who obtained other coverage, and the date that other coverage became effective.
If providing notification of Medicare enrollment, the name and address of the rneznber that became enrolled
in Medicare, and the date of the Medicare enrollment.
If providing notification of cessation of disability, the name and address of the formerly disabled member, the
date that the Social Security Administration determined that he or she was no longer disabled, and a copy of
the Social Security Administration's determination.
PIC07-760-R1 (1/09) 66 (PCH10409) 15.100.2.V
CONTINUATION CHART
If coverage under this GMC is lost Who is eligible to
because this ha ens... continue... Covera a ma be continued until...
The subscriber's leave of absence, early Subscriber, The earliest of the following occurs:
retirement, hours were reduced, layoff, covered spouse 1. 18 months after continuation began.
or his or her employment with the and covered 2. Coverage begins under another group
employer ended for reasons other than dependent health plan after continuation coverage is
gross misconduct. children elected under the GMC.
3. Coverage would otherwise end under the
GMC.
Death of the subscriber. Covered spouse The earliest of the following occurs:
and covered 1. Coverage begins under another group
Member must provide notice of such dependent health plan after continuation coverage is
event to the employer in accordance children elected under the GMC.
with the employer's notice procedures 2. Coverage would otherwise end under the
previously described for such events. GMC.
Divorce or legal separation from the Covered former The earliest of the following occurs:
subscriber. spouse and 1. Coverage begins under another group
covered health plan after continuation coverage is
Member must provide notice of such. dependent elected under the GMC.
event to the employer in accordance children 2. Coverage would otherwise end under the
with the employer's notice procedures GMC.
previously described for such events.
Enrollment of the subscriber- in Covered spouse The earliest of the following occurs:
Medicare. and covered 1. 36 months after continuation coverage
dependent began.
Member must provide notice of such children 2. Coverage begins under another group
event to the employer in accordance health plan.
with the employer's notice procedures 3. Coverage would otherwise end under the
previously described for such events. GMC.
Enrollment of the subscriber in Covered spouse The earliest of the following occurs:
Medicare within 18 months before the and covered 1. 36 months after enrollment of subscriber
subscriber's hours were reduced or dependent in Medicare.
termination of employment for reasons children 2. Coverage begins under another group
other than gross misconduct. health plan after continuation coverage is
elected under the GMC.
Member must provide notice of such 3. Enrollment, after continuation coverage is
event to the employer in accordance elected under the GMC, of the applicable
with the employer's notice procedures member in either Part A or Part B or both
previously described for such events. Parts of Medicare.
4. Coverage would otherwise end under the
GMC.
Loss of eligibility by a covered Covered The earliest of the following occurs:
dependent child. dependent child 1. 36 months after continuation coverage
began.
Member- must provide notice of such 2. Coverage begins under another group
event to the employer in accordance health. plan after continuation coverage is
with the employer's notice procedures elected under the GMC.
previously described for such events. 3. Coverage would otherwise end under the
GMC.
PIC07-760-R1 (1/09} 67 (PCH10409} 15.100.2.V
The employer files a voluntary or
involuntary petition for protection under
the bankruptcy laws found in Title XI of
the United States Code. Covered retiree,
covered spouse
and covered
dependent
children I. Lifetime continuation for covered
retiree.
2. 36 months after death of covered retiree
for covered spouse and covered
dependent children.
3. Coverage begins under another group
health plan after continuation coverage is
elected under the GMC.
4. Coverage would otherwise end under the
GMC.
The szzbscr~ber is absent from work due Subscriber, Coverage would otherwise end under this
to total disability that occurred while the covered spouse GMC.
subscriber is employed by the employer and covered
and covered under this GMC. dependent
children
The subscriber, covered spouse or Subscriber, The earliest of the following occurs:
covered dependent child is determined covered spouse 1. 29 months after continuation began or
by the Social Security Administration to and covered until the first month that begins more
be totally disabled within the first 60 dependent than 30 calendar days after the date of
calendar days of continuation coverage children any final. determination that subscriber,
that resulted from the subscriber's leave covered spouse or covered dependent
of absence, early retirement, reduction in child is no longer disabled.
hours, layoff, or his or her termination of 2. Coverage begins under another group
employment with the employer for health plan after continuation coverage is
reasons other than gross misconduct. elected under the GMC.
3. Enrollment, after continuation coverage
Notice of such disability must be is elected under the GMC, of the
provided. by the member- to the employer applicable member in either Part A or
in accordance with the employer's notice Part B or both Farts of Medicare.
procedures previously described for 4. Coverage would otherwise end under the
continuation extensions due to Social GMC.
Securi disability.
Special Enrollment Periods
If you are a subscriber, covered spouse or covered dependent who is enrolled in continuation coverage under
this COC due to a qualifying event (and not due to another enrollment event such as a special or annual
enrollment), the Special Enrollment Period provisions of this COC as referenced in the section which
describes eligibility and enrollment will apply to you during the continuation period required by federal law
as such provisions would apply to an active eligible employee. Eligible dependents that are newborn
children or newly adopted children (as described in the eligibility and enrollment section} that are acquired
by a subscriber- during such subscriber's continuation period required by federal law, and are enrolled
through special enrollment, are entitled to continue coverage for the maximum continuation period required
by law.
If the continuation period required by federal law has been exhausted, and you are enrolled for additional
continuation coverage pursuant to state law or the eligibility provisions of this COC, yozz may be entitled to
the special enrollment rights upon acquisition of a new dependent through marriage, birth, adoption,
placement for adoption, or legal guardianship, as referenced in the section entitled Special Enrollment
Period for New Dependents Only.
PICO'7-760-R1 (1/09} 68 (PCH10409) 15.100.2.V
Special Rule for Pre-Existing Conditions
A szzbscriber, his or her covered spouse or covered dependent child who is enrolled in continuation coverage
under this GMC and then obtains other group coverage that excludes benefits for pre-existing conditions
applicable to such member, may choose to remain on continuation coverage under the GMC for the
remainder of his or her continuation period for coverage of apre-existing condition.
Special Rule for Persons Qualifying for Federal Trade Act Adjustments
The Federal Trade Act of 2002 gives special continuation rights to subscribes who terminate employment
or experience a reduction of hours, and who qualify fora "trade readjustment allowance" or "alternative
trade adjustment assistance" under Federal Trade Act laws. These employees are entitled to a second
opportunity to elect continuation coverage for themselves and certain family members (if they did not
already elect continuation coverage), but only within a limited period of 60 calendar days (or less) and only
during the six months immediately after their group health plan coverage ended.
If yozr qualify or may qualify for trade adjustment assistance under the Trade Act, contact the employer for
additional information. Yozz must contact the employer promptly after qualifying for trade adjustment
assistance or you will lose yozzr special continuation rights.
All notices, elections, and information required to be furnished or submitted by a member, covered
spouse or covered dependent children for purposes of continuation coverage must be submitted in
writing to the employer at the employer's address. You must follow the employer's requirements for
submitting written notices.
Public Sector Eligible Retirees
A covered eligible retired employee of certain public or governmental entities of the State of Minnesota and
covered dependents of such retiree, who are enrolled for dependent coverage as of the date the retiree
terminated employment, may be eligible to continue such coverage upon retirement pursuant to Minnesota
Statute Section 471.6E If a covered eligible retired employee qualifies under this law, he or she may be
required to pay the entire contribution for continued coverage and will be required to notify his or her
employer, within the deadline required by law, of intent to continue coverage. An eligible retired employee
who does nct elect to continue coverage dces nct have a right to re-enter or re-enroll for coverage at a later
date.
PIC07-760-R1 (1/09} 69 (PCH10409) 15.100.2.V
Your Right to Convert Coverage
Your- employer must notify you of your right to convert coverage. You are eligible to convert to an individual
conversion plan without proof of good health or waiting periods on the later of the following dates:
1. Your coverage under the GMC ends, or;
2. Upon exhaustion of your eligibility for continuation coverage under the GMC.
However, you will not be eligible for a conversion contract if any of the following are true:
1. Yozc are covered under a plan providing similar benefits such as another qualified plan prescribed by Section
62E.06 of the Minnesota Statutes, group health plan, state plan under title XIX of the Social Security Act;
2. You are eligible for Medicare;
3. Coverage terminated due to the member's failure to pay, when due, any required contribution toward
premucm;
4. Coverage terminated due to fraud;
5. You are or could be covered under a continuation of coverage provision under the GMC.
If you are eligible for and timely apply for a conversion contract as described below, then coverage for you and
all yoacr enrolled dependents will be effective on the first calendar day following termination of coverage under
the GMC. There will be no gap in coverage.
What you must do:
1. Contact Customer Service for conversion information;
2. Select a qualified conversion plan;
3. Submit a written application and premiccm payment for a conversion contract within 31 calendar days after
your coverage under the GMC ends.
P1C07-760-R1 (1/09) 70 (PCH10409) 15.100.2.V
Subrogation and Reimbursement
PIC's Subrogation Rights
For the purposes of this section, "subrogation" means PIC's right to allocate risk in accord with Minnesota
Statutes 62A.095 and 62A.096 so that your medical claims are ultimately paid by the party that should rightfully
bear the burden of the loss.
PIC is subrogated to any and all claims and causes of action that may arise against any person, corporation,
and/or other entity and any insurance coverage, no-fault, uninsured motorist, underinsured motorist, medical
payment provision, liability insurance policies, homeowners liability insurance coverage, medical malpractice
insurance coverage, patient compensation fund, and any applicable umbrella insurance coverage or other
insurance or funds.
2. PIC's subrogation interest is the reasonable cash value of any benefits received by you. PIC's subrogation
and/or reimbursement interest applies only after you have received a full recovery for your sickness or injury
from another source of compensation for your sickness or injury.
3. PIC's right to recover its subrogation interest is subject to a pro rata subtraction for actual monies paid for
costs and reasonable attorney fees which shall not exceed the prevailing cost in the same geographical local
where the loss arises, and costs you pay in obtaining your recovery.
4. If the health carrier and covered person cannot reach agreement on allocation, the health carrier and covered
person shall submit the matter to binding arbitration.
5. Nothing in this section shall limit PIC's right to recovery from another source which may otherwise exist at
law.
Notice Requirement
Yozc must provide timely written notice to PIC of the pending claim, if yozc make a claim against a third party for
damages that include repayment for medical and medically related expenses incurred for your benefit. Not
withstanding any other law to the contrary, the statute of limitations applicable to PIC's rights for reimbursement
or subrogation does not commence to run until the notice has been given.
PIC07-760-R1 (1/09) 71 (PCH10409) 15.100.2.V
Coordination of Benefits
As a member, you agree to permit PIC to coordinate obligations under this COC with payments under any other
health benefit plans as specified below, which cover yazz as an employee or dependent. You also agree to
provide any information. or submit any claims to other health benefit plans necessary for this purpose. Yozr
agree to authorize billing to other health plans for purposes of coordination of benefits.
Unless applicable law prevents disclosure of the information without the consent of the member or the
member's representative, each member claiming benefits under PIC must provide any facts needed to pay the
claim. If the information cannot be disclosed without consent, PIC will not pay benefits until the information is
given.
A. APPLICATION: This Coordination of Benefits provision applies when yozz have health care coverage under
more than one plan. "Plan" is defined below.
B. DEFINITIONS. These definitions only apply to the Coordination of Benefits provision:
Allowable Expenses Means a health care service or expense, including deductibles or copayments, that is
covered at least in part by any of the plans covering the person. When a plan
provides benefits in the form of services, (for example an HMO) the reasonable
cash value of each service will be considered an allowable expense and a benefit
paid. An expense or service that is not covered by any of the plans is not an
allowable expense.
Claim Determination Means a calendar year. However, it does not include any part of a year during
Period which a person has no coverage under this plan, or before the date this
Coordination of Benefit provision or a similar provision takes effect.
Closed Panel Plan Means a plan that provides health benefits to persons primarily in the form of
services through a panel of providers that have contracted with or are employed
by the plan, and that limits or excludes benefits or services provided by other
providers, except in cases of emergency or referral by a panel member.
Custodial Parent Means a parent awarded custody by a court decree. In the absence of a court
decree, it is the parent with whom the child resides more than half of the
calendar year without regard to any temporary visitation.
Dependent Means the spouse or dependent child of an employee.
Plan Means any of the following that provides benefits or services for medical or dental
care or treatment. However, if separate policies are used to provide coordinated
coverage for members of a group, the separate policies are considered parts of the
same plan and there is no Coordination of Benefits among those policies.
a. group, blanket, franchise, closed panel ar other fornls of group or group type
coverage (insured or uninsured);
b. hospital indemnity benefits in excess of $200 per day;
c. medical care components of group long-term care policies, such as skilled
care;
d. alabor-management trustee plan or a union welfare plan;
e. an employer or multi-employer plan or employee benefit plan;
f Medicare or other governmental benefits, as permitted by law;
g, insurance required or provided by statute;
h. medical benefits under group or individual automobile policies;
i. individual or family insurance for hospital or medical treatment or expenses
j. closed panel or other individual coverage for hospital or medical treatment or
PIC07-760-R1 (1/09} 72 (PCH10409} 15.100.2.V
expenses.
Pian does not include any:
a. amounts of hospital indemnity insurance of $200 or less per day;
b. benefits for non-medical components of group long-term care policies;
c. school accident-type coverages;
d. Medicare supplement policies;
e. Medicaid policies and coverage under other governmental plans, unless
permitted by law.
Each contract for coverage listed above is a separate plan. If a plan has two parts
and Coordination of Benefits rules apply to one of the two, each of the parts is
treated as a separate plan. The benefits provided by a plan include those that
would have been provided if a claim had been duly made.
Primary Plan/ Means the order of benefit determination rules which determine whether this Plan
Secondary Plan is a "primary plan" or "secondary plan" when compared to the other plan covering
the person.
When this Plan is primary, its benefits are determined before those of any other plan and without considering any
other plan's benefits. When this Plan is secondary, its benefits are determined after those of another plan and may
be reduced because of the primary plan°s benefits.
C. ORDER OF BENEFIT DETERNIINATION RULES: The primary plan pays or provides its benefits as if the
secondary plan or plans did not exist. The order of benefit determination rules below determine which plan will
pay as the primary plan. The primary plan that pays first pays without regard to the possibility that another plan
may cover some expenses. A secondary plan pays after the primary plan and may reduce the benefits it pays so
that payments from all group plans do not exceed 100% of the total allowable expense.
A plan that does not contain a Coordination of Benefits provision that is consistent with this section is always
primary. Exception: Crroup coverage designed to supplement a part of a basic package of benefits may provide
that the supplementary coverage shall be excess to any other parts of the plan provided by the employer.
A plan may consider the benefits paid or provided by another plan in determining its benefits only when it is
secondary to that other plan.
PIC will not pay more than it would have paid had it been the primary plan. PIC determines its order of benefits
by using the first of the following that applies:
Group/Individual Coverage: The order of benefits when a person is covered by both an individual plan and
a group or group type plan is:
a. the group or group type plan covering the person is the primary plan; and
b. the individual plan is the secondary plan.
2. Nondependent/Dependent: The plan that covers the person other than as a dependent, for example as an
employee, subscribet•, or retiree, is the primary plan; and the plan that covers the person as a dependent is the
secondary plan.
Exception: If the person is a Medicare beneficiary and federal law makes Medicare:
a. secondary to the plan covering the person as a dependent; and
b. primary to the plan covering the person as a nondependent (e.g., a retired employee); then the order is
reversed, so the plan covering that person as a nondependent is secondary and the other plan is primary.
PIC07-760-R1 (1/09} 73 (PCH10409) 15.100.2.V
Child Covered Under More Than One Plan: The order of benefits when a child is covered by more than
one plan is:
a. The primary plan is the plan of the parent whose birthday is earlier in the year if:
• The parents are married;
• The parents are not separated (whether or not they ever have been married); or
• A court decree awards joint custody without specifying that one party has the responsibility to provide
health care coverage.
If both parents have the same birthday, the plan that covered either of the parents for a longer time is
primary.
b. If the specific terms of a court decree state that one of the parents is responsible for the child's health care
expenses or health care coverage and the plan of that parent has actual knowledge of those terms; then that
plan is primary. This rule applies to claim determination periods or plan years commencing after the plan
is given notice of the court decree.
c. If the parents are not married, or are separated (whether or not they ever have been married) or are
divorced, the order of benefits is:
• The plan of the custodial parent;
• The plan of the spouse of the custodial parent;
• The plan of the non-custodial parent; and then
• The plan. of the spouse of the non-custodial parent.
4. Active/Inactive Employee: The plan that covers a person as an employee who is neither laid. off nor retired
(or as that employee's dependent) is primary to a plan that covers the person as a laid off or retired employee
(or as that employee's dependent). If the other plan does not have this rule, and if, as a result, the plans do not
agree on the order of benefits; then this rule is ignored. This rule does not apply if the rule under paragraph 2
can determine the order of benefits. For example, coverage provided to a person as a retired worker and as a
dependent of an actively working spouse will be determined under the rule labeled 2.
Continuation Coverage: If a person whose coverage is provided under a right of continuation provided by
the federal or state law is also covered under another plan, then:
a. the plan covering the person as an employee, member, szbscriber, or retiree (or as a dependent of an
employee, member, subscriber, or retiree) is the primary plan; and
b. the continuation coverage is the secondary plan.
If the other pian does not have this rule; and if, as a result, the pians do not agree on the order of benefits then
this rule is ignored. This rule does not apply if the rule under paragraph 2 can determine the order of benefits.
6. Longer/Shorter Length of Coverage: The plan that covered the person as an employee, dependent or retiree
for a longer time is primary.
Note: PIC will not pay more than it would have paid had it been primary.
D. THE EFFECT ON THE BENEFITS OF THIS PLAN: When PIC is secondary, it may reduce its benefits, so
that the total benefits paid or provided by all plans during a claim determination period are not more than 100% of
total allowable expenses. Savings equal the difference between:
1. the benefit payment that PIC would have paid had it been the primary plan; and
2. the benefit payments that PIC actually paid or provided.
E. RIGHT TO RECEIVE AND RELEASE INFORMATION: Certain facts about health care coverage and
services are needed to apply Coordination of Benefit rules and to determine benefits payable under PIC and other
plans. PIC may get the facts it needs from or give them to any other organization or persons for the purpose of
applying these nlles and determining benefits payable under PIC and other plans covering the person claiming
benefits. PIC need not tell, or get the consent of, any person to do this. Each person claiming benefits under PIC
PIC07-760-R1 (1/09) 74 (PCHI0409) IS.I00.2.V
must give PIC any facts it needs to apply those rules and determine benefits payable. Release of information will
comply with state and federal laws.
F. FACILITY OF PAYMENT: A payment made under another plan may have included an amount that should have
been paid under PIC. If it does, PIC may pay that amount to the organization that made the payment. That
amount will then be treated as though it was a benefit paid under PIC. PIC will not pay that amount again. The
term "payment made" includes providing benefits in the form of services. In this case "payment made" means the
reasonable cash value of the benefits provided in the form. of services.
G. RIGHT OF RECOVERY: If PIC paid more than it should have paid, it may recover the excess from one or
more of the following:
1. the persons PIC has paid or for whom it has paid; or
2. any other person or organization that may be responsible for the benefits or services provided under PIC to the
member.
The "amount of payments made" includes the reasonable cash value of any benefits provided in the form of
services.
H. COORDINATING WITH MEDICARE: This section describes the method of payment if Medicare pays as
the primary plan.
If a provider has accepted assignment of Medicare, PIC determines allowable expenses based upon the amount
allowed by Medicare. PIC's allowable expenses are the lesser of the PIC Non-Participating Provider
Reinzbu~°sement Valve or the Medicare allowable amount. PIC pays the difference between what Medicare pays
and PIC's allowable expenses.
When Medicare would be the primary plan, but the member who is eligible for Medicare has not enrolled with
Medicare, then PIC will pay as the primary plan.
RerQal Failure. If you begin to have services related to renal failure, we request that you sign up for Medicare.
PIC07-760-R1 (l/09) 75 (PCH10409) 15.100.2.V
How to Submit a Bill if You Receive One for Covered Services
Bills from Participating Providers
When you present your identification card at the time of requesting services from participating providers,
paperwork and submission of post-service claims relating to services will be handled for you by your
participating prrovider. You may be asked by your provider to sign a form allowing your provider to submit
claims on your behalf. If you receive an invoice or bill from your provider for services, simply return the bill or
invoice to your provider, noting your enrollment with PIC. Your provider will then submit the post-service claim
with PIC in accordance with the terms of its participation agreement Your post-service claim will be processed
for payment according to PIC guidelines. PIC must receive post-service claims within 15 months after the date
services were incurred, except in the absence of your legal capacity. If the GMC is terminated, the deadline for
the receipt of post-service claims is 180 calendar days. Post-service claims received after the deadline will be
denied.
Bills from Non-Participating Providers
Claim Submission. You must submit an itemized bill for post service claims to PIC along with written proof that
documents the date and type of service, a specific medical diagnosis and treatment, service or procedure code,
and provider name and charges. PIC must receive post-service claims within 15 months after the date services
were inczrred, except in the absence of your legal capacity. If the GMC is terminated, the deadline for the receipt
ofpost-service claims is 180 calendar days. Post-service claims received after the deadline will be denied.
Payment of Post-Service Claims. Post-service claims for benefits will be paid promptly upon receipt of written
proof of loss. Benefits which are payable periodically during a period of continuing loss will be paid on a
periodic basis. All or any portion of any benefits provided by PIC may be paid directly to the provider rendering
the services. Payment will be made according to PIC coverage guidelines.
Initial Benefit Determinations of Post-Service Claims
Post-ser~~ice claims are claims that are filed for payment of benefits by PIC after medical care has been received
and submitted in accordance with PIC's post-service claim filing procedures.
If yorzr attending provider submits apost-sen~ice claim on your behalf, the provider will be treated as your
authorized representative by PIC for purposes of such claim and associated appeals unless you specifically direct
otherwise to PIC within ten (10) business days from PIC's notification that an attending provider was acting as
your authorized representative. Your direction will apply to any remaining appeals.
If your post-service claim is denied, PIC will communicate such denial within 30 calendar days after receipt of a
post-service claim. If PIC does not have all information it needs to make an initial benefit determination, it may
request the necessary information from you or a third party. You or the third party will then have at least 45
calendar days to provide the requested information. Once the necessary information has been supplied, PIC will
notify you of its initial benefit determination within 15 calendar days. If you or a third party fail to provide the
necessary information, PIC will notify you of its initial benefit determination within 15 days after the expiration
of the 45 day period. PIC may, but is not required to, take into account information provided more than 45
calendar days after PIC's request in reconsidering a claim. In no event, however, will PIC consider information
received more than 365 calendar days after the date services were irzczzrred.
PIC07-760-R1 (1/09) 76 (PCH10409) 15.100.2.V
Complaint and Appeal Procedures
How to Submit a Complaint
Yocc may submit a complaint by telephone or in writing to PIC. The complaint should include the specific reason
for the complaint and any supporting documents.
1. Complaints About Administrative Operations and Matters Other than Claims. If the telephone
complaint is not resolved to your satisfaction within 10 calendar days after PIC receives your complaint, you
may submit your complaint in writing. Customer Service is available to provide any assistance necessary to
complete a written complaint form.
PIC will notify you that it received your written complaint within 14 calendar days, unless your complaint
already is resolved.
PIC will notify you of its decision within 30 calendar days from the date that it receives your complaint.
In certain circumstances, PIC may take up to 14 additional calendar days to notify you of its decision. In
such cases, PIC will notify you, in advance, of the reasons for the extension and the date when you may
expect the final decision.
2. Complaints About Claims. PIC will notify you of its decision in accordance with the following time
periods:
If you are requesting benefits that require pre-certification (a pre-service claim), your request will be handled
in accordance with the pre-certification section of this COC. If yoccr complaint is about a claim for benefits for
services received (a post-service claim) yoccr complaint must be submitted to PIC within 180 calendar days
following denial of the initial determination.. A decision on your post-service claim complaint will be made
within 30 calendar days from receipt of your complaint. This time period maybe extended if you agree.
How to Request an Appeal
If after the first level of pre-certification or complaint review, your request was denied, you or your authorized
representative may appeal PIC 's decision by telephone or in writing. PIC will review yoccr appeal and will notify
you of its decision in accordance with the following procedures and time periods. PIC must be provided all the
information needed to make a decision. If PIC does not have all information it needs and cannot obtain complete
information from you or your provider within the time periods set forth below for deciding an appeal, your
request will be denied.
Pre-Service Claims. If the appeal concerns acute services, you may request an expedited review. Within 72
hours of receipt of such request, a decision on your appeal will be made. PIC will notify your attending
provider by telephone of its determination as quickly as yoccr medical condition requires, but no later than 72
hours after FIC receives the appeal Written notification will be sent to yocc and your attending provider
within ane business day of the determination, or sooner if yoccr medical condition requires. If the appeal
concerns non-acute services, a decision on your appeal will be made within 30 calendar days. This time
period maybe extended for up to 15 calendar days if you agree. This appeal must be submitted to PIC within
180 calendar days following denial of the initial determination. When you appeal the initial determination for
medical reasons, PIC will arrange for review of the clinical material by a plcysician in the same or similar
specialty who did not make the initial determination.
2. Post-Sec-vice Claims. If your complaint is not resolved to your satisfaction or if you received services after
your request for pre-certification was denied or after you failed to seek pre-certification for services for which
pre-certification was required, yocc may contact PIC and request a written appeal or a hearing within 60
PIC07-760-R1 (1/09) 77 (PCH10409) 15.100.2.V
calendar days of the first level complaint denial. If you want a written appeal, yvu should submit relevant
documents to PIC. PIC's decision on any written appeal will be made within 30 calendar days after receiving
your appeal request. You will receive a written copy of the decision, including the key findings on which the
decision is based.
If you request a hearing instead of a written appeal, you will have an opportunity to submit testimony,
correspondence, explanations or other information as appropriate. PIC's decision from any appeal hearing
will be made within 30 calendar days after receiving your request. You will receive a written copy of the
decision, including the key findings on which the decision is based.
The above time periods maybe extended if you agree.
Upon request and free of charge, you have the right to reasonable access to and copies of all documents,
records, and other information relevant to yotcr claim for benefits.
If the determination of the appeal is to uphold an initial determination not to cover the service, the
determination maybe submitted for an external review. See the subsection entitled "How to File an External
Review."
How to File a Complaint with the Commissioner of Commerce
You or someone acting on your- behalf may file a request for review with the Commissioner of Commerce at any
time. You may reach the Minnesota Department of Commerce at 651.296.4026 within the Twin Cities
metropolitan area or call 1.800.657.3602 from outside the Twin Cities.
How to File an External Review
An external review organization is an independent entity under contract with the State of Minnesota to review
health plan complaints. You may request an external review at any time including, if yore or someone acting on
your behalf has exhausted the PIC internal complaint and appeal processes, you or your representative may file a
request for external review to the Commissioner of Commerce at the following address:
Minnesota Department of Commerce
Attenticn: Enforcement Division
85 East Seventh Place
Suite 500
St. Paul, MN 55101-21.98
The fee required for an external review is $25. However, the fee may be waived due to hardship. All disputes
and complaints may be submitted for an external review, except cases of fraudulent marketing and agent
misrepresentation. External review decisions are binding on PIC, but not binding on the rncrnber-.
PIC07-760-R1 (1/09) 78 (PCH10409) 15.100.2.V
No Guarantee of Employment or Overall Benefits
The adoption and maintenance of this COC does not guarantee or represent that coverage will continue indefinitely
with respect to any class of employees and shall not be deemed to be a contract of employment between the employer
and any subscriber. Nothing contained herein shall give any subscriber the right to be retained in the employ of the
employer or to interfere with the right of the employer to discharge any subscriber, at any time, nor shall it give the
employer the right to require any subscriber to remain in its employ or to interfere with the subscriber's right to
terminate his or her employment at any time not inconsistent with any applicable employment contract. Nothing in
this COC shall be construed to extend benefits for the lifetime of any member- or to extend benefits beyond the date
upon which they would otherwise end in accordance with the provisions of the GMC or any benefit description.
Definitions
Bm~iatric Surgery Surgery related to the treatment of obesity.
Biofeedback The technique of making unconscious or involuntary bodily processes (such as
heartbeat or brain waves) perceptible to the senses in order to manipulate them by
conscious mental control.
Calendar Year The 12-month period beginning January 1 and ending the following December 31 for
provisions based on a calendar year.
Certificate of coverage The document describing, among other things, the benefits offered under PIC and
(COC) your rights and obligations.
Coinsrtrarzce A fixed percentage of eligible charges that is paid by you and a separate fixed
percentage that is paid by PIC to the provider for covered services and supplies.
Coinsurance will be based on (1) the discounted charge negotiated between PIC and
participating providers; or (2) the PIC Non-Participating Provider Reimbursement
halve for norz participating providers.
Combination Drug A prescription drug in which two or more chemical entities are combined into one
commercially available dosage farm.
Compounded Drug Drugs which are customized drugs prepared by a pharmacist from scratch using raw
chemicals, powders and devices according to a physician's specifications to meet an
individual patient need.
Cor finernent An uninterrupted stay of 24 hours or more in a hospital, skilled nursing facility,
rehabilitation facility or licensed residential treatment facility.
Continuous Coverage The maintenance of continuous and uninterrupted creditable coverage by an eligible
employee or dependent. An eligible employee or dependent is considered to have
maintained continuous coverage if the individual enrolls in PIC and the break in
creditable coverage is less than 63 calendar days. See waiting period.
Copavment
Cosmetic
The fixed amount of eligible charges you must pay to the provider- for covered health
care services received. The copayrnent may not exceed the charge billed for the
covered health care service.
Services, medications and procedures that improve physical appearance but do not
correct or improve a physiological function, or are not medically necessary.
F1C07-760-R1 (1/09) 79 (PCH10409} 15.100.2.V
Covered Services Services or supplies that are provided by your licensed provider or clinic and covered
by PIC, subject to all of the terms, conditions, limitations and exclusions of PIC.
Creditable Coverage The health benefits or health coverage provided under any of the following:
1. coverage under group health plans (whether or not provided through an insurer);
2. Medicaid;
3. Medicare;
4. public health plans;
5. national health plans or programs; as well as
6. all other types of coverage set forth in the Health Insurance Portability and
Accountability Act of 1996 (HIPAA).
Custodial Care Services to assist in activities of daily living and personal care that do not seek to
cure or do not need to be provided or directed by a skilled medical professional, such
as assistance in walking, bathing and feeding.
Dav Tr°eatment Any professional or health care services at a hospital or licensed treatment facility
Services for the treatment of mental and substance related conditions.
Deductible The amount of eligible charges that each member must incur in a calendar year
before PIC will pay benefits.
Dentist A licensed doctor of dental surgery or dental medicine, lawfully performing dental
services in accordance with governmental licensing privileges and limitations.
Dental Specialist A dentist board eligible or certified in the areas of endodontics, oral surgery,
orthodontics, pedodontics, periodontics and prosthodontics.
Dependent The subscriber's eligible dependent as described in the "Eligibility" section.
Designated A participating provider or group or association of participating providers that has
Electronic/Online been designated by PIC or its designee to provide electronic/online evaluations and
Participating Provider management services for members with specific chronic diseases, as determined by
PIC or its designee. A list of such providers may be obtained by calling Customer
Service.
Desigrruted Transplant Any licensed hospital, health care provider, group or association of health care
Nettivork Provider providers that has entered into a contract with or through PIC to provide organ or
bone marrow transplant or stem cell support and all related services and aftercare for
a member.
EdrrcationaZ A service or supply:
1. whose primary purpose is to provide training in the activities of daily living,
instruction in scholastic skills such. as reading and writing; preparation for an
occupation; or treatment for learning disabilities; or
2. that is provided to promote development beyond any level of function previously
demonstrated, except in the case of a child with congenital, developmental or
medical conditions that have significantly delayed speech or motor development
as long as progress is being made towards functional goals set by the attending
physician.
PIC07-760-R1 (1/09) 80 (PCH10409} 15.100.2.V
Effective Date The date a member becomes eligible for health care services and completes all
enrollment requirements, subject to any required waiting period.
Eligible Charges A charge for health care services and supplies subject to all of the terms, conditions,
limitations and exclusions of PIC and for which PIC or the member will pay.
Emergency Emergencv services provided after the sudden onset or change of a medical condition
manifesting itself by acute symptoms of sufficient severity, including severe pain,
such that the absence of immediate medical attention could reasonably be expected
by a prudent layperson to result in:
1. placing the member's health in serious jeopardy;
2. serious impairment to bodily functions; or
3. serious dysfunction of any bodily organ or part.
Enrollment Date With respect to an individual, the date of enrollment in the health benefit plan or, if
earlier, the first day of the waiting period for enrollment under PIC.
Fee for-Ser~~ice Method of payment for provider services based on each visit or service rendered.
Fee Schedule The amount that the participating provider has contractually agreed to accept as
reimbursement in full for covered services and supplies. This amount may be less
than the provider's usual charge for the service.
Formulary A list, which may change from time to time, of preferential prescription drugs that is
used by PIC plans.
Full-time An employee working a minimum number of hours per week as specified by the
employer.
Group Master Contract The legal contract between the employer and PIC relating to the provisions of health
(GMC) care services.
Habilitative Thera~?v Therapy provided to develop initial functional levels of movement, strength, daily
activity or speech.
Homebound When you are unable to leave home without considerable effort due to a medical
condition. Lack of transportation does not constitute homebound status.
Hospital A facility that provides diagnostic, medical, therapeutic, and surgical services by or
under the direction of physicians and with 24-hour registered nursing services. The
hospital is not mainly a place for rest or custodial care, and is not a nursing home or
similar facility.
IrICUYYed
Injury
Services and supplies rendered to yocr. Such expenses shall be considered to have
been incurred at the time or date the service or supply was actually purchased or
provided.
Bodily damage other than sickness including all related conditions and recurrent
symptoms.
PIC07-760-R1 (1/09) 81 (PCH10409) 15.100.2.V
Investigative As determined by PIC, a drug, device or medical treatment or procedure is
investigative if reliable evidence does not permit conclusions concerning its safety,
effectiveness, or effect on health outcomes. PIC will consider the following
categories of reliable evidence, none of which shall be determinative by itself:
Whether there is a final approval from the appropriate government regulatory
agency, if required. This includes whether a drug or device can be lawfully
marketed for its proposed use by the United States Food and Drug
Administration (FDA); if the drug or device or medical treatment or procedure
the subject of ongoing Phase I, II, or III clinical trials; or if the drug, device or
medical treatment or procedure is under study or if further studies are needed to
determine its maximum tolerated dose, toxicity, safety or efficacy as compared to
standard means of treatment or diagnosis; and
2. Whether there are consensus opinions or recommendations in relevant scientific
and medical literature, peer-reviewed journals, or reports of clinical trial
committees and other technology assessment bodies. This includes consideration
of whether a drug is included in the American Hospital Formulary Service as
appropriate for its proposed use; and
3. Whether there are consensus opinions of national and local health care providers
in the applicable specialty as determined by a sampling of providers, including
whether there are protocols used by the treating facility or another facility, or
another facility studying the same drug, device, medical treatment or procedure.
In addition to the above, PIC must determine, on a case-by-case basis, that a drug,
device or medical treatment or procedure meets the following criteria:
1. Reliable evidence preliminarily suggests a high probability of improved
outcomes compared to standard treatment (e. g. significantly increased life
expectancy or significantly improved function); and
2. Reliable evidence suggests conclusively that beneficial effects outweigh any
harmful effects; and
3. If applicable, the FDA has indicated that approval is pending or likely for its
proposed use; and
4. Reliable evidence suggests the drug, device or treatment is medically appropriate
for the member.
When PIC determines whether a drug, device, or medical treatment is investigative,
reliable evidence will also mean published reports and articles in the authoritative
peer-reviewed medical and scientific literature; the written protocols or protocols
used by the treating facility or the protocol(s) of another facility studying
substantially the same drug, device or medical treatment or procedure, which
describes among its objectives, determinations of safety, or efficacy in comparison to
conventional alternatives, or toxicity or the written informed consent used by the
treating facility or by another facility studying substantially the same drug, device or
medical treatment or procedure.
Reliable evidence shall mean consensus opinions and recommendations reported in
the relevant medical and scientific literature, peer-reviewed journals, reports of
clinical trial committees, or technology assessment bodies, and professional
consensus options of local and national health care providers.
PIC07-760-R1 (1/09) 82 (PCH10409) 15.100.2.V
Late Enrollee An eligible employee or dependent who enrolls under PIC other than during:
1. the first period in which the individual is eligible to enroll under PIC; or
2. the special enrollment period.
Maintenance Care Care that is not habililtative or rehabilitative therapy and there is a lack of
documented significant progress in functional status over a reasonable period of time.
Medically Necessary/ Diagnostic testing, preventive health care services, and medical treatment consistent
Medical NecessittiJ with the diagnosis of a prescribed course of treatment for member's condition, which
PIC determines and will use its discretion on a case-by-case basis are consistent with
the medical standards and accepted practice parameters of the community and
considered necessary for member's condition; and
1. help to restore or maintain member's health; or
2. prevent deterioration of member's condition; or
3. prevent the reasonably likely onset of a health problem or detect a problem that
has no or minimal symptoms.
Member A subscriber or dependent who is enrolled under the GMC.
Non-Participating A licensed provider not under contract as a participating provider.
Provider
Non-Participating Coverage for services provided by licensed providers other than:
Provider Benefits 1. participating providers; or
2. the provider to which the participating provider has referred the member.
With non participating provider benefits, there is member financial responsibility of a
deductible, coinsurance, and any amount in excess of the PIC Non-Participating
Provider Reimbuz cement Value.
Out-of-Pocket Limit The maximum amount of money you must pay in copayments, coinsurance and
deductible before PIC pays your eligible charges at 100%. If you reach benefit or
overall maximums, you are responsible for amounts that exceed the out-of-pocket
limit.
Ovez•-the-Counter
(OTC) Drugs
Participating Provider
Participating Provider
Benefits
Those drugs that are available without a physician's prescription being legally
required.
A licensed clinic, physician, provider or facility that is directly contracted to
participate in the PlC provider network
Participating Providers may also be offered from other Preferred Provider
Organizations that have contracted with PIC.
Coverage for health care services provided through participating pzoviders.
PIC07-760-R1 (1/09) 83 (PCH10409) 15.100.2.V
Physical Handicap A condition caused by a physical injurv or congenital defect to one or more parts of
the member's body and thereafter the member is incapable to self-sustaining
employment and is dependent on the subscriber for a majority of financial support
and maintenance.
Physician A licensed Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of
Podiatry (D.P.M.), Doctor of Optometry (O.D.) or Doctor of Chiropractic (D.C.).
PIC PreferredOne Insurance Company.
PTC Non-Participating The amount that will be paid by PIC to a non participating provider for a service is a
Provider percentage of the lesser of the:
Reimbursement Value 1. non participating provider's charge;
2. amount based on prevailing reimbursement rates or marketplace charges, for
similar services and supplies, in the geographic area; or
3. amount agreed upon between PIC and the non participating provider.
If the amount billed by the non participating provider is greater than the PIC non-
participating provider reimbursement valare, you must pay the difference. This
amount is in addition to any copavment, deductible, or coinsurance amount you may
be responsible for according to the terms of this COC.
Post-Sen~ice Claim A claim related to services.
Premium The payment PIC requires to be paid by an individual or employer on behalf of or for
members for the provision of the covered health care services listed in this COC.
Prescription Drug A drug approved by the Federal Drug Administration for use only as prescribed by a
physician.
Pre-Service Claim A claim related to services that have not yet been received, and require a request for
pre-certification that is made by a member or his or her authorized representative in
accordance with the procedures described in this COC.
Preventive Health Health supervision including evaluation and follow-up, immunization, early disease
Care detection and educational services as ordered by a provider.
Provider A health care professional or facility licensed, certified or otherwise qualified under
state law to provide health care services.
Reconstrzretive Surgery to restore or correct:
1. a defective body part when such defect is incidental to or follows surgery
resulting from injury, sickness, or other diseases of the involved body part; or
2. a congenital disease or anomaly which has resulted in a fiznetional defect as
determined by a physician; or
3. a physical defect that directly adversely affects the physical health of a body part,
and the restoration or correction is determined by PIC to be medically necessary.
PIC07-760-R1 (1/09) 84 (PCH10409) 15.100.2.V
Reconstructive Surgery Coverage for members receiving covered services under PIC in connection with a
Following a mastectomy and who elects breast reconstruction in connection with such
Mastectomy mastectomy will include:
1. reconstruction of the breast on which the mastectomy has been performed;
2. surgery and reconstruction of the other breast to produce symmetrical
appearance;
3. prostheses; and
4. treatment of physical complications at all stages of mastectomy, including
lymphedemas.
Services and supplies will be determined in consultation with the attending physician
and patient. Such coverage will be subject to coinsurance and other plan provisions.
Rehabilitative Care Skilled restorative service that is rendered for the purpose of maintaining and
improving functional abilities, within a predictable period of time, (generally within a
period of six months) to meet a patient's maximum potential ability to perform
functional daily living activities. Not considered rehabilitative care are: skilled
nursing facility care; home health services; chiropractic services; speech, physical and
occupational therapy services for chronic medical conditions, or long-term
disabilities, where progress toward such functional ability maintenance and
improvement is not anticipated.
Risk Allowance A percentage of the reimbursement to a participating provider that is held back by
PIC. The amount withheld generally will be less than 20% of the fee schedule
amount.
Service Area The geographic area in which PIC is approved by the appropriate regulatory
authority to market its benefit plans.
Sickness Presence of a physical or mental illness or disease.
Skilled Care Nursing or rehabilitation services requiring the skills of technical or professional
medical personnel to provide care or assess your changing condition. Long term
dependence on respiratory support equipment does not in and of itself define a need
for skilled care.
Skilled Nursing A Medicare licensed bed or facility (including an extended care facility, hospital
Facility swing-bed and transitional care unit) that provides skilled care.
Specialist Providers other than those practicing in the areas of family practice, general practice,
internal medicine, OB/GYN or pediatrics.
Specialty Drugs Injectable and non-injectable prescription drugs having one or more of the following
key characteristics:
1. frequent dosing adjustments and intensive clinical monitoring are required to
decrease the potential for drug toxicity and to increase the probability for
beneficial outcomes;
2. intensive patient training and compliance assistance are required to facilitate
therapeutic goals;
3. there is limited or exclusive product availability and/or distribution; or
4. there is specialized product handling and/or administration requirements.
PIC07-760-RI (1/09} 8S (PCH10409} IS.100.2.V
Standing referrul A process by which a member may access covered services from a specialist for a
period of time. The referral is subject to conditions specified in this COC. The
referral must be designated in writing and in advance by PIC and is only valid for the
designated specialist (not to exceed one year).
Stepchild(ren) A natural or adopted child of the subscriber's lawful spouse.
Subscriber The person:
1. on whose behalf contribution is paid; and
2. whose employment is the basis for membership, according to the GMC; and
3. who is enrolled under the GMC.
Total Disability Disability (i.e., due to injury, sickness, or pregnancy) that requires regular care and
attendance of a physician, and in the opinion of the physician renders the employee
unable to perform the duties of his or her regular business or occupation during the
first two years of the disability, and after the first two years of the disability, renders
the employee unable to perform the duties of any business or occupation for which
he or she was reasonably fitted.
Transplant Services Transplantation (including retransplants} of the human organs or tissue, including all
related past-surgical trearinent and drugs and multiple transplants for related care.
Urgent Care Center A licensed health care facility whose primary purpose is to offer and provide
immediate, short-term medical care for minor immediate medical conditions not on a
regular or routine basis.
Waiting Period The period of time that an individual must wait before being eligible for coverage
under PIC. Awaiting period will not:
1. apply towards a period of creditable coverage; or
2. be used in determining a break in continuous and creditable coverage.
You/Your
Refers to member.
PIC07-760-R1 (1/09} 86 (PCH10409) 15.100.2.V
PreferredQne°
INSURANCE COMPANY
READ YOUR CERTIFICATE CAREFULLY
GI7"Y ®~' COLI,JMSIA HEIGI~-I7"S
~ a00.7.~i.2~RxF'.~T
PIC07-740-R1 (1/04)
(PCH10409) 1500.75.2RxF.V
This COC issued in 2009 by PIC qualifies as a qualified high deductible health plan within the
meaning of Internal Revenue Code ("Code") section 223. This COC may be used in connection with
a health savings account (within the meaning of Code section 223} established by an eligible »zember
or the employer on behalf of the eligible zzzez~zber. PIC shall not be required to establish, maintain
or contribute to a health savings account on behalf of an eligible r~zenrber or the employer.
PIC07-740-RI (1/09) (PCHI0409} 1500.75.2RxEV
Questions? Our Customer Services staff is available to answer questions about your
coverage Monday through Friday, 7:00 a.m. - 7:00 p.m. Central Standard
Time (CST)
When contacting us, please have your member identification card available. If
your questions involve a bill, we will need to know the date of service, type of
service, the name of the licensed provider, and the charges involved.
Customer Service Telephone Monday through Friday 7:00 a.m.-7:00 p.m. CST 763.847.4477
Number Toll free 1.800.997.1750
Hearing impaired individuals 763.847.4013
Website www.preferredone.com
Office Mailing Address Claims, review requests, pre-certification, written inquiries may be mailed to:
Customer Services Department
PreferredOne Insurance Company
P.O. Box 59212
Minneapolis, MN 55459-0212
PIC07-740-RI (1/09} (PCHI0409) 1500.75.2RxF.V
TABLE OF CONTENTS
Important Member Information .................................................................................................................................1
Member Bill of Rights .................................................................................................................................................. 2
Disclosure of Provider Payment Methods ................................................................................................................... 2
Member Information for Non-Participating Provider Benefits ................................................................................. 3
PreferredOne Insurance Company (PIC) ................................................................................................................. .. 4
Introduction to Your Coverage ............................................................................................................................. .. 4
Certificate of Coverage (COC) .............................................................................................................................. ..4
Services Received in a Participating Provider Facility from aNon-Participating Provider ................................ ..4
Standing Referrals to Non-Participating Specialists :........................................................................................... ..4
Continuity of Care ................................................................................................................................................. ..4
Medical Emerge~tcy ................................................................................................................................................ .. 5
Group Master Contract (GMC) ............................................................................................................................ .. 5
Your Identification Card ....................................................................................................................................... .. 5
Provider Directory ................................................................................................................................................ .. 5
Changes in Coverage ............................................................................................................................................. ..5
Conflict with Existing Law .................................................................................................................................... .. 6
Privacy ................................................................................................................................................................... .. 6
Clerical Error ........................................................................................................................................................ ..6
Assignment ............................................................................................................................................................ .. 6
Notice ..................................................................................................................................................................... .. 6
Time Limit on Certain Defenses ........................................................................................................................... .. 6
Fraud ..................................................................................................................................................................... .. 6
Medical Technology and Treatment Review ........................................................................................................ .. 7
Recommendations by Health Care Providers ....................................................................................................... ..7
Legal Actions ......................................................................................................................................................... .. 7
Eligibility and Enrollment ........................................................................................................................................ .. 8
Schedule of Payments ................................................................................................................................................ 11
Pre-certification Requirement and Prior Authorization .......................................................................................... 13
Description of Benefits .............................................................................................................................................. 17
Pre-existing Condition Limitation ............................................................................................................................ 51
Exclusions .................................................................................................................................................................. 51
Ending Your Coverage .............................................................................................................................................. 58
Leaves of Absence ..................................................................................................................................................... 59
Family and Medical Leave Act (FMLA) ............................................................................................................... 59
The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) ................................ 59
Continuation Coverage ............................................................................................................................................. 61
Your Right to Convert Coverage ............................................................................................................................... 70
Subrogation and Reimbursement ............................................................................................................................. 71
Coordination of Benefits ........................................................................................................................................... 72
How to Submit a Bill if You Receive One for Covered Services ................................................................................ 76
Initial Benefit Determinations of Post-Service Claims .............................................................................................. 76
Complaint and Appeal Procedures ........................................................................................................................... 77
No Guarantee of Employment or Overall Benefits ................................................................................................... 79
Definitions ................................................................................................................................................................. 79
PIC07-740-R1 (1/09} (PCH10409) 1500.75.2RxF.V
Important Member Information
Covered Services: Services will be covered by PreferredOne Insurance Company (PIC). Your Certificate of
Coverage (COC} defines what services are covered and describes procedures you must follow to obtain coverage.
Providers: Enrolling in PIC does not guarantee services by a particular provider on the list of providers. When a
provider is no longer participating with PIC, you must choose among remaining PIC participating providers.
Contact Customer Service for the most recent listing of PIC providers.
Emergency Services: Emergency services from non participating providers will be covered only if proper
procedures are followed. Your COC explains the procedures and benefits associated with emergency care from
participating and non participating providers.
Exclusions: Certain services or medical supplies are not covered. You should read your COC for detailed
explanation of all exclusions.
Continuation: You may convert to an individual contract or continue coverage under certain circumstances.
These continuation and conversion rights are explained in your COC.
Termination: Your coverage may be terminated by you or PIC only under certain conditions. Your COC
describes all reasons for termination of coverage.
Prescription Drugs and Medical Equipment: Enrolling in PIC does not guarantee that any particular
prescf•iption drug will be available nor that any particular piece of medical equipment will be available, even if
the drug or equipment is available at the start of the contract year.
Notice Applicable To Small Employer Groups: Minnesota law requires this disclosure. This plan of benefits
is expected to return on average 86 percent of your premium dollar in health care. The lowest percentage
permitted by state law for these benefits is 71 percent for smalP employer groups with fewer than 10 members,
and 75 percent for all other small employer groups.
According to state law, "small employer" is defined as an entity actively engaged in business, that employed an
average of no fewer than two nor more than 50 employees on business days during the preceding calendar year
and tha± employs at leas*. t~~~o employees on ±he first calendar day of the calendar year-.
Small employer plans are guaranteed renewable as long as the employer remains eligible for a small employer
plan.
PIC07-740-R1 (1/09) 1 (PCH10409) 1500.75.2RxF.V
Member Bill of Rights
The laws of the State of Minnesota grant members certain legal rights.
As a PIC member, you have the fallowing rights and responsibilities.
Members have the right to:
1. available and accessible services, including emergency services 24 hours a day, 7 days a week;
2. be informed of health problems and receive information regarding treatment alternatives and risks that are
sufficient to assure informed choice;
3. refuse treatment recommended by PIC or any provider;
4. privacy of medical or dental and financial records maintained by PIC and its participating providers, in
accordance with existing law;
file a complaint with PIC and the Commissioner of Commerce and to initiate a legal proceeding when
experiencing a problem with PIC or its participating providers. For information, contact the Minnesota
Department of Commerce at 651.296.4026 or 1.800.657.3602 and request information.
Disclosure of Provider Payment Methods
PIC contracts with participating providers to provide health care services to members. Participating providers
submit claims for eligible charges to PIC with their usual charge for the health care services. At PIC, the
member benefits are determined for the service and the claims are paid according to the applicable fee schedule.
This may be based on various methodologies, depending on the provider type and contract (i.e. per service, per
event, per day, by diagnostic related group or percent of charge). The deductible and coirrsrrrartce amounts are
based on the fee schedule amount.
A participating provider may contractually agree to a risk allowance. The money withheld for the risk allowance
may or may not be returned to the provider, depending on various circumstances, such as quality of care,
efficiency, cost effectiveness, member satisfaction, and/or, the financial situation of PIC. The method by which
the risk allowance is repaid may differ by provider type/specialty and therefore may vary among participating
providers. Members are not responsible for payment of any risk allowance. Factors such as the quality,
efficiency and cost effectiveness of care that participating providers deliver may also affect future contract terms
between PIC and participating pr°oviders.
Post-service claims submitted to PIC for non participating provider benefits are paid on a fee for-service basis.
PIC determines member benefits based on the PIC Non-Participating Provider Reimbursement Valrre.
PIC does not specifically reward practitioners or other individuals for issuing denials of coverage or service care.
Financial incentives for utilization management decision makers do not encourage decisions that result in
underutilization. Utilization management decision making is based only on appropriateness of care and service
and existence of coverage.
PIC07-740-RI (1/09) 2 (PCH10409) 1500.75.2RxF.V
Member Information for Non-Participating Provider Benefits
Covered Services: PIC covers services from non participating providers, at varying levels of coverage.
Deductibles and maximum lifetime benefit restrictions may apply. Your COC lists the services available and
describes the procedures for receiving coverage through non participating providers.
Pre-Certification: There may be a reduction in the level of benefits available to you if you do not obtain pre-
certification. See section entitled "Pre-certification" in your COC for specific information about the need to
obtain pre-certification.
PIC07-740-R1 (1/09) 3 (PCH10409) 1500.75.2RxF.V
PreferredOne Insurance Company (PICA
Introduction to Your Coverage
This COC describes your PIC health care coverage. PIC may not cover all of your health care expenses. Read
this COC carefully to determine which expenses are covered. Many provisions are interrelated; therefore,
reading just one or two provisions may not give you a complete understanding of the coverage described under
this CDC. Italicized words used in this COC have special meanings and are defined at the back of this COC.
Certificate of Coverage (COC)
This COC describes the coverage under the GMC. PIC issues the GMC to your employer. The GMC provides
for the medical coverage described in this COC. It covers the subscriber and the enrolled dependents, if any, as
named on the subscriber's enrollment application.
Services Received in a Participating Provider Facility from aNon-Participating Provider
For services obtained through a participating provider facility, such as ancillary services, services from an x-ray
technician, and services of an emergency room physician, the participating provider level of benefits applies as
shown in the "Benefit Schedule". You will be responsible for any charges that may exceed the PIC Non-
Participating Provider Reimbzzz cement Value.
Standing Referrals to Non-Participating Specialists:
Services provided by anon-participating specialist as a result of a standing referral will be covered as if a
participating specialist had provided the services, if a participating specialist is not reasonably available or
accessible to treat yozzr condition. You may apply for, and if appropriate, receive a standing referral for treatment
of one of the following conditions:
1. a chronic health condition;
2. alife-threatening mental or physical illness;
3. a second or third trimester pregnancy;
4. a degenerative disease or disability; or
5. any other condition or disease of sufficient seriousness and complexity to require treatment by a specialist.
Continuity of Care
If the contract between PIC and yozzr- participating physician, participating hospital or participating specialist
terminates, and the termination was not for cause, PIC may, upon your written request to PIC, authorize
continued services from the terminating provider for up to 120 days for any of the following conditions:
1. An acute condition;
2. Life-threatening mental or physical illness;
3. Second or third trimester pregnancy;
4. Physical or mental disability defined as an inability to engage in one or more major life activities, provided
that the disability has lasted or can be expected to last for at least one year; or can be expected to result in
death; or
5. Disabling or chronic condition that is in an acute phase.
If the physician certifies that the rnernber has an expected. lifetime of 180 calendar days or less, services from the
terminating provider will be covered until the member's death. Continuity of care may also apply to members
who require an interpreter or are receiving culturally appropriate services and. the provider network does not have
such a provider or specialist in its network.
PIC07-740-R1 (1/09) 4 (PCH10409) I500.75.2RxF.V
Continuity of care may also be extended to new members who meet the criteria described above and whose
employer changed health plans. However, in such situations, the non participating provider must agree to all of
the following:
1. Accept as payment in full the lesser of PIC's reimbursement rate for such services when provided by
participating providers or the non participating provider's regular fee for such services;
2. Follow PIC's pre-certification requirements; and
3. Provide PIC with all necessary medical information related to the care provided to the member.
Requests for continuity of care will be denied if medical records and other supporting documentation are not
submitted to PIC. PIC's written policy regarding continuity of care is available upon request. Contact Customer
Service for assistance in obtaining a copy of PIC's written policy.
Medical Emergency
Yotc should be prepared for the possibility of a medical emergency by knowing your participating provider's
procedures for "on call" and after regular office hours before the need arises. Determine the telephone number to
call, which hospital your participating provider uses, and other information that will help you act quickly and
correctly. Keep this information in an accessible location in case a medical emergency arises.
If the situation is a medical emergency and if traveling to a participating provider would delay emergency care
and thus endanger your health, you should go to the nearest medical facility. However, call PIC or your
participating provider within 48 hours or as soon as reasonably possible to discuss your medical condition and to
coordinate any follow-up care. You may authorize someone else to act on your behalf. If the situation is not a
medical emergency and if you seek care at a hospital emergency room, coverage for such services may be denied.
Group Master Contract (GMC)
PIC's Group Master Contract (GMC) combined with this COC, any amendments, the employer's application, the
individual applications of the subscribers and any other documents referenced in the GMC constitute the entire
contract between PIC and the employer. If you wish to see the GMC, contact your employer.
Vn~r TrlerZt-i~iratinr~ f aril
PIC issues an identification (ID) card containing coverage information. Please verify the information on the ID
card and notify PIC Customer Service if there are errors. If any ID card information is incorrect, post-service
claims or bills for your health care may be delayed or temporarily denied. Yotc will be asked to present your ID
card whenever votc receive services.
Provider Directory
You may request from PIC a provider directory that lists facilities and individuals who are participating
providers and are available to yotc. You may also find participating providers on the designated website.
Coverage may vary according to your provider selection.
The directory frequently changes and PIC does not guarantee that a listed provider is a participating provider.
You may want to verify that a provider you choose is a participating provider by calling Customer Service.
Changes in Coverage
PIC may at any time modify the GMC so long as such modification is consistent with applicable statute or
regulation and effective on a uniform basis among all individuals with the same type of coverage. Any change in
PIC07-740-R1 (1/09} 5 (PCHI0409) I500.75.2RxF.V
coverage is subject to PIC approval If a change in coverage is requested by your employer, it is effective on the
date mutually agreed to by your employer and PIC. Only an officer of PIC has the authority to make or change
the GMC. Any change in coverage required by statute or regulation becomes effective according to statute or
regulation.
Conflict with Existing Law
If any provision of this COC conflicts with any applicable statute or regulation, only that provision is hereby
amended to conform to the minimum requirements of the statute or regulation.
Privacy
PIC is subject to the Health Insurance Portability and Accountability Act ("HIPAA") Privacy Rule. In
accordance with the HIPAA Privacy Rule, PIC maintains, uses, or discloses your Protected Health Information
for things like claims processing, utilization review, quality assessment, case management, and otherwise as
necessary to administer your PIC health care coverage. You will receive a copy of PIC's Notice of Privacy
Practices (which summarizes PIC's HIPAA Privacy Rule obligations, your HIPAA Privacy Rule rights, and how
PIC may use or disclose health information protected. by the HIPAA Privacy Rule) with your enrollment packet.
You may also call Customer Service to receive one. Your failure to provide authorization or requested information
may result in a denial of your claim.
Clerical Error
You will not be deprived of nor receive coverage under the GMC because of a clerical error by PIC. You will not
be eligible for coverage beyond the scheduled termination of your coverage because of a failure to record the
termination.
Assignment
PIC will have the right to assign any and all of its rights and responsibilities under the GMC to any affiliate of
PIC or to any other appropriate organization or entity.
Notice
Written notice given by PIC to a representative of the employer will be deemed notice to all affected in the
administration of the GMC, unless applicable laws and regulations require PIC to give direct notice to affected
members.
Time Limit on Certain Defenses
If there is any misstatement in the written application the employer completes, PIC cannot use the misstatement
to cancel coverage that has been in effect for two years or more. This time limit does not apply to fraudulent
misstatements.
Fraud
Coverage may be terminated, if a member falsifies their application for coverage; submits fraudulent, altered or
duplicate billings, for their or others personal gain; or allows another party not covered under this COC to use
their coverage.
PIC07-740-R1 (1/09} 6 (PCH10409) 1500.75.2RxEV
Medical Technology and Treatment Review
Depending on the focus of the technology or treatment, one of three committees (Medical/Surgical Quality
Subcommittee, Behavioral Health Quality Subcommittee or the Pharmacy and Therapeutics Quality
Subcommittee) determines whether new and existing medical treatments and technology should be covered
benefits. These committees are made up of PIC staff and independent community physicians who represent a
variety of medical specialties. Their goal is to find the right balance between making improved treatments
available and guarding against unsafe or unproven approaches. These committees carefully examine the scientific
evidence and outcomes for each treatment/technology being considered. The decisions of the subcommittees are
overseen by the Quality Management Committee that is made up of independent community physicians, a
consumer representative and PIC staff.
Recommendations by Health Care Providers
In some cases, your provider may recommend or provide written authorization for services that are specifically
excluded by the COC. When these services are referred or recommended, a written authorization from your
provider does not override any specific COC exclusions.
Legal Actions
No legal action may be brought after the expiration of three years after the time written proof of loss is required
to be provided.
PIC07-740-R1 (1/09) 7 (PCH10409} 1500.75.2RxF.V
Eligibility and Enrollment
Eligibility
To be eligible to enroll for coverage, you must be a:
1. full-time employee; or
2. dependent.
If the employer also sponsors and maintains a health reimbursement arrangement (HRA) plan, the employer may
require that eligibility, enrollment and coverage under this COC be coordinated with and conditioned upon
concurrent eligibility and enrollment for benefits under the HRA plan sponsored by the employer.
If concurrent eligibility and enrollment is required, then the eligibility requirements under this COC are also
applicable to the HRA plan and you must be concurrently enrolled under both programs (i.e., this COC and the
HRA plan) to participate in either program. If yozr are considered aself-employed individual within the meaning
of the HRA plan document and thus, ineligible for the HRA plan, you may enroll solely in this COC program and
will not be required to concurrently enroll in the HRA plan.
An employee must enroll for coverage as the subscriber in order to enroll his or her dependents. A spouse who is
covered as an employee of the employer is not an eligible dependent. A child who is covered as an employee of
the employer is not an eligible dependent. If both parents are covered as employees, children maybe covered as
dependents of either parent, but not both.
Eligible dependents include a subscriber's:
1. lawful spouse as defined under Minnesota Statute 517.01;
2. unmarried children, from birth through age 24, including:
a. natural children;
b. legally adopted children or children placed with the subscriber for legal adoption (date of placement
means the assumption and retention by a person of a legal obligation for total or partial support of a child
in anticipation of adoption of the child. The child's placement with a person terminates upon the
tCrmiiiation Gf tiie legal vbiigation of total or partial Support.);
c. stepchildren of the subscriber who reside in the subscriber's home in an on-going parent/child
relationship that is intended to continue to adulthood;
d. grandchild(ren) who reside in your home after the initial discharge from the hospital due to birth and are
dependent on you for their financial support;
e. a child covered under a valid Qualified Medical Child Support Order, as defined under section 609 of the
Employee Retirement Income Security Act (ERISA) and its implementing regulations ("QMCSO"),
which is enforceable against a subscriber. Your employer is responsible for determining whether or not a
medical child support order is a valid QMCSO. Yozz may request a copy of the procedures used to make
such determinations from your employer.
f. a child for whom the subscriber has been appointed legal guardian by a court of law up to the age stated
in the court appointment if less than age 25.
3. Unmarried handicapped dependents, provided they are:
a. incapable of self-sustaining employment because of plrysical handicap, mental retardation, mental illness
or mental health disorder; and
b. dependent on the szbscriber for a majority of financial support and maintenance.
Proof of incapacity must be provided with the subscriber's application for coverage.
After this initial proof, PIC may request proof again two years later, and each year after.
PIC07-740-RI (1/09} 8 (PCH10409) I500.75.2RxF.V
The handicapped dependent shall be eligible for coverage as long as he or she continues to be handicapped
and dependent, unless coverage otherwise terminates under the GMC.
For purposes of this COC, a stepchild's address is considered to be the same as the subscriber's address when
attending an accredited school on a full-time basis, even though the stepchild may be located outside of the
service area.
Enrollment
Initial Enrollment. Eligible employees must make written application to enroll, and such application must be
received within 31 calendar days of the date the employee and any eligible dependent first becomes eligible
subject to the 12-month pre-existing condition limitation. The subscriber must make written application to enroll
a newly acquired dependent and that application and any required payments, if any, must be received within 31
calendar days of when the employee first acquires the dependent.
Late Enrollment. If the eligible employee and any eligible dependents do not enroll within 31 calendar days of
the date they first become eligible they may enroll at a later date subject to the 18-month pre-existing condition
limitation. Coverage will be effective the first of the month following the date PIC receives the application for
coverage.
There may be additional situations when employees are eligible to enroll themselves and any eligible dependents
after the first 31 calendar days of eligibility, in accordance with the Special Enrollment Period provisions listed
below.
Newborn Enrollment. Newborn infants, including the subscriber's newborn grandchildren and children newly
adopted or placed for adoption, who were born, adopted or placed for adoption while the subscriber is covered
under the COC, will be covered immediately from the date of birth, regardless of when notice is received by PIC.
If you submit an application more than 31 days after the date of birth, adoption or placement for adoption, the
newborn or adopted child will still be covered back to the date of birth, adoption or placement for adoption,
however, there may be claim delays until the application is received and any required premiums are paid in full.
PIC must receive required payments, if any, from the date of eligibility before benefits will be paid and the
subscriber must be covered under this COC in order for the newborn infant to be covered.
rviilitary i~uty. Empioyees returning from active duty with the military and their eligible dependents wili be
eligible for coverage as required by law. See USERRA section of this COC for specific requirements.
Special Enrollment Period for Employees and Dependents. If you are an eligible employee or an eligible
dependent of an eligible employee but not enrolled for coverage under PIC, you may enroll for coverage subject
to the 12-month pre-existing condition limitation under the terms of PIC if all of the following conditions are
met:
1. you were covered under a group health plan or had health insurance coverage at the time coverage was
previously offered to the employee or dependent;
2. the eligible employee stated in writing at the time of initial eligibility that coverage under a group health plan
or health insurance coverage was the reason for declining enrollment, but only if the Employer required a
statement at such time and provided the employee with notice of the requirement and the consequences of
such requirement at the time;
3. your coverage described in 1. above was:
a. terminated under a COBRA or state continuation provision and the coverage under such provision was
exhausted; or
b. terminated as a result of loss of eligibility for the coverage (including as a result of legal separation,
divorce, death, termination of employment, or reduction in the number of hours of employment} or
employer contributions toward such coverage were terminated; and
PIC07-740-R1 (1/09) 9 (PCH10409) 1500.75.2RxF.V
4. the eligible employee requested such enrollment not later than 31 calendar days after the date of exhaustion
of coverage described in 3.a. above, or termination of coverage or employer contributions described in 3.b.
above.
Special Enrollment Period for New Dependents Only. New dependents may enroll subject to the 12-month
pre-existing condition limitation if all the following conditions are met:
1. a group health plan makes coverage available to a dependent of an employee;
2. the employee is eligible for coverage under PIC;
3. they become dependents of the employee through marriage, birth, adoption, placement for adoption, or legal
guardianship. PIC shall provide a dependent special enrollment period during which the person may be
enrolled under PIC as a dependent of the employee, and in the case of birth, adoption, placement for adoption
or the legal guardianship of a child; the employee may enroll and the spouse of the employee maybe enrolled
as a dependent of the employee if such spouse is otherwise eligible for coverage. The eligible employee, if
not previously enrolled, is required to enroll when a dependent enrolls for coverage under PIC. In the case of
marriage: the employee, the spouse and any new dependents resulting from the marriage may be enrolled, if
otherwise eligible for coverage; and
4. application must be received within 31 calendar days of the date the employee first acquires the dependent
and coverage shall begin on the later o£
a. the date dependent coverage is made available under PIC; or
b. in the case of marriage, the date of the marriage as described in 3. above; or
c. in the case of a dependent's birth, the date of the birth as described in 3. above; or
d. in the case of a dependent's adoption, placement for adoption or legal guardianship, the date of the
adoption, placement for adoption or legal guardianship as described in 3. above.
The pre-existing condition limitation does not apply to newborns, adopted children, or children placed for
adoption.
NOTE: Other dependents (such as siblings of a newborn child) are not entitled to special enrollment rights upon
the birth or adoption of a child.
PIC07-740-R1 (1/09) 10 (PCH10409) 1500.75.2RxF.V
Schedule of Payments
You are required to pay any deductible and coinsurance amount. Benefits listed in this Schedule of
Payments are according to what PIC pays. Any amount of coinsurance you must pay to the provider is
based on 100% of eligible charges less the percentage covered by PIC. PIC payment begins after you have
satisfied any applicable deductibles and coinsurance.
Discounts negotiated by PIC with providers may affect your coinsurance amount. PIC may pay higher
benefits if you choose participating providers. In addition to any coinsurance and deductible, you also pay
all charges that exceed the PIC non participating provider reinzburseirrent value when you use anon-
participatingprovider and receive non participating provider benefits.
NOTE: Your coverage is either "subscriber only" or "family." Therefore, only one of the following sections
"Subscriber only" or "Family" applies to you. If yozz have questions about which section applies to you, contact
PIC.
If you have subscriber only coverage, on the date that the coverage for your eligible dependent(s) becomes
effective, you and your new dependent(s) become subject to the terms and conditions of family coverage.
This is a Minnesota qualified plan.
Subscriber only
Deductible: The subscriber must first satisfy the deductible amount by incurring charges equal to that amount
for eligible services in a calendar year before PIC will pay benefits. PIC will not pay benefits for the eligible
charges applied toward the deductible. Any amount in excess of the PIC non participating provider
reimbzrsement value will not apply towards satisfaction of the deductible. The subscriber will not be required
to satisfy the deductible before PIC will pay benefits for the following: prenatal and child health services
received from a participating provider.
Out-of-Pocket Liniit: After the subscriber has met the out-of-pocket limit per calendar year for coinsurance and
deductibles, PIC covers 100% of charges incurred for all other eligible charges. The subscriber pays any
amounts greater than the out-of-pocket limit if any benefit maximums or the lifetime benefit maximum are
exceeded. It is the subscriber's responsibility to pay any amounts greater than the out-of-pocket limits if any
benefit maximums are exceeded. Expenses the subscriber pays for any amount in excess of the PIC non-
participatingprovider reimbursement value will not apply towards satisfaction of the oui-oj pockei limit.
Subscriber only Participating Provider Network Non-Participating Providers
Deductible $1,500 per calendar year for eligible services of participatingprovlders
and non participating pr-ovidezs combined.
Out-of-Pocket Linzit $1,500 per calendar year for eligible services of participating providers.
$2,000 per calendar year for eligible services of participating and non-
participa6ngproviders combined.
Lifetime Benefit Maximum $3,000,000 for all eligible services from participating and non participating
providers combined that the subscriber receives under this COC or any future
PIC COC or contract that has a lifetime benefit maximum.
PIC07-740-R1 (1/09) 11 (PCH10409) 1500.75.2RxF.V
Family (Subscriber and Enrolled Dependents)
Family Deductible: The family must first satisfy the family deductible amount by incurring charges equal to
that amount for eligible services in a calendar year before PIC will pay benefits. PIC will not pay benefits for
the eligible charges applied toward the family deductible. Any amount in excess of the PIC non participating
provider reimbzcz^ement value will not apply towards satisfaction of the family deductible. Members of the
family will not be required to satisfy the family deductible before PIC will pay benefits for the following:
prenatal and child health services received from a participating provider.
Family Out-of-Pocket Limit: After the family has met the family out-of-pocket limit per calendar year in
eligible charges in a calendar year for coinsurance and family deductibles, PIC covers 100% of charges
incurred for all other eligible charges. The family must pay any amounts greater than the family out-of-pocket
limit if any benefit maximums or the lifetime benefit maximum are exceeded. Expenses a member pays for any
amount in excess of the PIC non participating provider reimbursement value and will not apply towards
satisfaction of the family out-of-pocket limit.
Family (Subscriber and Participating Provider Network Non-Participating Providers
Dependents)
Family Deductible $3,000 per calendar year for eligible services of participating providers
and non participating providers combined.
No member deductible limit within the family deductible amount.
Out-of-Pocket Limit $3,000 per calendar year for eligible services of participating providers.
$4,000 per calendar year for eligible services ofparticipating and non-
participatingproviders combined.
No member out-of-pocket limit within the family out-of-pocket limit amount.
Lifetime Benefit Maximum $3,000,000 for all eligible services from participating and nonparticipating
pYOVIderS combined that the member receives under this COC or any future
PIC COC or contract that has a lifetime benefit maximum.
Cost Sharing: The coinsurance percentage is calculated on the lesser of the provider's billed charge, or the fee
schedule that PIC has negotiated with the participating provider, or the PIC Non-Participating Provider
Reimbursement Valzce if PIC does not have an agreement with the provider. If you have a deductible, it is first
subtracted from the billed charge, fee schedule, or the PIC Non-Participating Provider Reimbursement Value,
whichever is applicable, then the coinsurance is applied to the remainder.
P1C07-740-R1 (1/09) 12 (PCH10409} 1500.75.2RxF.V
Pre-certification Requirement and Prior Authorization
For pre-certification or prior authorization PIC will guarantee payment of services provided the services
are covered benefits, the member is eligible for coverage, the member has provided the appropriate
information for those services and the member has met all other terms of the COC. PPease read the entire
COC to determine which other provisions may also affect benefits.
If your attending provider requests pre-certification or prior authorization on your behalf, the provider will
be treated as your authorized representative by PIC for purposes of such request and the submission of
your claim and associated appeals unless you specifically direct otherwise to PIC within ten (10) business
days from PIC's notification that an attending provider was acting as your authorized representative. Your
direction will apply to any remaining appeals.
Provision Participating Provider Benefit Non-Participati~zg Provider
Benefit
Pre-certification Penalty None PIC will reduce the amount of
eligible charges by the lesser of
$500 or 25%.
Pre-Certification Requirement: Pre-certification is a screening process that permits early identification of
situations where case management would be beneficial or medical management is required. When a participating
provider renders services, the provider will notify PIC for you. It is yozzr responsibility to ensure that PIC has
been notified when non participating providers are used. Yozz must call Customer Service during normal business
hours and before services are performed. Failure to obtain pre-certification may result in a reduction of non-
participatingprovider benefits.
Pre-certification is required for:
1. all inpatient admissions including skilled nursing facility, rehabilitation, hospital, etc.;
2. tf°ansplant services;
3. non-emergency ambulance and ambulance transfers; and
4. eating disorder treatment services provided by a participating designated eating disorder program.
If you have questions about pre-certification and when you are required to obtain it, please contact Customer
Service.
PIC07-740-R1 (1/09) 13 (PCH10409} 1500.75.2RxF.V
Prior Authorization: It is recommended that you or your provider have certain services authorized in advance to
determine medical necessit3r, by PIC or its designee. When a participating provider renders services, the provider
will prior authorize with PIC for you. It is your responsibility to prior authorize with PIC when non-
participating providers are used. If you have questions about prior authorization, please contact Customer
Service.
Prior authorization is recommended before the following medical services are received:
1. drugs or procedures that could be construed to be cosmetic;
2. home health care and hospice;
3. outpatient surgeries;
4. outpatient mental. health or substance related services;
5. physical therapy, occupational therapy, speech therapy and other outpatient therapies;
6. pain therapy program services;
7. reconstructive surgery;
8. durable medical equipment (DME) and prosthesis that may exceed $5,000; and
9. physician directed weight loss programs when medically necessary to treat obesity as determined by PIC.
Certain prescription drugs may require prior authorization before you can have your prescription filled at the
pharmacy. These prescription drugs may include, but are not limited to:
I0. prescription drugs, that are over:
a. $150 if a compound prescription;
b. $1,500 if a retail prescription; or
c. $2,500 if a mail order prescription;
11. weight loss medications;
12. oral antifungal drugs; and
13. specialty drugs.
PIC07-740-R1 (1/09} 14 (PCH10409) 1500.75.2RxF.V
When a participating provider renders services, the provider will notify PIC for yon. It is yoaer responsibility to
ensure that PIC has been notified when non participating providers are used. You or the provider must call
Customer Service during normal business hours and before services are performed. Failure to obtain pre-
certification may result in a reduction of benefits. For nonparticipating providers yore need to follow the
following procedures:
I. A phone call must be made to Customer Service no less than 15 calendar days prior to the date services are
scheduled. An expedited review is available if yoezr provider believes it is warranted.
2. You and your attending provider will be notified of PIC's initial determination within 15 calendar days
following a request, but in no event later than the date on which the services are scheduled to be rendered,
provided PIC has all the necessary information. If you or your attending provider have not submitted the
request in accordance with these procedures, PIC will notify you within 5 calendar days. If PIC does not
have all information it needs to make a determination, this time period may be extended for an additional 15
calendar days upon written notice to you. You will then have at least 45 calendar days to provide the
requested information. PIC will notify you of its benefit determination within 15 calendar days after the
earlier of PIC's receipt of the requested information or the end of the time period specified for you to provide
requested information. The initial determination maybe made to your attending provider by telephone.
3. If the initial determination is that the service will not be covered, your attending provider will be promptly
notified by telephone within 1 business day after the decision has been made.
4. Written notification will then be provided to you and your attending provider explaining the principal reason
or reasons for the determination. The notification will also include the process to appeal the decision.
Note: If your request is denied, you may appeal that decision. Refer to the section entitled "Complaint and
Appeal Procedures" for details on how to appeal.
Should the state of Minnesota and/or the Minneapolis/St. Paul seven-county metropolitan area be declared subject
to a pandemic alert, PIC may suspend pre-certification requirements, prior authorization requirements, and other
services as maybe determined by PIC.
How to Obtain an Expedited Review
Expedited Review: An expedited initial determination will be used if your attending provider believes it is
warranted. Acute care services, which can warrant expedited review, are medical care or treatment with respect
to which the application of the time periods for making non-expedited review determinations could seriously
jeopardize your life or health or yocer ability to regain maximum function, or in the opinion of your attending
provider would subject you to severe pain that cannot be adequately managed without the care or treatment that is
the subject of the pre-service claim.
An expedited initial determination will be provided to you and your attending provider as quickly as your medical
condition requires, but no later than 72 hours following the initial request. If PIC does not have all information it
needs to make a determination, yoee will be notified within 24 hours. Yoze will then have at least 48 hours to
provide the requested information. Yoee will be notified of the determination within 48 hours after the earlier of
PIC's receipt of the requested information or the end of the time period specified for you to provide the requested
information. If the initial determination would deny coverage, you or your attending provider will have the right
to submit an expedited appeal.
Nate: If yaeer request is denied, you may appeal that decision. Refer to the section entitled "Complaint and
Appeal Procedures" for details on how to appeal.
PIC07-740-R1 (1/09} IS (PCHI0409) I500.75.2RxF.V
Case Management
In cases where the member's condition is expected to be or is of a serious nature, PIC may arrange for review
and/or case management services from a professional who understands both medical procedures and the PIC
health care coverage.
Under certain conditions, PIC will consider as eligible charges other treatments for a member's catastrophic
sickness or injury that would not normally be covered. PIC and the member's physician will determine whether
such treatments will be covered. Such care or treatment provided will not be considered as setting any precedent
or creating any future liability, with respect to that member or any other member.
Other treatments must meet both of these tests:
1. determined in advance by PIC to be medically appropriate and cost effective in meeting the long term or
intensive care needs of a member in connection with a catastrophic sickness or injury.
2. charges incurred for these services or supplies would not otherwise be payable or would be payable at a
lesser percentage.
PIC07-740-R1 (1/09) 16 (PCH10409) 1500.75.2RxF.V
Description of Benefits
1. Also refer to the Schedule of Payments to help determine your benefit level.
2. See the Pre-certification requirements for certain services.
3. Some rules for obtaining benefits are listed in your provider directory.
4. Be sure to review the list of Exclusions. A provider recommendation or performance of a service, even
if it is the only service available for your particular condition, does not mean it is a covered service.
Benefits are not available for medically necessary services, unless such services are also covered services,
and received while you are covered under this CDC.
Benefit Participating Provider Benefit Non Participating Provider Beneftt
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any deductibles and
coinsacrance, you pay all charges that
exceed the PICNnn-Participating
Provider Reimbursement Value.
Ambulance Services
Ambulance services for an 100% of eligible charges after the Same as participating provider benefit
emergency. Note: Non- deductible. for emergency services.
emergency transportation
must bepre-certified in 75% of eligible charges after the
advance by PIC. deductible for non-emergency
transportation.
Ambulance services for an emergency. PIC covers ambulance service to the nearest hospital or medical center
where initial care can be rendered for a medical emergency. Air ambulance is covered only when the condition
is an acute medical emergency and is authorized by a physician.
PIC covers emergency ambulance (air or ground) transfer from a hospital not able to render the medically
necessacy care to the nearest hospital or medical center able to render the medically necessacy care only when
the condition is a crzt:cal med:Cal s?t~»at?on and is nrrie,-ad by a ply~i~ian and rpnrdinatPd with a r~cPiving
phrysician.
Ambulance services for anon-emergency. Non-emergency ambulance service, from hospital to hospital when
care for your condition is not available at the hospital where you were first admitted. Transfers from a Iospital
to other facilities for subsequent covered care or from home to physician offices or other facilities for outpatient
treatment procedures or tests are covered if medical supervision is required enroute and when pre-certified.
PIC's medical director or designee must pre-certify non-emergency services in advance.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Non-emergency ambulance service from hospital to hospital such as transfers and admission to hospitals
performed. only for convenience.
PIC07-740-R1 (1/09) 17 (PCH10409) 1500.75.2RxF.V
Benefit Participating Provider Benefit Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For non participating providers, in
addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
Provider Reimbursement Value.
Chiropractic Services 100% of eligible charges after the 75% of eligible charges after the
deductible. deductible,
Limited to a maximum of 15 visits per
calendar year.
Coverage includes chiropractic services to treat acute musculoskeletal conditions, by manual manipulation
therapy. Diagnostic services are limited to medically necessary radiology. Treatment is limited to conditions
related to the spine or joints.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Services primarily edzzcational in nature.
c. Vocational rehabilitation.
d. Self-care and self-help training (non-medical).
e. Health clubs and spas.
f. Recreational therapy.
g. Rehabilitation services that are not expected to make measurable or sustainable improvement within 2
weeks to 3 months, depending on the physical and mental capacities of the individual.
h. Chiropractic therapy other than for treatment of acute musculoskeletal conditions.
i. Acupuncture, except for treatment in a chronic pain program and rendered by a provider licensed or
trained in acupuncture.
j. Blood, urine or hair analysis related to chiropractic services.
k. ~Tltrasnund~ MRi, FM(~, wayefnrm and nuclear medicine rliagno~ti~ studies related to r_.hirnprarti~
services.
1. Manipulation under anesthesia related to chiropractic services.
m. Homeopathic/holistic services related to chiropractic services.
PIC07-740-R1 (1/09) 18 (PCH10409) 1500.75.2RxF.V
Benefit Participating Provider Benefit Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
Provider Reimbttr cement Value.
Dental Services
Accidental Dental 100% of eligible charges after the 75% of eligible charges after the
Services deductible. deductible.
Note: Treatment and repair must be completed within twelve months of the
date of the injury.
Medically Necessary 100% of eligible charges after the 75% of eligible charges after the
Outpatient Dental Services deductible. deductible.
and Hospitalization for
Dental Care
This provision does not provide coverage for preventive dental procedures. PIC considers dental procedures to
be services rendered by a dentist or dental specialist to treat the supporting soft tissue and bone structure.
PIC covers the following dental services:
1. Accidental Dental Services. PIC covers services to treat and restore damage done to sound, natural teeth as
a result of an accidental injury. Coverage is for external trauma to the face and mouth only, not for cracked
or broken teeth that result from biting or chewing. A sound, natural tooth is a tooth without pathology
(including supporting structures} rendering it incapable of continued function for at least one year. Primary
(baba} teeth mi~ct Kaye a life exp~tanr_.y of one year before less.
2. Medically Necessary Outpatient Dental Services: PIC covers outpatient dental services, limited to dental
services required for treatment of an underlying medical condition, e. g. removal of teeth to complete
radiation treatment for cancer of the jaw, cysts and lesions.
Medically Necessary Hospitalization for Dental Care: PIC covers hospitalization for dental care. Tliis is
limited to charges incurred by a member who: (1) is a child under age 5; (2) is severely disabled; or (3) has
a medical condition, and requires hospitalization or general anesthesia for dental treatment. Coverage is
limited to facility and anesthesia charges. Oral surgeon/dentist or dental specialist professional fees are not
covered for dental services provided. The following are examples, though not all-inclusive, of medical
conditions that may require hospitalization for dental services: severe asthma, severe airway obstruction or
hemophilia. Care must be directed by a physician or by a dentist or dental specialist.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Dental services covered under your dental plan.
c. Preventive dental procedures.
d. Dental services and all associated expenses, except as stated in this section.
e. Orthodontia and all associated expenses, except as required by law.
PIC07-740-R1 (1/09} 19 (PCH10409} 1500.75.2RxF.V
f. Surgical extraction of impacted wisdom teeth.
g. Services for cracked or broken teeth that result from biting, chewing, disease or decay.
h. Dental implants.
i. Prescriptions written by a dentist unless in connection with dental procedures covered by PIC.
j. Dental services related to periodontal disease.
PIC07-740-RI (1/09) 20 (PCH10409) I500.75.2RxF.V
Benefit Participating Provider Benefit Non Participating Provider Benefzt
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any deductibles and
coinsttrance, you pay all charges that
exceed the PICNnn-Participating
Provider Reimbursement Value.
Durable Medical Equipment ("DME") Services, Prosthetics, and Orthotics
Limited to a maximum PIC payment of
$1,500 per item and an aggregate
maximum PIC payment of $3,750 per
calendar year.
DME and Orthotics 100% of eligible charges after the 75% of eligible charges after the
deductible. deductible.
Prosthetics 100% of eligible charges after the 75% of eligible charges after the
deductible. deductible.
Hearing aids for members 100% of eligible charges after the 75% of eligible charges after the
under age 19 for hearing deductible. deductible.
loss that is not correctable
by other covered
procedures.
Coverage limited to once
every three years.
Wigs for hair loss 100% of eligible charges after the 75% of eligible charges after the
resulting from alopecia deductible. deductible.
areata are ltmaed to a
maximum PIC payment of
$350 per calendar year.
Special dietary treatment 100% of eligible charges after the 75% of eligible charges after the
for phenylketonuria deductible. deductible.
(PKU), and enteral
feedings
Diabetic supplies 100% of eligible charges after the 75% of eligible charges after the
deductible. deductible.
Coverage includes over-
the-counter diabetic
supplies, including glucose
monitors, syringes, blood
and urine test strips, and
other diabetic supplies as
medically necessary, if
you have gestational
diabetes, type I diabetes,
or type II diabetes.
PIC07-740-R1 (1/09) 21 (PCH10409) 1500.75.2RxF.V
PIC covers equipment and services ordered by a physician and provided by DME/prosthetic/orthotic vendors.
For verification of eligible equipment and supplies, call Customer Service. Contact lenses are eligible for
coverage only when prescribed as medically necessary for treatment of keratoconus. Members must pay for
lens replacement. Coverage is provided for: (1) amino-acid based formulas, electrolyte substances to treat
PKU, and other inborn errors of metabolism when medically necessary; (2) enteral feedings and other oral
nutritional and electrolyte substances only as required to sustain life.
Payment is limited to the most cost effective and medically necessary alternative. When the member purchases
a model that is more expensive than what is considered medically necessary by the PIC medical director or its
designee, the member will be responsible for the difference in purchase and maintenance cost. PIC's payment
for rental shall not exceed the purchase price, unless PIC has determined that the item is appropriate for rental
only. PIC reserves the right for its medical director or designee to determine if an item will be approved for
rental or purchase.
If a member purchases new equipment or supplies when the PIC medical director or designee determines that
repair costs of the member's current equipment or supplies would be more cost effective, then the member will
be responsible for the difference in cost.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Any durable medical equipment or supplies not listed as eligible on PIC's durable medical equipment list,
or as determined by PIC.
c. Disposable supplies or non-durable supplies and appliances, including those associated with equipment
determined not to be eligible for coverage.
d. Revision of durable medical equipment and prosthetics, except when made necessary by normal wear or
use.
e. Replacement or repair of items when: (1) damaged or destroyed by misuse, abuse or carelessness; (2) lost;
or (3) stolen.
f. Duplicate or similar items.
g. Items that are primarily educational in nature or for vocation, comfort, convenience or recreation.
h. Hearing aids, devices to improve hearing and related fittings (except as provided in the schedule above).
i. Communication aids or devices; equipment to create, replace or augment communication abilities
including, but not limited to, speech processors, receivers, communication board, or computer or electronic
assisted communication.
j. Household equipment, household fixtures and modifications to the structure of the home, escalators or
elevators, ramps, swimming pools, whirlpools, hot tubs and saunas, wiring, plumbing or charges for
installation of equipment, exercise cycles, air purifiers, central or unit air conditioners, water purifiers,
hypoallergenic pillows, mattresses or waterbeds.
k. Vehicle/car or van modifications including, but not limited to, hand brakes, hydraulic lifts and car carrier.
1. Over-the-counter orthotics and appliances.
m. Orthopedic shoes and custom molded foot orthotics, except for members with diabetes or peripheral
vascular disease.
n. Charges for sales tax, mailing and delivery.
o. Durable equipment necessary for the operation of equipment determined not to be eligible for coverage.
p. Durable medical equipment, orthotics and prosthetics that are necessary for activities beyond activities of
daily living (ADCs).
q. Wigs for conditions other than alopecia areata.
r. Enteral feedings and other oral nutritional and electrolyte substances, except amino-acid based formulas
when medically necessary and electrolyte substances to treat PKU or otherwise required to sustain life.
s. Upgrades to or replacement of any items that are considered eligible charges and covered under this
section, unless the item is no longer functional and is not repairable.
PIC07-740-R1 (1/09} 22 (PCHI0409) 1500.75.2RxF.V
Benefit Participating Provider Benefit Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
Provider Reimbursement Value.
Emergency Room Services 100% of eligible charges after the Same as the participating provider
deductible. benefit.
You should be prepared for the possibility of a medical emergency by knowing your participating provider's
procedures for "on call" and after regular office hours before the need arises. Determine the telephone number
to call, which hospital your participating provider uses, and other information that will help you act quickly and
correctly. Keep this information in an accessible location in case a medical emergency arises.
If you have an emergency situation that requires immediate treatment, call 911 or go to the nearest emergency
facility. If possible under the circumstances, you should telephone your physician or the participating clinic
where yon normally receive care. A physician will advise you how, when and where to obtain the appropriate
treatment.
Note: Non-emergency services received in an emergency room are not covered. If yozz choose to receive non-
emergency health services in an emergency room, you are solely responsible for the cost of these services. See
emergency under "Definitions".
Covered hospital services are subject to all of the benefit limitations set forth in this COC. To receive
maximum coverage under this part, you or your representative must notify PIC of admittance within 48 hours or
as soon as reasonably possible, if medically stable.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Non-emergency services received in an emergency room.
PIC07-740-R1 (1/09) 23 (PCH10409) I500.75.2RxF.V
Benefit Participating Provider Benefit Norz Participating Provider Benefit
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Nora-Participating
Provider Reimbursement Value.
Home Health Services Note: For non participating parovider
services, coverage of all home health
services is limited to a maximum PIC
payment of $3,750 per calendar year.
Note: Coverage for all home health services is limited to a maximum PIC
payment of $25,000 per member per calendar year.
Home health care as an 100% of eligible charges after the 75% of eligible charges after the
alternative to hospital deductible. deductible.
confinement or skilled
naarsing facility care.
One well-baby home visit 100% of eligible charges. 75% of eligible charges after the
by a registered nurse fora deductible.
mother and newborn child Not subject to the deductible.
if the inpatient hospital
stay for the birth of the
newborn was less than 48
hours following a vaginal
delivery or less than 96
hours following a
caesarean section. This
visit must occur within 4
days aftc"r t he date of
discharge from the
hospital.
PIC covers skilled nursing services, physical therapy, occupational therapy, speech therapy, respiratory therapy,
and other therapeutic services, laboratory services, equipment, supplies and drugs, as appropriate, and other
eligible home health services prescribed by a physician for the care and treatment of the member's sickness or
injury and rendered in the member's home.
You must be homebound for care to be received in your home, or PIC or its designee must deem the care
medically appropriate and/or that the care is more cost effective than care in a hospital or clinic.
A service shall not be considered a skilled nursing service merely because it is performed by, or under the direct
supervision of, a licensed, registered nurse. Where a service (such as a tracheotomy suctioning or ventilator
monitoring or like services) can be safely and effectively performed by anon-medical person, or self-
administered, without the direct supervision of a licensed, registered nurse, the service shall not be regarded as a
skilled nursing service, whether or not a skilled nurse actually provides the service. The unavailability of a
competent person to provide anon-skilled service shall not make it a skilled service when a skilled nurse
provides it. Only the skilled nursing component of so-called "blended" services (i. e., service, that include
skilled and non-skilled components) are covered under PIC.
PIC07-740-RI (1/09) 24 (PCH10409) 1500.75.2RxF.V
Exclusions:
a. Please see the section entitled "Exclusions."
b. Companion and home care services, unskilled nursing services, services provided by your family or a person
who shares your legal residence.
c. Services provided as a substitute for a primary caregiver in the home.
d. Services that can beperformed by anon-medical person or self-administered.
e. Home health aides.
f. Services provided in your home for convenience.
g. Services provided in your home due to lack of transportation.
h. Custodial care.
i. Services at any site other than your home.
j. Recreational therapy.
PIC07-740-R1 (1/09) 25 (PCHI0409) I500.75.2RxF.V
Benefit Participating Provider Benefit Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For non ~articipatirtg providers,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
Provider Reimbursement Value.
Hospice Care 100% of eligible charges after the 75% of eligible charges after the
deductible. deductible.
PIC covers hospice services for members who are terminally ill patients and accepted as home hospice program
participants. Members must meet the eligibility requirements of the program, and elect to receive services
through the home hospice program. The services will be provided in the patient's home, with inpatient care
available when medically necessary as described below. Members who elect to receive hospice services do so
in lieu of curative or restorative treatment for their terminal illness for the period they are enrolled in the home
hospice program.
1. Eligibility. In order to be eligible to be enrolled in the home hospice program, a member must:
a. be a terminally-ill patient with physician certification of 6 months or less to live; and
b. have chosen a palliative treatment focus (i. e., emphasizing comfort and supportive services rather than
restorative treatment or treatment attempting to cure the disease or condition).
A member may withdraw from the home hospice program at any time.
2. Covered Services. Hospice services include the following services, provided in accordance with an
approved hospice treatment plan:
a. part-time (defined as up to two hours of service per calendar day) care in the member's home by an
interdisciplinary hospice team (which may include a physician, nurse, social worker, and spiritual
counselor) and home health aide services, if prior authorized by PIC's medical director or its designee.
9_ ~ .. ~ 4 ~n ~ 4H f <) ~a e nr
u. one Or iiiOre pciiodS Gi ~GritiriuoilS care in ~l'ic iiZenibei" ~ hon'ie yr in a setting Lllat prcvades da, ,,T' .,
pain or symptom management, when medically necessary, as determined by PIC's medical director or
designee. Continuous care is defined as two to twelve hours of service per calendar day provided by a
registered nurse, licensed practical nurse, or home health aide, during a period of crisis in order to
maintain a terminally ill patient at home.
c. medically necessary inpatient services, when pre-certified by PIC's medical director or designee.
d. respite care for caregivers in the member's home or in an appropriate setting. Respite care should be
prior authorized by PIC's medical director or designee, to give the patient's primary caregivers (i.e.,
family members or friends) rest and/or relief when necessary in order to maintain a terminally ill patient
at home. The period of respite care is limited to 30 calendar days while enrolled in the hospice
program.
e. medically necessary medications for pain and symptom management, if prior authorized by PIC's
medical director or designee.
f. hospital beds and other durable medical equipment when medically necessary and should be prior
authorized by PIC's medical director or its designee.
EXCILiSIOI1S:
a_ Please see the section entitled "Exclusions."
b. Services provided by your family or a person who shares your legal residence.
c. Respite or rest care except as specifically described in this section.
PIC07-740-R1 (1/09) 26 (PCH10409) 1500.75.2RxF.V
Benefit Participating Provider Benefit Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For nonparticipatingproviders,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
Provider Reimbursement value.
Hospital Services Notify PIC upon admission to a non participating provider hospital as soon as medically
ossible.
Inpatient Hospital 100% of eligible charges after the 75% of eligible charges after the
Services deductible. dedcctible.
Note: Each member's Coverage for confinements in non-
confinement, including participating hospitals and skilled
that of a newborn child, is nccrsing facilities are limited to a
separate and distinct from combined maximum of 120 calendar
the confinement of any days per calendar year.
other member.
If you have subscriber
only coverage, on the date
of birth of a newborn, you
and your new dependent(s)
become subject to the
terms and conditions of
family coverage.
Outpatient Hospital 100% of eligible charges after the 75% of eligible charges after the
Services, Ambulatory Care deductible. deductible.
or Surgical Facility
Services
Rehabilitation Services in 100% of eligible charges after the 75% of eligible charges after the
a Day Hospital Program deductible. deductible.
Injectable drugs that are 100% of eligible charges after the 75% of eligible charges after the
not specialty dr-crgs, deductible. deductible.
excluding insulin.
Eating Disorder Treatment 100% of eligible charges after the 75% of eligible charges after the
Program deductible. deductible.
Services must be provided
by a PIC designated
participating eating
disorder treatment
programs and pre-certified
by the PIC medical
director or its designee.
PIC07-740-RI (I/09) 27 (PCH10409} I500.75.2RxF.V
Medically necessary genetic
testing determined by PIC to
be covered services, as
described below:
• Prenatal fetal or maternal
genetic testing (e.g.,
amniocentesis, chorionic
vinous sampling) done as
a component of care of
the member's pregnancy.
• Genetic testing services if
you are diagnosed with a
specific sickness by a
physician.
• Genetic testing services if
you are considered to be
high risk for a specific
sickness as determined by
a
100% of eligible charges after the 75% of eligible charges after the
deductible. deductible.
When anon-participating hospital is used, notify PIC of an admission to the non-participating hospital within
48 hours or as soon as reasonably possible after an emergency. For non-emergencies, a phone call must be
made to Customer Service no less than 15 calendar days prior to the date of services.
1. Inpatient Hospital Services. PIC covers services and supplies for the treatment of acute sickness or injury,
that requires the level of care only available in an acute care facility. Inpatient hospital services include, but
are not limited to:
a. room and board;
b. the use of operating rooms, intensive care facilities; newborn nursery facilities;
c. general nursing care, anesthesia, radiation therapy, physical, speech and occupational therapy,
prescription drugs or other medications administered during treatment, blood and blood plasma and
other diagnostic or treatment related hospital seances,
d. phvsiciarr and other professional medical and surgical services;
e. laboratory tests, pathology and radiology;
f. for aventilator-dependent patient, up to 120 hours of services, provided by a private-duty nurse or
personal care assistant, solely for the purpose of communication or interpretation for the patient; and
g. professional medical and surgical services provided by an assistant surgeon, which is defined as a
certified physician assistant (PA-C), nurse practitioner (NP), clinical nurse specialist (CNS), RN first
assistant, certified registered nurse first assistants (CRNFA), certified nurse midwives (CNM), or a
physician.
PIC covers asemi-private room, unless a phrysician recommends that a private room is medically necessary
and so orders. In the event a member chooses to receive care in a private room under circumstances in
which it is not medically necessary, PIC's payment toward the cost of the room shall be based on the
average semi-private room rate in that facility. PIC's medical director or designee will determine if a
private room meets medically necessary criteria.
2. Outpatient Hospital, Ambulatory Care or Surgical Facility Services. PIC covers the following services
and supplies, for diagnosis or treatment of sickness or injury on an outpatient basis:
a. use of operating rooms or other outpatient departments, rooms or facilities;
PIC07-740-R1 (1/09) 28 (PCH10409) 1500.75.2RxF.V
b. the following outpatient services: general nursing care, anesthesia, radiation therapy, prescription
drugs or other medications administered during treatment, blood and blood plasma, and other
diagnostic or treatment related outpatient services;
c. laboratory tests, pathology and radiology;
d. physician and other professional medical and surgical services rendered while an outpatient;
e. physician directed weight loss programs only when medically necessary to treat obesity as determined
by PIC; and
f. professional medical and surgical services provided by an assistant surgeon, which is defined as a
certified physician assistant (PA-C), nurse practitioner (NP), clinical nurse specialist (CNS), RN first
assistant, certified registered nurse first assistants (CRNFA), certified nurse midwives (CNM), or a
physician.
PIC also covers preventive health services performed in an outpatient hospital setting. These preventive
services will be covered as listed in the Office Visits and Urgent Care Center Visits section.
Rehabilitation Services in a Day Hospital Program. PIC covers rehabilitation services in a day hospital
program. Coverage is limited to services for rehabilitative care in connection with a sickness or injzzry.
Eating Disorder Treatment Program. PIC covers the treatment of eating disorders provided by a PIC
designated participating eating disorder treatment program.
Emergency Services at a Hospital that leads to an Inpatient Admission
You need to provide notice to PIC of an emergency hospital admission. However, if yozz are incapacitated in a
manner that prevents you from providing notice of the admission within 48 hours or as soon as reasonably
possible, or if you are a minor and your parent (or guardian) was not aware of your admission, then the 48 hour
time period begins when the incapacity is removed, or when yozzr parent (or guardian) is made aware of the
admission. You are considered incapacitated only when: (1) you are physically or mentally unable to provide
the required notice; and (2) you are unable to provide the notice through another person.
Statement of Rights Under the Newborns' and Mothers' Health Protection Act
Under state law, group health plans and health insurance issuers offering group health insurance coverage as
specified below may not restrict benefits for any hospital length of stay in connection with childbirth for the
mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a
delivery by cesarean section. However, the group health plan or health issuer may pay for a shorter stay if the
attending pz-avider (e.g., yozzr physician, nurse midwife, or physician assistant}, after consultation with and
mutual agreement by the mother, discharges the mother or newborn earlier.
Also, under federal law, group health plans and health issuers may not set the level of benefits or out-of-pocket
costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother
or newborn than any earlier portion of the stay.
In addition, a group health plan or health issuer may not, under federal law, require that a physician or other
health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours).
However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to
obtain pre-certification as described in the pre-certification provisions of the Schedule of Payments
PIC07-740-R1 (1/09) 29 (PCH10409) 1500.75.2RxF.V
Exclusions:
a. Please see the section entitled "Exclusions."
b. Travel, transportation, other than ambulance transportation, or living expenses.
c. Hospitalization, transportation, supplies, or medical services, including physicians' services furnished by
the United States Government or by an institution operated by the United States Government, unless
payment is required in accordance with applicable law.
d. Private room, except when medically necessary or if it is the only option available at the admitted facility.
e. Non-emergency ambulance service from hospital to hospital, such as transfers and admissions to hospitals
performed only for convenience.
f. Services and/or drugs to treat conditions that are cosmetic in nature.
g. Orthoptics and refractive surgery (i. e. lasik) for opthalmic conditions that are correctable by contacts or
glasses.
h. Services and/or surgery and associated expenses for gender reassignment unless determined to be medically
necessary. These services and associated expenses will be reviewed on a case by case basis and, if
determined to be medically necessary, services must be received at a PIC designated treatment center.
i. Genetic testing and associated services when done as a screening test to predict whether yorr may be a
carrier of a specific sickness when you are not diagnosed with the specific sickness by a physician or yorr are
not at high risk for the specific sickness as confirmed by a physician.
j. Homeopathic medicine; hypnosis; chelation therapy, except chelation therapy will be covered when
medically necessary for the treatment of heavy metal poisoning.
k. Acupuncture, except for treatment in a chronic pain program and rendered by a provider licensed or trained
in acupuncture.
1. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease.
m. Autopsies.
n. Bariatric surgeries.
o. Services for items for personal convenience, such as television rental.
p. Commercial weight loss programs.
q. Nutritional counseling, except when:
1. provided during a confinement;
2. for the diagnosis and treatment of diabetes or an eating disorder; or
3. a member has been diagnosed with a chronic medical condition by a physician.
_ .. ,. ~ - -
4. in all cases, except confinemeni, nutritional counseling must be provided m a physician's of ice, c,irnc
system or hospital setting.
r. Treatment of eating disorders, except as shown in the Eating Disorders Treatment Program benefit.
PIC07-740-RI (1/09) 30 (PCH10409) 1500.75.2RxF.V
__
Benefit Participating Provider Benefrt Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
Provider Reimbursement Value.
Infertility Services 100% of eligible charges after the Same as participating provider benefit.
Note: Limited to diagnostic deductible.
services only.
PIC covers professional services for the diagnosis of infertility and treatment of an underlying medical
condition, tests, facility charges and laboratory work related to covered services (such as, but not limited to,
diagnostic radiology, laboratory services, semen analysis and diagnostic ultrasounds).
Exclusions:
a. Please see the section entitled "Exclusions."
b. Reversal of voluntary sterilization.
c. Adoption costs.
d. In vitro fertilization.
e. Gamete and zygote intrafallopian transfer (GIFT and ZIFT) procedures.
f. Surrogate pregnancy.
g. Sperm banking.
h. Embryo and egg storage.
i. Artificially assisted technology, such as, but not limited to, artificial
insemination (IL7I).
j. Donor sperm.
k. Oral and injectable drugs for infertility.
insemination (AI) and intrauterine
PIC07-740-R1 (1/09} 31 (PCH10409) 1500.75.2RxF.V
Benefit Participating Provider Benefit Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any dedzzctibles and
coinsurance, yozz pay all charges that
exceed the PIC Non-Participating
Provider Reimbursement Valzze.
Mental and Substance-Related Disorder Services
Office Visits 100% of eligible charges after the 75% of eligible charges after the
deductible. deductible.
Inpatient Services 100% of eligible charges after the 75% of eligible charges after the
deductible. deductible.
Coverage for confinements in non-
participating hospitals and skilled
nursing facilities is limited to a
combined maximum of 120 calendar
days per calendar year.
Outpatient Hospital, 100% of eligible charges after the 75% of eligible charges after the
Partial Hospital and Day deductible. deductible.
Treatment Services
Each two calendar days of partial
hospital or day treatment services will
be considered equal to one calendar day
of treatment in a hospital. These days
are part of the 120 calendar day
maximum limit listed under "Inpatient
Services."
PIC covers services performed by providers for a mental and/or substance abuse related diagnosis that is
defined in the most current edition of the Diagnostic and Statistical Manual of Mental Disorders ("DSM"), leads
to significant disruption of function in your life situation, and has a recognized effective treatment. PIC's
medical director or designee determines when there is a serious or persistent mental or nervous disorder that
meets criteria for coverage.
Coverage is available as follows:
1. Home Care. PIC's medical director or designee must authorize in advance any services received in your
home.
2. Office Visits. PIC covers:
a. Outpatient professional services for evaluation, diagnosis, crisis intervention, therapy including
medically necessary group therapy, psychiatric services, treatment of a minor (and/or family therapy
but only for treatment on the minor), treatment of mental and nervous disorders, and
b. Diagnosis and treatment of substance-related disorders, including evaluation, diagnosis, therapy and
psychiatric services.
PIC07-740-R1 (1/09) 32 (PCH10409} 1500.75.2RxF.V
The results of a comprehensive diagnostic assessment will be used by a mental health professional to
evaluate the appropriate treatment modality and the extent of services that are medically necessary. These
services may have to be authorized by a provider who is a mental health professional or his or her designee.
Inpatient Services. PIC covers inpatient services in a hospital or licensed residential treatment facility and
professional services. These services must be pre-certified by PIC's medical director or designee.
PIC covers asemi-private room, unless a physician recommends that a private room is medically necessary
and so orders. Benefits for a private room are available only when the private room is medically necessary
for a sickness or injury or it is the only option available at the admitted facility. If you choose a private
room when it is not medically necessary, PIC's payment toward the cost of the room shall be based on the
average semi-private room rate in that facility. PIC's medical director or designee will determine if a
private room meets medically necessary criteria.
4. Outpatient Hospital, Partial Hospital, and Dav Treatment Services. PIC covers such services in a hospital
or licensed treatment facility. These services must bepre-certified by PIC's medical director or designee.
5. Hospital or Residential Treatment Facility Care for Emotionally Handicapped Children. PIC covers
medically necessary inpatient treatment for emotionally handicapped children as diagnosed by a physician
under the Minnesota Department of Human Services criteria. This care must be authorized by and arranged
through a mental health professional. For treatment provided by a hospital or residential treatment center
licensed by the Minnesota Commissioner of Human Services, inpatient coverage for emotionally
handicapped children is the same as the inpatient benefit. The child through age 18 years of age must be an
eligible dependent according to the terms of the COC.
Court-Ordered Services. PIC covers mental health and/or substance related evaluations and treatment ordered
by a Minnesota court under a valid court order when the services ordered are covered under this COC and:
1. The court-ordered behavioral care evaluation is performed by a participating provider or other provider as
required by law and the provider is a licensed psychiatrist, licensed chemical dependency counselor, or
doctoral level licensed psychologist.
2. The treatment is provided by a participating provider or other provider as required by law and is based on a
behavioral care evaluation that meets the criteria of (1) above and includes a diagnosis and an individual
treatment plan for care in the most appropriate and least restrictive environment.
PIC must receive a copy of any court order and evaluation. PIC or its designee may make a motion to modify a
court ordered plan and may request a new behavioral care evaluation.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Counseling, studies, services or confinements ordered by a court or law enforcement officer that are not
determined to be medically necessary by PIC, except as specifically covered above.
c. Marital counseling, relationship counseling, family counseling except as described in this COC, or other
similar counseling or training services.
d. Substance or mental health related conditions that according to generally accepted professional standards
cannot be improved with treatment, except as stated in this COC.
e. Services to hold or confine a member under chemical influence when no medically necessary services are
required, regardless of where the services are received (e. g. detoxification centers).
f. Early behavioral interventions for children including but not limited to Lovaas therapy, applied behavioral
analysis, discrete trial training, and intensive intervention programs.
g. Private room, except when medically necessary or if it is the only option available at the admitted facility.
PIC07-740-R1 (1/09) 33 (PCH10409) 1500.75.2RxF.V
h. Home-based mental or behavioral health services.
i. Biofeedback.
j. Mental retardation or mental conditions that, according to generally accepted professional standards, are not
amenable to favorable modification, except for initial evaluation, diagnosis or crisis intervention.
PIC07-740-R1 (1/09) 34 (PCH10409) 1500.75.2RxF.V
Benefit Participating Provider Benefit Non Participating Provider Benefit
PIC pays: PIC pays:
Note: For non-participating providers,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
Provider Reimbursement Value.
Office Visits and Urgent Care Center Visits
Sickness or injury -office 100% of eligible charges after the 75% of eligible charges after the
and argent care center deductible. deductible.
visits related to diagnosis,
care or treatment of a
condition, sickness or
injury.
Electronic/online 100% of eligible charges after the 75% of eligible charges after the
evaluation of chronic deductible. deductible.
conditions; limited to 6
evaluations per member
per calendar year.
(In order to be covered, the
evaluation must be
conducted by a designated
electronic%nline
participating provider only
for established patients
with specific chronic
diseases, such as diabetes
or heart disease, as
determined by PIC or its
de.°ii gia°ve. j
PIC07-740-R1 (1/09} 35 (PCH10409) 1500.75.2RxF.V
Medically necessary genetic 100% of eligible charges after the 75% of eligible charges after the
testing determined by PIC to deductible. deductible.
be covered services, as
described below:
• Prenatal fetal or maternal
genetic testing (e.g.,
amniocentesis, chorionic
vinous sampling) done as
a component of care of
the member's pregnancy.
• Genetic testing services if
you are diagnosed with a
specific sickness by a
physician.
• Genetic testing services if
you are considered to be
high risk for a specific
sickness as determined by
a physician.
Implantable and insertable 100% of eligible charges after the 75% of eligible charges after the
drug delivery devices for deductible. deductible.
birth control. Implantable
drug delivery devices for
contraceptive therapy are
limited to one device
every 5 years.
Allergy injections 100% of eligible charges after the 75% of eligible charges after the
deductible. deductible.
Port wine stain -treatment 100% of eligible charges after the 75% of eligible charges after the
to lighten or remove the deductible. deductible.
discoloration
Postnatal care 100% of eligible charges after the 75% of eligible charges after the
deductible. deductible.
PIC07-740-RI (1/09} 36 (PCffi0409) I500.75.2RxF.V
Preventive Health Care 100% of eligible charges. 75% of eligible charges after the
Services Not subject to the deductible. deductible.
Immunizations (over
age 6)
Laboratory tests,
pathology and
radiology
Preventive health
physicals
Cancer screening
(including routine
PSA tests, pap
smears, colorectal
tests, and
mammograms)
Routine preventive eye
examinations, limited
to one exam per
member per calendar
year.
Well-baby/child health 100% of eligible charges. 75% of eligible charges after the
services (including Not subject to the deductible. deductible.
immunizations up to
age 6)
Prenatal care
Injectable drugs that are 100% of eligible charges after the 75% of eligible charges after the
not specialty drugs, deductible. deductible.
excluding insulin.
PIC covers the professional medical and surgical services of licensed: plrvsicians, health care providers and
nurses.
1. Services are provided for the following:
a. Office and zzrgertt care center visits relating to the diagnosis, care or treatment of a condition, sickness
or injury.
b. Treatment of diagnosed Lyme disease.
c. Contact lenses prescribed as medically necessary for the treatment of keratoconus, the lenses and fitting
are eligible charges under the DME benefit. Members must pay for lens replacement.
d. Laboratory tests, pathology and radiology.
2. a. Implantable and insertable drug delivery devices. This is limited to one device every five years for
contraceptive therapy, unless services are medically necessary earlier due to complications of the
device. Includes associated physician charges.
b. Contraceptive devices and delivery methods, other than implantable drug delivery devices, available in
the physician's office.
3. Port wine stain treatment to lighten or remove the discoloration.
4. Postnatal exams,
5. Allergy injections.
6. Preventive health cure services, as defined by PIC when submitted by the provider with a routine
preventive health care exam diagnosis.
a. Routine screening procedures for cancer, including mammograms, pap smears, colorectal tests and
prostate specific antigen (PSA).
PIC07-740-R1 (1/09) 37 (PCH10409) 1500.75.2RxF.V
b. Immunizations as recommended by your physician.
c. Laboratory tests, pathology and radiology.
d. Preventive care exams and periodic health supervision services provided during an office visit,
including evaluation and follow-up, when there is no existing condition or complaint about your health.
A physician will counsel you as to how often health assessments are needed based on your age, sex and
health status.
e. Prenatal care.
£ Well baby and child health supervision services including pediatric preventive health care services,
routine immunizations, developmental assessments and laboratory services.
g. Routine eye screening and exam.
7. Surgical services performed in the office, including but not limited to:
a. Oral surgery for: (1) treatment of oral neoplasms and non-dental cysts; (2} fracture of the jaws; (3)
trauma of the mouth and jaws; and (4) any other oral surgery procedures provided as medically
necessary dental services.
b. Surgical and non-surgical treatment of confirmed, existing temporomandibular disorder (TMD) and
craniomandibular disorder (CMD), that is medically necessary. TMD splints and adjustments are
covered if your primary diagnosis is TMD. Dental services required to directly treat TMD or CMD are
eligible.
8. Treatment of cleft lip and cleft palate for a covered dependent child. Treatment must be scheduled or have
started prior to the covered dependent child reaching age 19. Treatment includes orthodontic treatment and
oral surgery directly related to the cleft. Dental services required for the treatment of cleft lip or cleft palate
are covered. If a covered dependent child is also covered under a dental plan, which includes orthodontic
services, that dental plan shall be considered primary for the necessary orthodontic services. Oral
appliances are subject to the same conditions and limitations as durable medical equipment.
9. Treatment of diagnosed diethylstilbestrol (DES).
10. Diabetic outpatient self-management training and education.
11. An emergency examination of a child ordered by judicial authorities.
12. Prenatal screening for Cystic Fibrosis when a pregnancy is considered at high risk.
13. Smoking cessation programs covered through a smoking cessation provider designated by PIC. Limited to
participation in one program in a 12-month period.
14. OB/GYN services for a pregnancy. Female members may obtain the obstetric and gynecologic services
from obstetricians and gynecologists in the participating provider network without a referral from, or prior
approval through, another physician, PIC, or its designees.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Services, seminars, or programs that are primarily edzrcational in nature.
c. Health education, except when provided during an office visit.
d. Smoking cessation programs, except as provided in this COC.
e. Weight loss programs, including, but not limited to, consultations, Laboratory services, testing, nutritional
and food supplements, and weight loss drugs when not being treated for obesity, except when medically
necessary as determined by PLC's medical director or designee.
£ Nutritional counseling, except when:
1. provided during a confinement;
2. for the diagnosis and treatment of diabetes, or an eating disorder; or
3. a member has been diagnosed with a chronic medical condition by a physician.
In all cases, except confinement, nutritional counseling must be provided in a physician's office, clinic
system or hospital setting.
g. Recreational therapy.
h. Professional sign language and foreign language interpreter services in a provider's office, except as
provided in the Continuity of Care provision.
PIC07-740-R1 (1/09) 38 (PCH10409) I500.75.2RxF.V
i. Exams, other evaluations and/or services for employment, insurance, licensure, judicial or administrative
proceedings or research, except as otherwise covered under this section or as part of a routine preventive
health examination.
j. Charges for duplicating and obtaining medical records from non participating providers unless requested
by PIC.
k. Genetic testing and associated services when done as a screening test to predict whether you may be a
carrier of a specific sickness when you are not diagnosed with a specific sickness by a physician or you are
not at high risk for the specific sickness as confirmed by a physician.
1. Homeopathic medicine; hypnosis; chelation therapy, except chelation therapy will be covered when
medically necessary for the treatment of heavy metal poisoning.
m. Acupuncture, except for treatment in a chronic pain program and rendered by a provider licensed or trained
m acupuncture.
n. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease.
o. Treatment of cleft lip and cleft palate, except as otherwise provided in this COC.
p. Vision therapy/orthoptics.
q. Services provided by an audiologist that are not provided in an office setting.
r. Biofeedback.
s. Routine hearing exams.
PIC07-740-R1 (1/09) 39 (PCH10409) 1500.75.2RxF.V
Benefit Designated Transplant Non-Designated Transplant
Network Provider Network Provider
Organ and Bone Marrow Office visits: 100% of eligible Office visits: 75% of eligible
Transplant Services charges after the deductible. charges after the deductible.
Hospital Services: 100% of eligible Hospital Services: 75% of eligible
charges after the deductible. charges after the deductible.
PIC covers eli i~ ble transplant services that PIC's medical director or designee pre-certifies and determines in
advance to be medically necessary and not im~estigative. If the transplant is medically necessary, but is part of a
clinical trial, then benefits are available only for the transplant services that are not part of the clinical trial and
therefore not investigative. It is recommended that transplant ser-vices be received at a designated transplant
network provider.
Coverage for organ transplants, bone marrow transplants and bone marrow rescue services is subject to periodic
review. PIC evaluates transplant services for therapeutic treatment and safety. This evaluation continues at
least annually or as new information becomes available and it results in specific guidelines about benefits for
transplant services. Yozr may call PIC at the telephone number listed inside the cover of this COC for
information about these guidelines.
Benefits, if the transplant meets the definition of an eligible charge, is medically necessary, and not
investigative, are available for the following eli ig ble transplants:
1. Bone marrow transplants and peripheral stem cell transplants.
2. Heart transplants.
3. Heart/lung transplants.
4. Lung transplants.
5. Kidney transplants.
6. Kidney/pancreas transplants.
7. Liver transplants.
R, Pancreas transplat~t~~
9. Small bowel transplants.
Transplant coverage includes a private room and all related post-surgical treatment and drugs. The transplant-
related treatment provided shall be subject to and in accordance with the provisions, limitations and other terms
of this COC.
Medical and hospital expenses of the donor are covered only when the recipient is a member and the transplant
has been pre-certified in advance by the medical director or designee. Treatment of medical complications that
may occur to the donor are not covered.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Services related to organ, tissue and bone marrow transplants and stem cell support procedures or peripheral
stem cell support procedures for a condition that is investigative.
c. Services, chemotherapy, supplies, drugs and aftercare for or related to human organ transplants not
specifically approved as medically necessary by PIC.
d. Services, chemotherapy, radiation therapy or any therapy that damages the bone marrow, except in cases
involving a bone marrow or stem cell transplant.
PIC07-740-R1 (1/09) 40 (PCH10409) 1500.75.2RxF.V
e. Non-ernergency> ambulance service from hospital to hospital such as transfers and admission to hospitals
performed only for convenience.
£ Treatment of medical complications to a donor after procurement of a transplanted organ.
g. Computer search for donorse
h. Private collection and storage of blood and umbilical cord/umbilical cord blood.
i. Travel expenses related to a covered transplant.
PIC07-740-R1 (1/09) 41 (PCHI0409) 1500.75.2RxF.V
Benefit Participating Provider Benefit Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any deductibles and
coinsurance, yotz pay all charges that
exceed the PIC Non-Participating
Provider Reimbursement t~ahze.
Physical Therapy, 100% of eligible charges after the 75% of eligible charges after the
Occupational Therapy And dedttctible. deductible.
Speech Therapy
Sensory integration therapy Coverage is limited to a maximum of 8 visits
for the treatment of feeding per member per calendar year.
disorders
100% of eligible charges after the 75% of eligible charges after the
deductible. deductible.
PIC covers outpatient physical therapy (PT), occupational therapy (OT) and speech therapy (ST) for
rehabilitative cure rendered to treat a medical condition, sickness or injzzty. PIC also covers outpatient PT, OT
and ST habilitative therapy for medically diagnosed conditions that have significantly limited the successful
initiation of normal motor or speech development. Therapy must be ordered by a physician, physician's assistant
or certified nurse practitioner and the therapy must be provided by or under the direct supervision of a licensed
physical therapist, occupational therapist or speech therapist for appropriate services within their scope of
practice. Coverage is limited to rehabilitative care or habilitative therapy that demonstrates measurable and
sustainable improvement within 2 weeks to 3 months, depending on the physical and mental capacities of the
individual.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Cusiodiai care or mainienunce care.
a Recreational, educational, or self-help therapy (such as, but not limited to, health club memberships or
exercise equipment).
d. Therapy provided in your home for convenience.
e. Rehabilitation services that are not expected to make measurable or sustainable improvement within 2
weeks to 3 months, depending on the physical and mental capacities of the individual.
f. Therapy for conditions that are self-correcting.
g. Voice training and voice therapy absent of a medical condition.
h. Investigative therapies for the treatment of autism, such as seeretin infusion therapies.
i. Sensory integration therapy when used for a reason other than the treatment of feeding disorders.
j. Group therapy for PT, OT and ST.
PIC07-740-R1 (1/09) 42 (PCH10409) 1500.75.2RxF.V
Benefits*
Drugs abtained at a pharmacy __
Drugs obtained at a pharmacy that is
that is a participating provider. not a participating provider. PIC pays:
PIC a s: See "Pre-certification" section.
NOTE: Benefits for specialty drugs are as described in this section,
regardless of the place of service where the specialty drug is dispensed or
administered.
Prescription Drug Services Formulary drugs: Formulary and non formulary
100% of eligible charges after the 75% of eligible charges after the
1. Prescription drugs that deductible. deductible.
can beself-administered
for up to a 31-calendar Non formulary drugs: 100% of
day supply. eligible charges after the
2. Up to a 31-day supply for deductible.
one type of insulin.
3. Oral contraceptives for
a 1-month supply.
4. Contraceptive devices
and delivery methods,
other than oral
contraceptives and
injectable contraceptives,
available from a
pharmacy.
5. Compoctnded drugs.
• Mail order prescription Formulary drugs: Not covered.
drugs for up to a 93 100% of eligible charges after the
calendar day supply. deductible.
Non formulary drugs: 100% of
eiigibie ciiaigeS aftci the
deductible.
Diabetic supplies 100% of eligible charges after the 75% of eligible charges after the
dedctctible. deductible.
Coverage includes over-
the-counter diabetic
supplies, including glucose
monitors, syringes, blood
and urine test strips, and
other diabetic supplies as
medically necessury, if
you have gestational
diabetes, type I diabetes,
or type II diabetes.
PIC07-740-R1 (1/09) 43 (PCH10409) 1500.75.2RxF.V
Prescription drugs and Formulary drugs: Formulary and non formulary
over-the-counter (OTC} 100% of eligible charges after the 75% of eligible charges after the
items used in connection deductible. deductible.
with smoking cessation for
up to 31 calendar days per Non formulary drugs: 100% of
prescription and limited to eligible charges after the
a 93 calendar day supply deductible.
per calendar year.
Specialty drugs 100% of eligible charges after the 75% of eligible charges after the
a. Up to a 31 day deductible. deductible.
supply.
b. Specialty drugs may
be oral or injectable.
c. Must be purchased
through a specialty
pharmacy. A list of
the specialty
pharmacies maybe
obtained on the PIC
website or calling
Customer Service.
d. A list of these
specialty drugs may
be obtained on the
PIC website or by
calling PIC Customer
Service.
e. The list of specialty
drags may be revised
from time to time
without notice.
Injectable drugs that are 100% of eiigibie charges after the 75 o of eiigibie charges after rile
not specialty drugs, deductible. deductible.
excluding insulin.
Over-the-Counter (OTC) 100% of eligible charges after the deductible.
DI"ISgS
(Only includes OTC
drugs on the PIC OTC
drug list).
Limited up to a 30
calendar day supply per
prescription.
PIC uses its drug formulary and the preference of dispensing to determine which prescription drugs, including
their generic equivalents are covered. A list of these drugs may be obtained on the PIC website or by calling
PIC Customer Service.
PIC07-740-R1 (1/09) 44 (PCH10409) 1500.75.2RxF.V
For certain medical conditions, there is a need to manage the use of specific drugs before alternative (second
line} drugs are prescribed far the same medical condition. This is known as step therapy. Members in a step
therapy program will need to meet the requirements of that program prior to receiving the second line drug.
Step therapy can apply to formulary or non formulary drugs and brand or generic drugs. The Step Therapy List
is subject to periodic review and modification by PIC.
Some dispensed prescription drugs require the use of quantity limits, which ensure that the quantity of each
prescription remains consistent with clinical guidelines. Quantity limits can apply to formulary or non-
fornrtclury drugs and brand or generic drugs. A list of those prescription drugs with quantity limits is available
upon request. The quantity limits list is subject to periodic review and modification by PIC. Requests for
quantities in excess of the established limits will not be reviewed. You will be responsible for additional
coinsurance for quantities received that are in excess of the quantity limit.
Certain drugs available over-the-counter (OTC) are covered by PIC as determined by the PreferredOne
Pharmacy and Therapeutics Committee. A list of such OTC drugs is available upon request. Those OTC drtcgs
that are covered by PIC will require a physician's prescription. To receive PIC's payment toward your OTC
drug you must present your prescription at a participating pharmacy counter. You will still be responsible far
applicable coinszcrarzce or deductible amounts.
Yozc or your provider may request an exception to the drug formulary. If an exception applies, the non-
formulary drugs that are approved as an exception will be covered at the same level as formulary drugs.
Exceptions to the drug formulary are available as follows:
1. When a plivsician designates that the prescription for an antipsychotic drug must be dispensed as
communicated and certifies in writing to PIC that the physician has considered all equivalent drugs in the
formulary and has determined that the drug prescribed will best treat your condition.
2. If you received a prescription drug to treat a diagnosed mental illness or emotional disturbance PIC will
continue to cover the drug, as though it were a formulary drug, for up to one year after it is removed from
the for~rnulary or you change health plans and become covered under this COC, provided the drug has been
shown to effectively treat yozcr illness or disturbance and the following conditions are met:
a. Yotc were treated with the drug for 90 calendar days before a change in PIC's formulary or a change in
^~^"health ^lan
y~ r ~
b. Your physician designates that the prescription must be dispensed as communicated, and
c. Your physician certifies in writing to PIC that the prescription drug will best treat your- condition.
An exception is valid for up to one year. Yozn~ plrysician may request the exception annually, following the
procedure described above. The exception does not apply if PIC removed the drug from the formulary for
safety reasons. Contact Customer Service for a copy of the written guidelines and procedures or for assistance
in requesting an exception.
When prescription drugs from a non participating provider pharmacy are covered, eligible charges include
only the PIC non participating provider reimbursement value. The PIC non participating provider
reimbursement vahce is the cost of the generic equivalent of the prescription drug and the dispensing fee, or if a
generic equivalent does not exist, the charge that PIC determines is to be customary for such prescription drug.
If the rnentber requests a brand name drug when a generic drug alternative is available, the member will be
required to pay the applicable coinsurance plus the difference in cost between the brand name and the generic
drug. The difference in cost between the brand name drug and the generic drug will not apply to any applicable
deductible or coinsurance costs the member incurs. When the member has reached the out-of-pocket limit, the
nrenzber still pays the difference in the allowed amount between the brand name and the generic drug, even
though the rrrernber is no longer responsible for the prescription drug coinsurance.
PIC07-740-R1 (1/09) 45 (PCH10409) 1500.75.2RxF.V
Compounded drugs will be covered provided that at least one active ingredient is a prescription drug. Payment
for a compounded drug that has a commercially prepared product available that is identical to or similar to the
compounded product, will be considered for coverage after documented failure of the commercially prepared
product(s). A commercially prepared product is one that is available at the pharmacy in its final, usable form
and does not need to be compounded at the pharmacy. The applicable benefit level will be applied.
Compounded drugs containing any product that is excluded by PIC will not be covered, including dosages and
route of administration that have not been approved by the FDA.
Compounded drugs will be covered according to the member's pharmacy network benefits. If a non-
participating provider pharmacy is used to obtain the compounded prescription, the non participating provider-
benefit level will apply, without exception.
Off-label uses of drugs for cancer treatment are covered when the drug is recognized for cancer treatment in the
standard reference compendium, or in an article in medical literature from a major peer reviewed medical
journal. The article must use generally acceptable scientific standards other than case reports. Off-label uses of
specialty drugs are not covered.
Prior Authorization. Certain prescription drugs may require prior authorization before you can have your
prescription filled at the pharmacy. For information, you may call PIC at the phone number listed on the inside
front cover of this COC. These prescription drzrgs may include, but are not limited to:
1. prescription drugs, that are over:
a. $150 if a compound prescription;
b. $1,500 if a retail prescription; or
c. $2,500 if a mail order prescription;
2. specialty drugs;
3. weight loss drugs to treat obesity; and
4. oral antifungal drugs.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Replacement of a prescription drug due to loss, damage, or theft.
l.lo rho t~ (!1 (''1 t ~t ., a" l;r~a la 1 xxr stn t rarni e a r~rPCrrix~ti~n extent a~
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provided in this COC.
d. Prescription drugs that are equivalent or similar to OTC drugs, except as provided in this COC.
e. OTC home testing products, except as provided in this COC.
f. Drugs not approved by the FDA.
g. Take home drugs when dispensed by a physician.
h. Weight loss drugs, except when medically necessary to treat obesity.
i. Prescription drzrgs and OTC drugs for smoking cessation, except as provided in this COC.
j. Prescriptions written by a dentist unless in connection with dental procedures covered under this Plan.
k. Drugs used for cosmetic purposes.
1. Unit dose packaging.
m. Homeopathic medicine, including dietary supplements.
n. Prescription drugs for the treatment of infertility.
o. Topical or oral acne treatments for members age 19 and over.
p. Non-FDA approved route of administration (e.g., drug that is FDA approved for oral use, but is being
applied topically).
q. Drugs that are given or administered as part of a drug manufacturer's study.
r. Prescription drugs if purchased by mail order through a program not administered by PIC's pharmacy
vendor.
s. Prescription drugs for the treatment of erectile dysfunction.
PIC07-740-R1 (1/09) 46 (PCH10409) 1500.75.2RxF.V
t. Prescription drugs are excluded that have a similar OTC drug (on the PIC OTC list} which has an identical
strength, identical route of administration, identical active chemical ingredient(s), and identical dosage
form.
u. Off-label use of specialty drugs.
v. Certain combination drugs and other drugs, regardless of formulary status, will not be covered according to
the PIC pharmacy policy titled "Cost Benefit Program." Contact Customer Service for a copy of this policy
or a list of the affected drugs. This policy is subject to change.
PIC07-740-R1 (1/09) 47 (PCH10409) 1500.75.2RxF.V
-._
Benefit Participating Provider Benefit Non Participating Provider Benefit
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
Provider Reimbtzrseznent Value.
Reconstructive Surgery 100% of eligible charges after the 75% of eligible charges after the
deductible. deductible.
PIC covers reconstructive surgery due to sickness, accident or congenital anomaly. Eligible charges include
eligible hospital, physician, laboratory, pathology, radiology and facility charges. Contact Customer Service to
determine if a specific procedure is covered.
Reconstructive surgery following a mastectomy includes the following:
1. reconstruction of the breast on which the mastectomy has been performed;
2. surgery and reconstruction of the other breast to produce symmetrical appearance;
3. prostheses; and
4. treatment of physical complications at all stages of mastectomy, including lymphedemas.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Services and/or drugs to treat conditions that are cosmetic in nature.
PIC07-740-R1 (1/09) 48 (PCH10409) 1500.75.2RxF.V
_._ ___
Benefit Participating Provider Benefit Norz-Participating Provider Benefit
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Pm~ticipating
Provider Reimbursement Value.
Skilled Nursing Facility Care
Skilled rehabilitation, 100% of eligible charges after the 75% of eligible charges after the
including room and board deductible. dedicctible.
Coverage for confinements in non-
participating hospitals and skilled nicrsin
facilities is limited to a combined
maximum of 120 calendar days per
calendar year.
Daily skilled care as an 100% of eligible charges after the 75% of eligible charges after the
alternative to hospital deductible. deductible.
confinements
PIC covers the eligible skilled nursing facility services for post-acute treatment and rehabilitative care of
sickness or it jury. These services must be directed or referred by a physician and pre-certified by PIC's
medical director or designee.
Skilled niersing facility services include room and board, daily skilled nursing and related ancillary services.
PIC covers asemi-private room unless a physician recommends that a private room is medically necessary and
so orders. PIC's medical director or designee determines if a private room is medically necessary. In the event
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a iiieiiiuer cuuuac~ w recci`vc Carl, in a prlJa~., rvClii il2iuer C.....,,.~ h m..»•.,.- .j n.........,--•„
PIC's payment toward the cost of the room shall be based on the average semi-private room rate in that facility.
Only services that qualify as reimbursable under Medicare are covered benefits, and coverage is limited to the
maximum number of calendar days per calendar year if the services would qualify as reimbursable under
Medicare.
Exclusions:
a. Please see the section entitled "Exclusions."
b. Hospitalization, transportation, supplies, or medical services, including physicians' services furnished by
the United States Government or by an institution operated by the United States Government, unless
payment is required in accordance with applicable law.
c. Private room, except when medically necessary or if it is the only option available at the admitted facility.
d. Respite or custodial care.
PIC07-740-R1 (1/09) 49 (PCH10409) 1500.75.2RxF.V
Specified Nan-Participating Provider Services
The services listed below are covered at the same benefit level as the type of service benefit shown in the
schedule above for participating provider benefits. You are not required to receive these services from a
participating provider. For example, an office visit, {whether by a participating provider or a non-
participating provider) for the services listed below will be covered at the participating provider benefit level.
1. Voluntary family planning of the conception and bearing of children.
2. The provider visit(s) and test(s) necessary to make a diagnosis of infertility.
3. Testing for sexually transmitted diseases, AIDS, and other HIV-related conditions.
4. Treatment of sexually transmitted diseases, except AIDS and other HIV-related conditions.
Exclusions:
a. Please see the section entitled "Exclusions."
PIC07-740-RI (1/09) 50 (PCHI0409) 1500.75.2RxF.V
Pre-existing Condition Limitation
Pre-Existing Condition Any condition, regardless of the cause of the condition, for which medical advice,
diagnosis, care or treatment was recommended or received, during the 6 month
period immediately preceding the member's enrollment date under PIC. Genetic
information or pregnancy will not be considered apre-existing condition.
In the case of a late enrollee, apre-existing condition is excluded from coverage until the end of 18 months
from the effective date. For eligible employees and any eligible dependents when first eligible for coverage, a
pre-existing condition is excluded from coverage until the end of 12 months from the enrollment date. For those
that enroll under the Special Enrollment provision, apre-existing condition is excluded from coverage until the
end of 12 months from the enrollment date.
The pre-existing condition limitation is reduced by any period of time during which the member had continuous
and creditable coverage prior to his or her enrollment under the GMC. This limitation does not apply to
newborns, adopted children, or children placed for adoption.
Exclusions
In addition to any other exclusions or limitations specified in this COC, PIC will not cover charges
incurred for any of the following services:
1. Services or supplies that PIC determines are not medically necessary.
2. Investigative procedures and associated expenses.
3. Charges for services determined to be duplicate services by PIC.
4. Personal comfort or convenience items.
5. Procedures that are always cosmetic, or for convenience or comfort reasons, as listed on PIC's Cosmetic
Procedures Policy. This policy maybe obtained by calling PIC Customer Service.
6. Orthognathie surgery.
7. Services received before coverage under PIC begins or after your coverage under PIC ends.
8. Services or supplies not directly related to your care.
9. Services or supplies through a provider ordered or rendered by providers that are unlicensed or not certified
by the appropriate state regulatory agency.
10. PIC or the tnernber are not liable for services, drugs or supplies not rendered in the most cost-efficient
setting or methodology appropriate for the condition based on medical standards and accepted practice
parameters of the community, or provided at a frequency other than that accepted by the medical
community as medically appropriate.
11, Charges that exceed the PIC Non-Participating Provider Reimbursement Value for services or supplies
received from non ~~articipating providers, including non-participating pharmacies.
12. Services prohibited by law or regulation, or illegal under applicable laws.
PIC07-740-R1 (1/09) 51 (PCH10409) 1500.75.2RxEV
13. Charges for services that are eligible for payment under any insurance policy, including auto insurance, or
under Workers' Compensation law, employer liability law or any similar law.
14. Services under this plan that are paid under Medicare Part B but only to the extent: (i) you are eligible to be
covered under Medicare Part B; (ii) you and/ or PIC are not subject to Medicare secondary rules; and (iii)
such an exclusion is permitted by applicable state and federal law.
15. Charges incurred outside the United States if the member traveled to such a location for the primary
purpose of obtaining medical services, drugs or supplies.
16. Eyeglasses, frames and their related fittings.
17. Contact lenses and their related fittings, except when prescribed as medically raecessarv for the treatment of
keratoconus.
18. Any service, drug or supply provided by a relative (i.e., a spouse, parent, brother, sister or child of the
subscriber or of the subscriber's spouse) or anyone who customarily lives in the subscriber's household.
19. PIC or the member are not liable for charges for services performed by certified surgical technicians,
surgical technicians or certified operating room technicians.
20. All services, except emergency services, for members when outside the United States.
21. Services provided by massage therapists, doulas, and personal trainers.
22. Sexual devices, services; or supplies or prescription drugs for the treatment of sexual dysfunction.
23. Charges that are paid under medical payment, automobile or other coverage that is payable without regard
to fault, including charges that are applied toward any coinsurance requirement of such a policy.
24. Massage therapy.
25. Telephone consultations.
26. Electronic mail consultations except as covered in Office Visits and Urgent Care Center Visits of this COC.
27. Preventive medical services, such as but not limited to, flu shots, cholesterol testing, glucose testing and
mammograms, that are not ordered by a physician.
28. Financial or legal counseling services.
29. Light-based treatments for acne.
30. Elective abortions.
31. PIC shall not be liable for any loss to which a contributing cause was the member's commission of or
attempt to commit a felony or to which a contributing cause was the member's being engaged in an illegal
occupation.
32. Travel, transportation or living expenses.
P1C07-740-R1 (1/09) 52 (PCH10409) 1500.75.2RxF.V
The following exclusions are repeated from the "Schedule of Payment" section":
~ For ease of reference, some exclusions may contain headings for categories of benefit services and
supplies. Please note that, exclusions listed under all categories of benefit services and supplies shall
apply to all services and supplies, regardless of the heading under which they are listed.
33. Ambulance Services:
a. See all exclusions.*
b. Non-ernergerrcy ambulance service from hospital to hospital such as transfers and admission to
hospitals performed only for convenience.
34. Chiropractic Services:
a. See all exclusions.*
b. Services primarily educational in nature.
c. Vocational rehabilitation.
d. Self-care and self-help training (non-medical).
e. Health clubs and spas.
£ Recreational therapy.
g. Rehabilitation services that are not expected to make measurable or sustainable improvement within 2
weeks to 3 months, depending on the physical and mental capacities of the individual.
h. Chiropractic therapy other than for treatment of acute musculoskeletal conditions.
i. Acupuncture, except for treatment in a chronic pain program and rendered by a provider licensed or
trained in acupuncture.
j. Blood, urine or hair analysis related to chiropractic services.
k. Ultrasound, MRI, EMG, waveform, and nuclear medicine diagnostic studies related to chiropractic
services.
1. Manipulation under anesthesia related to chiropractic services.
m. Homeopathic/holistic services related to chiropractic services.
35. Dental Services:
a. See all exclusions.
b. Dental services covered under your dental plan.
c. Preventive dental procedures.
d. mental ser:nces and all associated exn@nseS, except as stated in this section.
e. Orthodontia and all associated expenses, except as required by law.
f. Surgical extraction of impacted wisdom teeth.
g. Services for cracked or broken teeth that result from biting, chewing, disease or decay.
h. Dental implants.
i. Prescriptions written by a dentist unless in connection with dental procedures covered by PIC.
j. Dental services related to periodontal disease.
36. Durable Medical Equipment (DME), Services and Prosthetics:
a. See all exclusions.*
b. Any durable medical equipment or supplies not listed as eligible on PIC's durable medical list, or as
determined by PIC.
c. Disposable supplies or non-durable supplies and appliances, including those associated with equipment
determined not to be eligible for coverage.
d. Revision of durable medical equipment and prosthetics, except when made necessary by normal wear
or use.
e. Replacement or repair of items when: (1) damaged or destroyed by misuse, abuse or carelessness; (2)
lost; or (3) stolen.
f. Duplicate or similar items.
g. ltems that are primarily educational in nature or for vocation, comfort, convenience or recreation.
PIC07-740-R1 (1/09) 53 (PCFi10409} 1500.75.2RxF.V
h. Hearing aids, devices to improve hearing and related fittings (except as provided in the Durable
Medical Equipment (DME), Services and Prosthetics provision}.
i. Communication aids or devices; equipment to create, replace or augment communication abilities
including, but not limited to, speech processors, receivers, communication board, or computer or
electronic assisted communication.
j. Hausehold equipment, household fixtures and modifications to the structure of the home, escalators or
elevators, ramps, swimming pools, whirlpools, hot tubs and saunas, wiring, plumbing or charges for
installation of equipment, exercise cycles, air purifiers, central or unit air conditioners, water purifiers,
hypoallergenic pillows, mattresses or waterbeds.
k. Vehicle/car or van modifications including, but not limited to, hand brakes, hydraulic lifts and car
carrier.
1. Over-the-counter orthotics and appliances.
m. Orthopedic shoes and custom molded foot orthotics, except for members with diabetes or peripheral
vascular disease.
n. Charges for sales tax, mailing and delivery.
o. Durable equipment necessary for the operation of equipment determined not to be eligible for coverage.
p. Durable medical equipment, orthotics and prosthetics that are necessary for activities beyond activities
of daily living (ADCs).
q. Wigs for conditions other than alopecia areata.
r. Enteral feedings and other oral nutritional and electrolyte substances, except amino-acid based formulas
when medically necessacy and electrolyte substances to treat PKU or otherwise required to sustain life.
s. Upgrades to or replacement of any items that are considered eligible charges and covered under this
section, unless the item is no longer functional and is not repairable.
37. Emergency Room Services:
a. See alI exclusions.*
b. Non-emergency services received in an emergency room.
3~. Hame Health Services:
a. See all exclusions.
b. Companion and home care services, unskilled nursing services, services provided by your family or a
person who shares your legal residence.
c. Services provided as a substitute for a primary caregiver in the home.
d. Services that can be performed by anon-medical person or self-administered.
e. Home health aides.
f. Services provided in your home for convenience.
g. Services provided in yoPer home due to lack of transportation.
h. Custodial care.
i. Services at any site other than your home.
j. Recreational therapy.
39. Hospice Care:
a. See all exclusions.*
b. Services provided by yoecr family or a person who shares your legal residence.
c. Respite or rest care except as specifically described in this section.
40. Hospital Services:
a. See all exclusions.
b. Travel, transportation, other than ambulance transportation, or living expenses.
c. Hospitalization., transportation, supplies, or medical services, including physicians' services furnished
by the United States Government or by an institution operated by the United States Government, unless
payment is required in accordance with applicable law.
d. Private room, except when medically necessac.v or if it is the only option available at the admitted
facility.
PIC07-740-R1 (1/09) 54 (PCH10409) 1500.75.2RxF.V
e. Non-emergency ambulance service from hospital to hospital, such as transfers and admissions to
hospitals performed only for convenience.
f. Services and/or drugs to treat conditions that are cosmetic in nature.
g. Orthoptics and refractive surgery (i.e. lasik) for opthalmic conditions that are correctable by contacts or
glasses.
h. Services and/or surgery anal associated expenses for gender reassignment unless determined to be
medically necessary. These services and associated expenses will be reviewed on a case by case basis
and, if determined to be medically necessary, services must be received at a PIC designated treatment
center.
i. Genetic testing and associated services when done as a screening test to predict whether you maybe a
carrier of a specific sickness when you are not diagnosed with the specific sickness by a physician or
you are not at high risk for the specific sickness as confirmed by a physician.
j. Homeopathic medicine; hypnosis; chelation therapy, except chelation therapy will be covered when
medically necessary for the treatment of heavy metal poisoning.
k. Acupuncture, except for treatment in a chronic pain program and rendered by a provider licensed or
trained in acupuncture.
1. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease.
m. Autopsies.
n. Bariatric sarrgeries.
o. Services for items for personal convenience, such as television rental.
p. Commercial weight loss programs.
q. Nutritional counseling, except when:
1. provided during a confinement;
2. for the diagnosis and treatment of diabetes or an eating disorder; or
3. a member has been diagnosed with a chronic medical condition by a physician.
In all cases, except confinement, nutritional counseling must be provided in a physician's office, clinic
system or hospital setting.
r. Treatment of eating disorders, except as shown in the Eating Disorders Treatment Program benefit.
41. Infertility Services:
a. See all exclusions.*
b. Reversal of voluntary sterilization.
c. Adoption costs.
,l T«. "1-.-.. -F....4. 4; ter.
U. 111 V111V 1G111 IGaL1Vt1.
e. Gamete and zygote intrafallopian transfer (GIFT and ZIFT) procedures.
£ Surrogate pregnancy.
g. Sperm banking.
h. Embryo and egg storage.
i. Artificially assisted technology, such as, but not limited to, artificial insemination (AI) and intrauterine
insemination (IUI}.
j. Donor sperm.
k. Oral and injectable drugs for infertility.
42. Mental and Substance-Related Disorder Services:
a. See all exclusions.*
b. Counseling, studies, services or confinernerzts ordered by a court or law enforcement officer that are not
determined. to be medically necessary by PIC, except as specifically covered above.
c. Marital counseling, relationship counseling, family counseling except as described in this COC, or other
similar counseling or training services.
d. Substance or mental health related conditions that according to generally accepted professional
standards cannot be improved with treatment, except as stated in this COC.
e. Services to hold or confine a member under chemical influence when no medically necessary services
are required, regardless of where the services are received (e. g. detoxification centers).
PIC07-740-R1 (1/09) 55 (PCH10409) 1500.75.2RxF.V
f. Early behavioral interventions for children including but not limited to Lovaas therapy, applied
behavioral analysis, discrete trial training, and intensive intervention programs.
g. Private room, except when medically necessazy or if it is the only option available at the admitted
facility.
h. Home-based mental or behavioral health services.
i. Biofeedback.
j. Mental retardation or mental conditions that, according to generally accepted professional standards, are
not amenable to favorable modification, except for initial evaluation, diagnosis or crisis intervention.
43. Office Visits and Urgent Care Center Visits:
a. See all exclusions.
b. Services, seminars, or programs that are primarily educational in nature.
c. Health education.
d. Smoking cessation programs, except as provided in this COC.
e. Weight loss programs, including, but not limited to, consultations, laboratory services, testing,
nutritional and food supplements, and weight loss drugs when not being treated for obesity, except
when medically necessary as determined by PIC's medical director or designee.
£ Nutritional counseling, except when:
1. provided during a confinement;
2. for the diagnosis and treatment of diabetes or an eating disorder; or
3. a member has been diagnosed with a chronic medical condition by a physician.
In all cases, except confinement, nutritional counseling must be provided in a physician's office, clinic
system or hospital setting.
g. Recreational therapy.
h. Professional sign language and foreign language interpreter services in a provider's office, except as
provided in the Continuity of Care provision.
i. Exams, other evaluations and/or services for employment, insurance, licensure, judicial or
administrative proceedings or research, except as otherwise covered under this section or as part of a
routine preventive health examination.
j. Charges for duplicating and obtaining medical records from non participating providers unless
requested by PIC.
k. Genetic testing and associated services when done as a screening test to predict whether you may be a
carrier of a specific sickness when you are not diagnosed with a specific sickness by a physician or you
are llot at hlgll rl3k for tl'ic SpcciliC Si.Cki/"ceSS aS Coiu rmed by a pli'y'.isa,aan.
1. Homeopathic medicine; hypnosis; chelation therapy, except chelation therapy will be covered when
medically= necessazy for the treatment of heavy metal poisoning.
m. Acupuncture, except for treatment in a chronic pain program and rendered by a provider licensed or
trained in acupuncture.
n. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease.
o. Treatment of cleft lip and cleft palate, except as otherwise provided in this COC.
p. Vision therapy/orthoptics.
q. Services provided by an audiologist that are not provided in an office setting.
r. Biofeedback.
s. Routine hearing exams.
44. Organ and Bone Marrow Transplant Services:
a. See all exclusions.*
b. Services related to organ, tissue and bone marrow transplants and stem cell support procedures or
peripheral stem cell support procedures for a condition that is investigative.
c. Services, chemotherapy, supplies, drugs and aftercare for or related to human organ transplants not
specifically approved as medically necessazy by PIC.
d. Services, chemotherapy, radiation therapy or any therapy that damages the bone marrow, except in
cases involving a bane marrow or stem cell transplant.
PIC07-740-R1 (1/09) 56 (PCH10409) 1500.75.2RxF.V
e. Non-emergency ambulance service from hospital to hospital such as transfers and admission to
hospitals performed only for convenience.
f. Treatment of medical complications to a donor after procurement of a transplanted organ.
g. Computer search for donors.
h. Private collection and storage of blood and umbilical cord/umbilical cord blood.
i. Travel expenses related to a covered transplant.
45. Physical Therapy, Occupational Therapy and Speech Therapy:
a. See all exclusions.*
b. Custodial care or maintenance care.
c. Recreational, educational, or self-help therapy (such as, but not limited to, health club memberships or
exercise equipment).
d. Therapy provided in your home for convenience.
e. Rehabilitation services that are not expected to make measurable or sustainable improvement within 2
weeks to 3 months, depending on the physical and mental capacities of the individual.
£ Therapy for conditions that are self-correcting.
g. Voice training and voice therapy absent of a medical condition.
h. Investigative therapies for the treatment of autism, such as secretin infusion therapies.
i. Sensory integration therapy when used for a reason other than the treatment of feeding disorders.
j. Group therapy for PT, OT and ST.
46. Prescription Drug Services:
a. See all exclusions.
b. Replacement of a prescription drug due to loss, damage, or theft.
c. Drugs available over-the-counter (OTC) that by applicable law do not require a prescription, except as
provided in this COC.
d. Prescription dracgs that are equivalent or similar to OTC dr++gs, except as provided in this COC.
e. OTC home testing products, except as provided in this COC.
f. Drugs not approved by the FDA.
g. Take home drugs when dispensed by a physician.
h. Weight loss drugs except when medically necessary to treat obesity.
i. Prescription dr++gs and OTC drugs for smoking cessation, except as provided in this COC.
j. Prescriptions written by a dentist unless in connection with dental procedures covered under this Plan.
k. Di ug~ ilScd ivr CGSiiietiC pilrpGS~o.
1. Unit dose packaging.
m. Homeopathic medicine, including dietary supplements.
n. Prescriptio» drugs for the treatment of infertility.
o. Topical or oral acne treatments for members age 19 and over.
p. Non-FDA approved route of administration (e.g., drug that is FDA approved for oral use, but is being
applied topically).
q. Drugs that are given or administered as part of a drug manufacturer's study.
r. Prescription drugs if purchased by mail order through a program not administered by PIC's pharmacy
vendor.
s. Prescription drugs for the treatment of erectile dysfunction.
t. Prescription drugs are excluded that have a similar OTC drug (on the PIC OTC list) which has an
identical strength, identical route of administration, identical active chemical ingredient(s), and identical
dosage form.
u. Off-label use of specialty dre+gs.
v. Certain combination drugs and other drugs, regardless of form+dary status, will not be covered
according to the PIC pharmacy policy titled "Cost Benefit Program." Contact Customer Service for a
copy of this policy or a list of the affected drugs. This policy is subject to change.
PIC07-740-R1 (1/09} 57 (PCHI0409} I500.75.2RxF.V
47. Reconstructive Surgery:
a. See all exclusions.*
b. Services and/or drugs to treat conditions that are cosmetic in nature.
48. Skilled Nursing Facility Care:
a. See all exclusions.
b. Hospitalization, transportation, supplies, or medical services, including physicians' services furnished
by the United States Government or by an institution operated by the United States Government, unless
payment is required in accordance with applicable law.
c. Private room, except when medically necessary or if it is the only option available at the admitted
facility.
d. Respite or custodial care.
49. Specified Non-Participating Provider Services:
a. See all exclusions.*
Ending Your Coverage
Coverage of the subscriber and/or his or her dependents will terminate on the earliest of the following dates,
except that coverage may be continued or converted in some instances as specified in the "Continuation of
Coverage" and "Your Right to Convert Coverage" sections:
1. For the subscriber and dependents, the end of the month in which PIC terminates the GMC.
2. For the subscriber and dependents, the end of the month in which the subscriber retires, unless PIC and the
employer have agreed to provide coverage for retirees under the GMC.
3. For the subscriber and dependents, the end of the month in which the subscriber's eligibility under the GMC
ends.
4. For the subscriber and dependents, the end of the month following the receipt of a written request from the
stbscriber to cancel coverage.
5. For a child covered as a dependent, the end of the month in which the child is no longer eligible as a
dependent, unless the eligible dependent is handicapped.
6. For the subscriber and dependents, termination will be retroactive to the last calendar day for which the
subscriber's contribution towards premium has been received.
7. For the subscriber and dependents, the date you have preformed an act or practice that constitutes fraud or
made an intentional misrepresentation or material fact under the terms of the GMC.
8. For the covered spouse of the subscriber, the end of the month in which the covered spouse is no longer
eligible as a covered spouse.
9. For COCs that are coordinated with a health reimbursement arrangement (HRA) plan sponsored by the
employer, for the subscriber and dependents including those enrolled for continuation coverage (COBRA),
the date the subscriber ceases to be enrolled as a participant (including the date the applicable member ceases
to be enrolled for continuation coverage (COBRA) in a HRA plan.
PIC07-740-R1 (1/09) 58 (PCH10409) 1500.75.2RxF.V
Extension of Benefit:
An extension will be provided to a member who is confined in a hospital or skilled nursing facility on the date of
termination of the GMC. PIC will pay benefits during the confinement, until discharge, upon receipt of due proof
of the following:
1. the member incurred eligible charges during the confinement;
2. the eligible charges are related to the sickness or injury causing the confinement; and
3. the eligible charges would have resulted in a valid post-service claim if this benefit had been in effect at the
time expenses were incurred.
Leaves of Absence
Family and Medical Leave Act (FMLA)
If yozz are absent from work due to an approved family or medical leave under the Family and Medical Leave
Act of 1993 (FMLA), coverage may be continued for the duration of the approved leave of absence as if there
was no interruption in employment. Such coverage will continue until the earlier of the expiration of such leave
or the date yozc notify the employer that yozc do not intend to return to work. You are responsible for all required
contributions.
If you do not return after an approved leave of absence, coverage may be continued under the "Continuation
Coverage" section, provided you elect to continue under that provision. If the member returns to work
immediately following his or her approved FMLA leave, no waiting periods or pre-existing condition
limitations will apply.
The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA)
Continuation of Benefits. Subscribers who are absent due to service in the uniformed services and/or their
covered dependents may continue coverage pursuant to USERRA for up to 24 months after the date the
subscriber is first absent due to uniformed service duty.
Eligibility. A sebscriber is eligible for continuation under USERRA if he or she is absent from employment
r t--` ~ t__ r,.....,,. ,7 r., r A,-,V,o.a 0 v T~7at~n a (a4 r /~ir
DecaUSe of vOl Ulltar y or lrlvolUnlal y periv1111ancc of tiut.y in tlii. ~ uu...u For vv°S, u'•Zi:) 1.,.2..n..1 a. ,
National Guard or the commissioned corps of the Public Health Service. Duty includes absence for active duty,
active duty for training, initial active duty for training, inactive duty training and for the purpose of an
examination to determine fitness for duty.
Covered dependents who have coverage under PIC immediately prior to the date of the subscriber's covered
absence are eligible to elect continuation under USERRA.
Upon the subscriber's return to work immediately following his or her leave under USERRA, no waiting
periods or pre-existing condition limitations will apply.
Contribution Payment. If continuation of coverage is elected under USERRA, the subscriber or covered
dependent is responsible for payment of the applicable cost of coverage. If the subscriber is absent for not
longer than 31 calendar days, the cost will be the amount the subscriber would otherwise pay for coverage. For
absences exceeding 31 calendar days, the cost may be up to 102% of the cost of coverage under PIC. This
includes the subscriber's share and any portion previously paid by the employer.
PIC07-740-R1 (1./09} 59 (PCH10409) 1500.75.2RxF.V
Duration of Coverage. Elected continuation of coverage under USERRA will continue until the earlier of:
1. 24 months, beginning the first day of absence from employment due to service in the uniformed services;
2. the day after the subscriber fails to apply for or return to employment as required by USERRA, after
completion of a period of service;
3. the early termination of USERRA continuation coverage due to the subscriber's court-martial or
dishonorable discharge from the uniformed services; or
4. the date on which the GMC is terminated.
The continuation available under USERRA runs concurrently with continuation available under "Continuation
Coverage." Subscriber's should contact their employer with any questions regarding coverage normally
available during a military leave of absence or continuation coverage and notify the employer of any changes in
marital status or a change of address.
Return to Work Requirements. Under USERRA a service member is entitled to return to work following an
honorable discharge as follows:
1. Less than 31 days service: By the beginning of the first regularly scheduled work period after the end of
the calendar day of duty, plus time required to return home safely and an eight hour rest period.
2. 31 to 180 days: The employee must apply for reemployment no later than 14 days after completion of
military service.
3. 181 days or more: The employee must apply for reemployment no later than 90 days after completion of
military service.
4. Service-connected injury or illness: Reporting or application deadlines are extended for up to two years
for persons who are hospitalized or convalescing.
PIC07-740-R1 (1/09) 60 (PCH10409) 1500.75.2RxF.V
Continuation Coverage
Important Note if Employer also Sponsors HRA Program: If coverage under this COC is paired with benefits
offered under a health reimbursement arrangement or HRA (within the meaning of IRS Revenue Ruling 2002-41)
established and maintained by the employer, then your right to continue coverage under this COC is not
conditioned upon your concurrent enrollment for continuation coverage (COBRA) under the employer's I-IRA
program. Thus, to enroll for continuation coverage (COBRA) under this COC, an otherwise eligible subscriber
and/or covered member is not required to elect, enroll or be enrolled for, or maintain continuation coverage under
the employer's HRA program. Notwithstanding the foregoing, the employer's I-IRA program may condition the
right to continue coverage under such HRA program upon the subscriber's and/or covered member's election,
concurrent enrollment for, and maintenance of continuation coverage (COBRA) under this COC. A failure to
elect and maintain continuation coverage under this COC may terminate your right to continue coverage under the
employer's HRA program. Termination of continuation coverage (COBRA) under this COC before expiration of
the maximum continuation period may terminate continuation coverage (COBRA) under the employer's HRA
program. To enroll for continuation coverage under this COC, you must make a timely separate election to
continue coverage under this COC and timely pay separate continuation premiums for such coverage as required
under this COC. To also enroll for continuation coverage under the employer's HRA program, you must make a
timely separate election to continue such coverage and timely pay separate continuation premiums for such
coverage as required under the employer's HRA program.
Notwithstanding the foregoing paragraph relating to continuation coverage, coverage for an otherwise (active)
eligible employee and his/her dependents under this COC that is non-continuation coverage shall be coordinated
with and conditioned upon enrollment and coverage under the HRA program offered and maintained by the
employer.
PIC shall not be required to establish, maintain or contribute to a HRA on behalf of an eligible member or the
employer.
The subscriber, his or her covered spouse and covered dependent children may continue coverage under PIC
when a qualifying event occurs. You may elect continuation coverage for yourself regardless of whether the
subscriber or other eligible dependents in yoccr family elect continuation coverage. A subscriber and a covered
spouse may elect continuation coverage on behalf of each other and/or their covered dependent children. Only
the subscriber, his or her covered spouse and covered dependent children are eligible for continuation coverage.
Vther mC11v1dualS, even thOUgh ellglble t0 eIlUll fVr Cuvcragc Ziridci tiiiS CtniC, are ineilgibl°v f.;r Contlntlatlon
Coverage under this COC.
If a loss of coverage qualifying event occurs:
1. In certain cases, the sccbscriber may continue his or her coverage and may also continue coverage for his or
her covered spouse and covered dependent children when coverage would normally end;
2. In certain cases, the covered spouse and covered dependent children may continue coverage when coverage
would normally end;
3. Coverage will be the same as that for other similar members; and
4. Continuation coverage with PIC ends when the GMC terminates or as explained in detail on the following
Continuation Chart. The subscriber, his or her covered spouse and covered dependent children may,
however, be entitled to continuation coverage under another group health plan offered by the employer. You
should contact the employer for details about other continuation coverage. Also refer to the "Your Right to
Convert Coverage" section following this "Continuation Coverage" section for your conversion rights.
For additional information about your rights and obligations under the GMC and/or state or federal COBRA
continuation law, you should contact the employer.
PIC07-740-R1 (1/09) 61 (PCH10409) 1500.75.2RxF.V
Qualifying Events
1. Loss of coverage under the GMC by the szrbscriber due to one of these events:
a. Voluntary or involuntary termination of employment of the szrbscriber for reasons other than "gross
misconduct."
b. Reduction in the hours of employment of the szrbscriber.
c. Layoff of the szrbscriber.
d. Leave of absence of the subscriber.
e. Early retirement of the subscriber.
f. Total disability of the szrbscriber while employed by the employer.
2. Loss of coverage under the GMC by the covered spouse and/or covered dependent children due to one of
these events:
a. Voluntary or involuntary termination of employment of the szrbscriber for reasons other than "gross
misconduct."
b. Reduction in the hours of employment of the subscriber.
c. Layoff of the subscriber.
d. Leave of absence of the subscriber.
e. Early retirement of the subscriber.
£ Total disability of the szrbscriber while employed by the employer.
g. szrbscriber becoming enrolled in Medicare.
h. Divorce or legal separation of the szrbscriber.
i. Death of the subscriber.
3. Loss of coverage under the GMC by the covered dependent child due to his or her loss of "dependent child"
status under the GMC.
4. Loss of coverage under the GMC due to the bankruptcy of the employer under Title XI of the United States
Code. For purposes of this qualifying event (bankruptcy), a loss of coverage includes a substantial
elimination of coverage that occurs within one year before or after commencement of the bankruptcy
a' 1' +!. +i,o .1 h2g or ~ c`v ~~~-ell g ~i„gP anvil rnv ail Io v rlvi~t rhilrlrPn
procecuing. Applies av uia. cover eu retu ee, . hv. p er_.. c..,p..n_.....
Throughout the rest of this section, "Employer" or "Continuation Administrator" is referenced based on the entity
responsible for administering Minnesota Continuation.
Required Procedures
When the initial qualifying event is death, termination of employment or reduction in hours (including leave of
absence, layoff, or retirement), total disability while employed, or Medicare enrollment of the subscriber, the
employer will offer continuation coverage to qualified members. Yozr do not need to notify the employer of these
qualifying events. However, for other qualifying events including divorce or legal separation of the szrbscriber
and loss of dependent child status, continuation is available only if you provide timely, written notice to the
employer. Yozr must also provide timely, written notice to the employer of other events, such as a Social Security
disability determination or second qualifying events, in order to be eligible for an extension of continuation
coverage as required below by the employer. To elect continuation coverage, you must make a timely, written
election as required below by the employer.
What the employer must do:
Provide initial general continuation notices as required by law; determine if the member is eligible to
continue coverage according to applicable laws;
PIC07-740-R1 (1/09) 62 (PCH10409) 1500.75.2RxF.V
2. Notify persons of the unavailability of continuation coverage;
3. Notify the member of his or her rights to continue coverage provided that all required notice and notification
procedures have been followed by the subscriber, covered spouse and/or covered dependent children;
4. Inform the member of the premium contribution required to continue coverage and how to pay the premium
contribution; and
5. Notify the member when he or she is no longer entitled to continuation coverage or when his or her
continuation coverage is ending before expiration of the maximum (18-, 29-, 36-month) continuation period.
What you must do:
1. You must notify the employer in writing of a divorce or legal separation within 60 calendar days after the date
of the qualifying event, or the date coverage would end due to the qualifying event, whichever is later;
2. You must notify the employer in writing of a covered dependent child ceasing to be eligible within 60
calendar days after the date of the qualifying event, or the date coverage would end due to the qualifying
event, whichever is later;
You must submit your written notice of a qualifying event within the 60 day timeframe, as explained
previously in Item #1 and #2, using the employer's approved notice form. (Yogi may obtain a copy of the
approved form from the employer.) This notice must be submitted to the employer in writing and must
include the following:
a. the name of the employer;
b. the name and address of the subscriber or former subscriber;
c. the names and addresses of all applicable dependents;
d. the description and date of the qualifying event;
e. documentation pertaining to the qualifying event such as: decree of divorce or legal separation, marriage
certificate for child, student transcript showing last day of student enrollment for child etc.; and
f. the name, address, and telephone number of the individual submitting the notice. This individual can be
a SiibSCiZbei", LvLiner siibi%ribel^, .,r h:S .,r her dependent(s); or a repr~eptati~ia a~t~naU nn behalf of the
employee or dependent(s).
If you do not supply all notice requirements in writing as previously described, then yoci must follow the
employer's requirements and specified time period for submitting, in writing, all required information and
supporting documentation.
All written notices as described previously in 1, 2, and 3, under "What you must do," must be sent to
the employer.
4. To elect continuation, you must notify the employer of your election in writing within 60 calendar days after
the date the member's coverage ends, or the date the employer notifies the member of continuation rights,
whichever is later. To elect continuation coverage, yoci must complete and submit yocn^ written election
within the 60-day timeframe using the employer's approved election form. (Yoci may obtain a copy of the
approved form from the employer.) This election must be submitted in writing to the employer; and
5. You must pay continuation premium contributions:
a. The premicim contribution to continue coverage is the combined employer plus subscriber rate charged
under the GMC, plus the employer may charge an additional 2% of that rate (rate also applies if the
qualifying event is the total disability of the subscriber while employed}. For a member receiving an
PIC07-740-R1 (1/09} 63 (PCH10409) 1500.75.2RxF.V
additional 11 months of coverage after the initial 18 months due to a continuation extension for Social
Security disability, the premium contribution for those additional months may be increased to 150% of
the employer's total cost of coverage. The continuation election form will set forth yocrr continuation
premium contribution rate(s).
b, The first premium contribution must be paid by check within 45 calendar days after electing to continue
the coverage or such longer period as required by law. Thereafter, the member's monthly payments are
due and payable by check at the beginning of each month for which coverage is continued.
c. The member must pay subsequent premiatm contributions by check on or before the required due date,
plus the 30-calendar day grace period required by law, and if authorized by PIC,, such longer period
allowed by the employer or required by law.
What you must do to apply for continuation extension:
A. Social Security Disability:
If you are currently enrolled in continuation coverage under the GMC, and it is determined that you are
totally disabled by the Social Security Administration within the first 60 calendar days of your current
continuation coverage, then you may request an extension of coverage provided that your current
continuation coverage resulted from the subscriber's leave of absence, retirement, reduction in hours,
layoff, or his or her termination of employment for reasons other than gross misconduct. To request an
extension of continuation, you must notify the employer in writing of the Social Security Administration's
determination. within 60 calendar days after the latest o£
a. the date of the Social Security Administration's disability determination;
b. the date of the subscriber's termination of employment, reduction of hours, leave of absence,
retirement, or layoff; or
c. the date on which you would lose coverage under the GMC as a result of the subscriber's
termination, reduction of hours, leave of absence, retirement, or layoff.
Yoa~ must submit your written notice of total disability within the 60 day timeframe, as described
previously in Item #1, and before the end of the 18`h month of your initial continuation coverage using the
employer's approved disability notice form. (You may obtain a copy of the approved form from the
employer.) This notice must be submitted, in writing, to the employer and must include the following:
a. the name of the employer;
b. the name and address of the subscriber or former subscribes ;
c. the names and addresses of all applicable dependents currently on continuation coverage;
d. the description and date of the initial qualifying event that started your continuation coverage;
e. the name of the disabled member;
f. the date the member became disabled;
g. the date the Social Security Administration made its determination of disability;
h. a copy of the Social Security Administration's determination of disability; and
i. the name, address, and telephone number of the individual submitting the notice. This
j. individual can be a subscriber, former subscriber, or his or her dependent(s); or a representative
acting on behalf of the employee or dependent(s).
If yocr do not supply all notice requirements in writing as previously described, then yoit must follow the
employer's requirements and specified time period for submitting, in writing, all required information
and supporting documentation.
3. To elect an extension of continuation, you must notify the employer of the Social Security
Administration's determination, in writing, within the 60 calendar day and the initial 18-month
continuation period. timeframes, by following the notification procedure as previously explained in Item
#1 and #2, and. submitting the employer's approved form; and
PIC07-740-RI (1/09) 64 (PCH10409} 1500.75.2RxF.V
4. You must pay continuation premizzzn contributions:
a. The premium contribution to continue coverage is the combined employer plus subscriber rate
charged under the GMC, plus the employer may charge an additional 2% of that rate. For a member
receiving an additional 11 months of coverage after the initial 18 months due to a continuation
extension for Social Security disability, the premium contribution for those additional months maybe
increased to 150% of the employer's total cost of coverage. The disability notice form will set forth
your continuation premium contribution rate(s).
b. The first premium contribution must be paid by check within 45 calendar days after electing to
continue the coverage. Thereafter, the member's monthly payments are due and payable by check at
the beginning of each month for which coverage is continued.
c. The mecnber must pay subsequent premiccm contributions by check on or before the required due
date, plus the 30-calendar day grace period required by law, and if authorized by PIC, such longer
period allowed by the employer.
B. Second Oualifvin~ Events for Covered Deyendents Only:
If you are currently enrolled in continuation coverage under this GMC and the subscriber dies, or in the
case of divorce or a legal separation of the subscriber, or a covered dependent child loses eligibility, then
you may request an extension of coverage provided that your current continuation coverage resulted from
the szebscriber's leave of absence, retirement, reduction in hours, layoff or his/her termination of
employment for reasons other than gross misconduct or resulted from a Social Security Administration
disability determination. To request an extension of continuation, yon must notify the employer in
writing within 60 calendar days after the later of:
a. the date of the second qualifying event (death, divorce, legal separation, loss of dependent child
status); or
b. the date on which the covered dependent(s) would lose coverage as a result of the second qualifying
event.
Note: This extension is only available to a covered spouse and covered dependent children. This
extension is not available when a subscriber becomes enrolled in Medicare.
2. Yozc must submit your written notice of a second qualifying event within the 60 day timeframe, as
previously described in Item #l, using the employer's approved second event notice form. (You may
obtain a copy of the approved form from the employer.) This notice must be submitted to the employer
in writing and must include the following:
a. the name of the employer;
b. the name and address of the subscriber or former subscczbec ;
c. the names and addresses of all applicable dependents currently on continuation;
d. the description and date of the initial qualifying event that started your continuation coverage;
e. the description and date of the second qualifying event;
f. documentation pertaining to the second qualifying event such as: a decree of divorce or legal
separation, death certificate, marriage certificate for child, student transcript showing last day of
student enrollment, etc.; and
g. the name, address, and telephone number of the individual submitting the notice. This individual can
be a scbscriber, former subscriber, or his or her dependent(s); or a representative acting on behalf of
the employee or dependent(s).
If you do not supply all notice requirements in writing as previously described, then yocz must follow the
employer's requirements and specified time period for submitting, in writing, all required information
and supporting documentation.
PIC07-740-RI (1/09) 65 (PCH10409) 1500.75.2RxF.V
3. To elect an extension of continuation coverage, you must notify the employer of the second qualifying
event in writing within the 60 calendar day timeframe, by following the notification procedure as
previously explained in Item #1 and #2, and submitting the employer's approved form; and
4. You must pay continuation premium contributions:
a. The premiccm contribution to continue coverage is the combined employer plus subscriber rate
charged under the GMC, plus the employer may charge an additional 2% of that rate. For a member
receiving an additional 11 months of coverage after the initial 18 months due to a continuation
extension for Social Security disability, the premium contribution for those additional months may be
increased to 150% of the employer's total cost of coverage. The election form will set forth yoccr
continuation premiccm contribution rates.
b. The first premium contribution must be paid by check within 45 calendar days after electing to
continue the coverage or such longer period as required by law. Thereafter, the member's monthly
payments are due and payable by check at the beginning of each month for which coverage is
continued.
c. The member must pay subsequent premiccm contributions by check on or before the required due
date, plus the 30-calendar day grace period required by law, and if authorized by PIC, such longer
period allowed by the employer or as required by law.
Additional Notices You Must Provide: Other Coverages, Medicare Enrollment and Cessation of
Disability
You must also provide written notice of (1) your other group coverage that begins after continuation is elected
under the GMC; (2) yoccr Medicare enrollment (Part A, Part B or both parts) that begins after continuation is
elected under the GMC; and (3} the member, whose disability resulted in a continuation extension due to
disability, being determined to be no longer disabled by the Social Security Administration.
Your written notice must be submitted using the employer's approved notification form within 30 calendar days
of the events requiring additional notices as previously described. The notification form can be obtained from the
employer and must be completed by you and timely submitted to the employer. In addition to providing all
required information requested on the employer's approved notification form, your written notice must also
include the following:
1. If providing notification of other coverage that began after continuation was elected, the name of the member
who obtained other coverage, and the date that other coverage became effective.
2. If providing notification of Medicare enrollment, the name and address of the member that became enrolled
in Medicare, and the date of the Medicare enrollment.
3. If providing notification of cessation of disability, the name and address of the formerly disabled member, the
date that the Social Security Administration determined that he or she was no longer disabled, and a copy of
the Social Security Administration's determination.
PIC07-740-R1 (I/09) 66 (PCH10409) 1500.75.2RxF.V
CONTINUATION CHART
If coverage under this GMC is lost Who is eligible to
because this ha ens... continue... Covera a ma be continued until...
The subscriber's leave of absence, early Subscriber, The earliest of the following occurs:
retirement, hours were reduced, layoff, covered spouse 1. 18 months after continuation began.
or his or her employment with the and covered 2. Coverage begins under another group
employer ended for reasons other than dependent health plan after continuation coverage is
gross misconduct. children elected under the GMC.
3. Coverage would otherwise end under the
GMC.
Death of the subscriber. Covered spouse The earliest of the following occurs:
and covered 1. Coverage begins under another group
Member must provide notice of such dependent health plan after continuation coverage is
event to the employer in accordance children elected under the GMC.
with the employer's notice procedures 2. Coverage would otherwise end under the
previously described. for such events. GMC.
Divorce or legal separation from the Covered former The earliest of the following occurs:
subscriber-. spouse and 1. Coverage begins under another group
covered health plan after continuation coverage is
Member must provide notice of such dependent elected under the GMC.
event to the employer in accordance children 2. Coverage would otherwise end under the
with the employer's notice procedures GMC.
reviously described for such events.
Enrollment of the subscriber in Covered spouse The earliest of the following occurs:
Medicare. and covered 1. 36 months after continuation coverage
dependent began.
Member must provide notice of such children 2. Coverage begins under another group
event to the employer in accordance health plan.
with the employer's notice procedures 3. Coverage would otherwise end under the
previously described for such events. GMC.
Enrollment of the subscriber in Covered spouse The earliest of the following occurs:
Medicare within 18 months before the and covered 1. 36 months after enrollment of subscriber
subscriber's hours were reduced or dependent in Medicare.
termination of employment for reasons children 2. Coverage begins under another group
other than gross misconduct. health plan after continuation coverage is
elected under the GMC.
Member must provide notice of such 3. Enrollment, after continuation coverage is
event to the employer in accordance elected under the GMC, of the applicable
with the employer's notice procedures member in either Part A or Part B or both
previously described for such events. Parts of Medicare.
4. Coverage would otherwise end under the
GMC.
Loss of eligibility by a covered Covered The earliest of the following occurs:
dependent child. depeaulent child 1. 36 months after continuation coverage
began.
Member must provide notice of such 2. Coverage begins under another group
event to the employer in accordance health plan after continuation coverage is
with the employer's notice procedures elected under the GMC.
previously described for such events. 3. Coverage would otherwise end under the
GMC.
PIC07-740-R1 (1/09) 67 (PCH10409} 1500.752RxF.V
The employer files a voluntary or
involuntary petition for protection under
the bankruptcy laws found in Title XI of
the United States Code. Covered retiree,
covered spouse
and covered
dependent
children 1. Lifetime continuarian for covered
retiree.
2. 36 months after death of covered retiree
for covered spouse and covered
dependent children.
3. Coverage begins under another group
health plan after continuation coverage is
elected under the GMC.
4. Coverage would otherwise end under the
GMC.
The subscriber is absent from work due Subscriber, Coverage would otherwise end under this
to total disability that occurred while the covered spouse GMC.
subscriber is employed by the employer and covered
and covered under this GMC. dependent
children
The subscriber, covered. spouse or Subscriber, The earliest of the following occurs:
covered dependent child is determined covered spouse 1. 29 months after continuation began or
by the Social Security Administration to and covered until the first month that begins more
be totally disabled within the first 60 dependent than 30 calendar days after the date of
calendar days of continuation coverage children any final determination that subscriber,
that resulted from the subscriber's leave covered spouse or covered dependent
of absence, early retirement, reduction in child is no longer disabled.
hours, layoff, or his or her termination of 2. Coverage begins under another group
employment with the employer for health plan after continuation coverage is
reasons other than gross misconduct. elected under the GMC.
3. Enrollment, after continuation coverage
Notice of such disability must be is elected under the GMC, of the
provided by the member to the employer applicable member in either Part A or
in accordance with the employer's notice Part B or both Parts of Medicare.
procedures previously described for 4. Coverage would otherwise end under the
continuation extensions due to Social GMC.
Security disability.
Special Enrollment Periods
If you are a szzbscriber•, covered spouse or covered dependent who is enrolled in continuation coverage under
this COC due to a qualifying event (and nat due to another enrollment event such as a special or annual
enrollment), the Special Enrollment Period provisions of this COC as referenced in the section which
describes eligibility and enrollment will apply to you during the continuation period required by federal law
as such provisions would apply to an active eligible employee. Eligible dependents that are newborn
children or newly adopted children (as described in the eligibility and enrollment section) that are acquired
by a subscriber during such subscriber's continuation period. required by federal law, and are enrolled
through special enrollment, are entitled to continue coverage for the maximum continuation period required
by law.
If the continuation period required by federal law has been exhausted, and yozz are enrolled for additional
continuation coverage pursuant to state law or the eligibility provisions of this COC, yozz may be entitled to
the special enrollment rights upon acquisition of a new dependent through marriage, birth, adoption,
placement for adoption, or legal guardianship, as referenced in the section entitled Special Enrollment
Period for New Dependents Only.
PIC07-740-RI (1/09) 68 (PCH10409} 1500.75.2RxF.V
Special Rule for Pre-Existing Conditions
A subscriber, his or her covered spouse or covered dependent child who is enrolled in continuation coverage
under this GMC and then obtains other group coverage that excludes benefits for pre-existing conditions
applicable to such member, may choose to remain on continuation coverage under the GMC for the
remainder of his or her continuation period for coverage of apre-existing condition.
Special Rule for Persons Qualifying for Federal Trade Act Adjustments
The Federal Trade Act of 2002 gives special continuation rights to subscribers who terminate employment
or experience a reduction of hours, and who qualify fora "trade readjustment allowance" or "alternative
trade adjustment assistance" under Federal Trade Act laws. These employees are entitled to a second
opportunity to elect continuation coverage for themselves and certain family members (if they did not
already elect continuation coverage), but only within a limited period of 60 calendar days (or less) and only
during the six months immediately after their group health plan coverage ended.
If yoz~ qualify or may qualify for trade adjustment assistance under the Trade Act, contact the employer for
additional information. You must contact the employer promptly after qualifying for trade adjustment
assistance or you will lose your special continuation rights.
All notices, elections, and information required to be furnished or submitted by a member, covered
spouse or covered dependent children for purposes of continuation coverage must be submitted in
writing to the employer at the employer's address. You must follow the employer's requirements for
submitting written notices.
Public Sector Eligible Retirees
A covered eligible retired employee of certain public or governmental entities of the State of Minnesota and
covered dependents of such retiree, who are enrolled for dependent coverage as of the date the retiree
terminated employment, may be eligible to continue such coverage upon retirement pursuant to Minnesota
Statute Section 471.61. If a covered eligible retired employee qualifies under this law, he or she may be
required to pay the entire contribution for continued coverage and will be required to notify his or her
employer, within the deadline required by law, of intent to continue coverage. An eligible retired employee
W110 dOeS nOt elect t0 GOntlnLle CUVerage dyes iiot tiavc a rigiii iu re-enter yr re-enrvii yr Cvve'i'uge at a later
date.
PIC07-740-R1 (1/09} 69 (PCH10409} 1500.75.2RxF.V
Your Right to Convert Coverage
Your employer must notify you of your right to convert coverage. You are eligible to convert to an individual
conversion plan without proof of good health or waiting periods on the later of the following dates:
1. Your coverage under the GMC ends, or;
2. Upon exhaustion of your eligibility for continuation coverage under the GMC.
However, you will not be eligible for a conversion contract if any of the following are true:
1. You are covered under a plan providing similar benefits such as another qualified plan prescribed by Section
62E.06 of the Minnesota Statutes, group health plan, state plan under title XIX of the Social Security Act;
2. Yozz are eligible for Medicare;
3. Coverage terminated due to the member's failure to pay, when due, any required contribzztion toward
premium;
4. Coverage terminated due to fraud;
5. You are or could be covered under a continuation of coverage provision under the GMC.
If you are eligible for and timely apply for a conversion contract as described below, then coverage for you and
all your enrolled dependents will be effective on the first calendar day following termination of coverage under
the GMC. There will be no gap in coverage.
What you must do:
1. Contact Customer Service for conversion information;
2. Select a qualified conversion plan;
3. Submit a written application and premium payment for a conversion contract within 31 calendar days after
your coverage under the GMC ends.
PIC07-740-R1 (1/09) 70 (PCH10409) 1500.75.2RxF.V
Subrogation and Reimbursement
PIC's Subrogation Rights
For the purposes of this section, "subrogation" means PIC's right to allocate risk in accord with Minnesota
Statutes 62A.095 and 62A.096 so that your medical claims are ultimately paid by the party that shauld rightfully
bear the burden of the loss.
1. PIC is subrogated to any and all claims and causes of action that may arise against any person, corporation,
and/or other entity and any insurance coverage, no-fault, uninsured motorist, underinsured motorist, medical
payment provision, liability insurance policies, homeowners liability insurance coverage, medical malpractice
insurance coverage, patient compensation fund, and any applicable umbrella insurance coverage or other
insurance or funds.
2. PIC's subrogation interest is the reasonable cash value of any benefits received by you. PIC's subrogation
and/or reimbursement interest applies only after you have received a full recovery for your sickness or irzjccry
from another source of compensation for your sickness or injauy.
3. PIC's right to recover its subrogation interest is subject to a pro rata subtraction for actual monies paid for
costs and reasonable attorney fees which shall not exceed the prevailing cost in the same geographical local
where the loss arises, and costs you pay in obtaining your recovery.
4. If the health carrier and covered person cannot reach agreement on allocation, the health carrier and covered
person shall submit the matter to binding arbitration.
5. Nothing in this section shall limit PIC's right to recovery from another source which may otherwise exist at
law.
Notice Requirement
You must provide timely written notice to PIC of the pending claim, if you make a claim against a third party for
damages that include repayment for medical and medically related expenses incurred for your benefit. Not
withstanding any other law to the contrary, the statute of limitations applicable to PIC's rights for reimbursement
or subrogation does not commence to run until the notice has been given.
PIC07-740-R1 (1/09) 71 (PCH10409) 1500.75.2RxF.V
Coordination of Benefits
As a member, you agree to permit PIC to coordinate obligations under this COC with payments under any other
health benefit plans as specified below, which cover you as an employee or dependent. You also agree to
provide any information or submit any claims to other health benefit plans necessary for this purpose. You
agree to authorize billing to other health plans for purposes of coordination of benefits.
Unless applicable law prevents disclosure of the information without the consent of the member or the
member's representative, each member claiming benefits under PIC must provide any facts needed to pay the
claim. If the information cannot be disclosed without consent, PIC will not pay benefits until the information is
given.
A. APPLICATION: This Coordination of Benefits provision applies when you have health care coverage under
more than one plan. "Plan" is defined below.
B. DEFINITIONS. These definitions only apply to the Coordination of Benefits provision:
Allowable Expenses Means a health care service or expense, including deductibles or copayments, that is
covered at least in part by any of the plans covering the person. When a plan
provides benefits in the form of services, (for example an HMO) the reasonable
cash value of each service will be considered an allowable expense and a benefit
paid. An expense or service that is not covered by any of the plans is not an
allowable expense.
Claim Determination Means a calendar year. However, it does not include any part of a year during
Period which a person has no coverage under this plan, or before the date this
Coordination of Benefit provision or a similar provision takes effect.
Closed Panel Plan Means a plan that provides health benefits to persons primarily in the form of
services through a panel of providers that have contracted with or are employed
by the plan, and that limits or excludes benefits or services provided by other
providers, except in cases of emergency or referral by a panel member.
Custodial Parent Means a parent awarded custody by a court decree. In the absence of a court
decree, it is the parent with whom the child resides more than half of the
calendar year without regard to any temporary visitation.
Dependent Means the spouse or dependent child of an employee.
Plan Means any of the following that provides benefits or services for medical or dental
care or treatment. However, if separate policies are used to provide coordinated
coverage for members of a group, the separate policies are considered parts of the
same plan and there is no Coordination of Benefits among those policies.
a. group, blanket, franchise, closed panel or other forms of group or group type
coverage (insured or uninsured);
b. hospital indemnity benefits in excess of $200 per day;
c. medical care components of group long-term care policies, such as skilled
care;
d. alabor-management trustee plan or a union welfare plan;
e. an employer or multi-employer plan or employee benefit plan;
f. Medicare or other governmental benefits, as permitted by law;
g. insurance required or provided by statute;
h. medical benefits under group or individual automobile policies;
i. individual or family insurance for hospital or medical treatment or expenses
j. closed panel or other individual coverage for hospital or medical treatment or
PIC07-740-RI (I/09) 72 (PCH10409) 1500.75.2RxF.V
expenses.
Plan does not include any:
a, amounts of hospital indemnity insurance of $200 or less per day;
b. benefits for non-medical components of group long-term care policies;
c. school accident-type coverages;
d. Medicare supplement policies;
e. Medicaid policies and coverage under other governmental plans, unless
permitted by law.
Each contract for coverage listed above is a separate plan. If a plan has two parts
and Coordination of Benefits rules apply to one of the two, each of the parts is
treated as a separate plan. The benefits provided by a plan include those that
would have been provided if a claim had been duly made.
Primary Plan/ Means the order of benefit determination rules which determine whether this Plan
Secondary Plan is a "primary plan" or "secondary plan" when compared to the other plan covering
the person.
When this Plan is primary, its benefits are determined before those of any other plan and without considering any
other plan's benefits. When this Plan is secondary, its benefits are determined after those of another plan and may
be reduced because of the primary plan's benefits.
C. ORDER OF BENEFIT DETERMINATION RULES: The primary plan pays or provides its benefits as if the
secondary plan or plans did not exist. The order of benefit determination rules below determine which plan will
pay as the primary plan. The primary plan that pays first pays without regard to the possibility that another plan
may cover some expenses. A secondary plan pays after the primary plan and may reduce the benefits it pays so
that payments from all group plans do not exceed 100% of the total allowable expense.
A plan that does not contain a Coordination of Benefits provision that is consistent with this section is always
primary. Exception: Group coverage designed to supplement a part of a basic package of benefits may provide
that the supplementary coverage shall be excess to any other parts of the plan provided by the employer.
A Tian ma•~ consider the benefits „aid or »,-n~rided by another »lan in determining its benefits only when it is
1,...,. ~ r r ~ r ----- -
secondary to that other plan.
PIC will not pay more than it would have paid had it been the primary plan. PIC determines its order of benefits
by using the first of the following that applies:
Group/Individual Coverage: The order of benefits when a person is covered by both an individual plan and
a group or group type plan is:
a. the group or group type plan covering the person is the primary plan; and
b. the individual plan is the secondary plan.
2. Nondependent/Dependent: The plan that covers the person other than as a dependent, for example as an
employee, subscriber, or retiree, is the primary plan; and the plan that covers the person as a dependent is the
secondary plan.
Exception: If the person is a Medicare beneficiary and federal law makes Medicare:
a. secondary to the plan covering the person as a dependent; and
b. primary to the plan covering the person as a nondependent (e.g., a retired employee); then the order is
reversed, so the plan covering that person as a nondependent is secondary and the other plan is primary.
PIC07-740-R1 (1/09) 73 (PCH10409) 1500.75.212xF.V
Child Covered Under More Than One Plan: The order of benefits when a child is covered by more than
one plan is:
a. The primary plan is the plan of the parent whose birthday is earlier in the year if
• The parents are married;
• The parents are not separated (whether or not they ever have been married); or
• A court decree awards joint custody without specifying that one party has the responsibility to provide
health care coverage.
If both parents have the same birthday, the plan that covered either of the parents for a longer time is
primary.
b. If the specific terms of a court decree state that one of the parents is responsible for the child's health care
expenses or health care coverage and the plan of that parent has actual knowledge of those terms; then that
plan is primary. This rule applies to claim determination periods or plan years commencing after the plan
is given notice of the court decree.
c. If the parents are not married, or are separated (whether or not they ever have been married) or are
divorced, the order of benefits is:
• The plan of the custodial parent;
• The plan of the spouse of the custodial parent;
• The plan of the non-custodial parent; and then
• The plan of the spouse of the non-custodial parent.
4. Active/Inactive Employee: The plan that covers a person as an employee who is neither laid off nor retired
(or as that employee's dependent) is primary to a plan that covers the person as a laid off or retired employee
(or as that employee's dependent). If the other plan does not have this rule, and if, as a result, the plans do not
agree on the order of benefits; then this rule is ignored. This rule does not apply if the rule under paragraph 2
can determine the order of benefits. For example, coverage provided to a person as a retired worker and as a
dependent of an actively working spouse will be determined under the rule labeled 2.
5. Continuation Coverage: If a person whose coverage is provided under a right of continuation provided by
the federal or state law is also covered under another plan, then:
a. the plan covering the person as an employee, member, subscriber, or retiree (or as a dependent of an
employee, member; subscriber, or retiree) is the primary plan; and
b. the continuation coverage is the secondary plan.
If the other plan does not have this rule; and if, as a result, the plans do not agree on the order of benefits then
this rule is ignored. This rule does not apply if the rule under paragraph 2 can determine the order of benefits.
6. Longer/Shorter Length of Coverage: The plan that covered the person as an employee, dependent or retiree
for a longer time is primary.
Note: PIC will not pay more than it would have paid had it been primary.
D. THE EFFECT ON THE BENEFITS OF THIS PLAN: When PIC is secondary, it may reduce its benefits, so
that the total benefits paid or provided by all plans during a claim determination period are not more than 100% of
total allowable expenses. Savings equal the difference between:
1. the benefit payment that PIC would have paid had it been the primary plan; and
2. the benefit payments that PIC actually paid or provided.
E. RIGHT TO RECEIVE AND RELEASE INFORMATION: Certain facts about health care coverage and
services are needed to apply Coordination of Benefit rules and to determine benefits payable under PIC and other
plans, PIC may get the facts it needs from or give them to any other organization or persons for the purpose of
applying these rules and determining benefits payable under PIC and other plans covering the person claiming
benefits. PIC need not tell, or get the consent of, any person to do this. Each person claiming benefits under PIC
PIC07-740-RI (1/09) 74 (PCH10409) 1500.75.2RxF.V
must give PIC any facts it needs to apply those rules and determine benefits payable. Release of information will
comply with state and federal laws.
F. FACILITY OF PAYMENT: A payment made under another plan may have included an amount that should have
been paid under PIC. If it does, PIC may pay that amount to the organization that made the payment. That
amount will then be treated as though it was a benefit paid under PIC. PIC will not pay that amount again. The
term "payment made" includes providing benefits in the form of services. In this case "payment made" means the
reasonable cash value of the benefits provided in the form of services.
G. RIGHT OF RECOVERY: If PIC paid more than it should have paid, it may recover the excess from one or
more of the following:
1. the persons PIC has paid or for whom it has paid; or
2. any other person or organization that maybe responsible for the benefits or services provided under PIC to the
membef-.
The "amount of payments made" includes the reasonable cash value of any benefits provided in the form of
services.
H. COORDINATING WITH MEDICARE: This section describes the method of payment if Medicare pays as
the primary plan.
If a provider has accepted assignment of Medicare, PIC determines allowable expenses based upon the amount
allowed by Medicare. PIC's allowable expenses are the lesser of the PIC Non-Participating Provider
Reimbursement Value or the Medicare allowable amount. PIC pays the difference between what Medicare pays
and PIC's allowable expenses.
When Medicare would be the primary plan, but the member who is eligible for Medicare has not enrolled with
Medicare, then PIC will pay as the primary plan.
Renal Failure. If you begin to have services related to renal failure, we request that you sign up for Medicare.
PIC07-740-RI (1./09) 75 (PCH10409} 1500.75.2RxF.V
How to Submit a Bill if You Receive One for Covered Services
Bills from Participating Providers
When you present your identification card at the time of requesting services from participating providers,
paperwork and submission of post-service claims relating to services will be handled for yozt by your
participating provider. You may be asked by your provider to sign a form allowing your provider to submit
claims on your behalf. If you receive an invoice or bill from your provider for services, simply return the bill or
invoice to your provider, noting your enrollment with PIC. Your provider will then submit the post-service claim
with PIC in accordance with the terms of its participation agreement. Your past-service claim will be processed
for payment according to PIC guidelines. PIC must receive post-service claims within 15 months after the date
services were inczrred, except in the absence of your legal capacity. If the GMC is terminated, the deadline for
the receipt of post-service claims is 180 calendar days. Post-service claims received after the deadline will be
denied.
Bills from Non-Participating Providers
Claim Submission. You must submit an itemized bill for post service claims to PIC along with written proof that
documents the date and type of service, a specific medical diagnosis and treatment, service or procedure code,
and provider name and charges. PIC must receive post-service claims within 15 months after the date services
were incurred, except in the absence of your legal capacity. If the GMC is terminated, the deadline for the receipt
ofpost-service claims is 180 calendar days. Post-service claims received after the deadline will be denied.
Payment of Post-Service Claims. Post-service claims for benefits will be paid promptly upon receipt of written
proof of loss. Benefits which are payable periodically during a period of continuing loss will be paid on a
periodic basis. All or any portion of any benefits provided by PIC may be paid directly to the provider rendering
the services. Payment will be made according to PIC coverage guidelines.
Initial Benefit Determinations of Post-Service Claims
Post-service claims are claims that are filed for payment of benefits by PIC after medical care has been received
and submitted in accordance with PIC's post-service claim filing procedures.
If your attending provider submits apost-service claim on your behalf, the provider will be treated as your
authorized representative by PIC for purposes of such claim and associated appeals unless you specifically direct
otherwise to PIC within ten (10) business days from PIC's notification that an attending provider was acting as
your authorized representative. Your direction will apply to any remaining appeals.
If your post-service claim is denied, PIC will communicate such denial within 30 calendar days after receipt of a
post-service claim. If PIC does not have all information it needs to make an initial benefit determination, it may
request the necessary information from you or a third party. You or the third party will then have at least 45
calendar days to provide the requested information. Once the necessary information has been supplied, PIC will
notify you of its initial benefit determination within 15 calendar days. If you or a third party fail to provide the
necessary information, PIC will notify you of its initial benefit determination within 15 days after the expiration
of the 45 day period. PIC may, but is not required to, take into account information provided more than 45
calendar days after PIC's request in reconsidering a claim. In no event, however, will PIC consider information
received more than 365 calendar days after the date services were incurred.
PIC07-740-R1 (1/09) 76 (PCH10409) 1500.75.2RxF.V
Complaint and Appeal Procedures
How to Submit a Complaint
You may submit a complaint by telephone or in writing to PIC. The complaint should include the specific reason
for the complaint and any supporting documents.
1. Complaints About Administrative Operations and Matters Other than Claims. If the telephone
complaint is not resolved to your satisfaction within 10 calendar days after PIC receives your complaint, you
may submit yoccr complaint in writing. Customer Service is available to provide any assistance necessary to
complete a written complaint form.
PIC will notify you that it received your written complaint within 14 calendar days, unless your complaint
already is resolved.
PIC will notify you of its decision within 30 calendar days from the date that it receives your complaint.
In certain circumstances, PIC may take up to 14 additional calendar days to notify you of its decision. In
such cases, PIC will notify yocc, in advance, of the reasons for the extension and the date when you may
expect the final decision.
2. Complaints About Claims, PIC will notify you of its decision in accordance with the following time
periods:
If you are requesting benefits that require pre-certification (a pre-serti>iee claim), your request will be handled
in accordance with the pre-certification section of this COC. If your complaint is about a claim for benefits for
services received (a post-service claim) your complaint must be submitted to PIC within 180 calendar days
following denial of the initial determination. A decision on your post-sen~ice claim complaint will be made
within 30 calendar days from receipt of your complaint. This time period maybe extended if you agree.
How to Request an Appeal
T_f after the fret level of pre-certification or complaint review, your request was denied, you or your authorized
representative may appeal PIC 's decision by telephone or in writing. PIC will review your appeal and will notify
you of its decision in accordance with the following procedures and time periods. PIC must be provided all the
information needed to make a decision. If PIC does not have all information it needs and cannot obtain complete
information from you or your provider within the time periods set forth below for deciding an appeal, yocrr
request will be denied.
Pr-e-Service Claims. If the appeal concerns acute services, you may request an expedited review. Within 72
hours of receipt of such request, a decision on your appeal will be made. PIC will notify yocrr attending
provider by telephone of its determination as quickly as your medical condition requires, but no later than 72
hours after PIC receives the appeal. Written notification will be sent to you and your- attending provider
within one business day of the determination, or sooner if your medical condition requires. If the appeal
concerns non-acute services, a decision on your appeal will be made within 30 calendar days. This time
period maybe extended. for up to 15 calendar days if yocr agree. This appeal must be submitted to PIC within
180 calendar days following denial of the initial determination. When you appeal the initial determination for
medical reasons, PIC will arrange for review of the clinical material by a physician in the same or similar
specialty who did not make the initial determination.
2. Post-Service Claims. If your complaint is not resolved to your satisfaction or if you received services after
yocrr request for pre-certification was denied or after you failed to seek pre-certification for services for which
pre-certification was required, you may contact PIC and request a written appeal or a hearing within 60
PIC07-740-R1 (1/09) 77 (PCH10409) 1500.75.2RxF.V
calendar days of the first level complaint denial. If you want a written appeal, you should submit relevant
documents to PIC. PIC's decision on any written appeal will be made within 30 calendar days after receiving
your appeal request. You will receive a written copy of the decision, including the key findings on which the
decision is based.
If you request a hearing instead of a written appeal, you will have an opportunity to submit testimony,
correspondence, explanations or other information as appropriate. PIC's decision from any appeal hearing
will be made within 30 calendar days after receiving yozzr request. Yozz will receive a written copy of the
decision, including the key findings on which the decision is based.
The above time periods maybe extended if yozz agree.
Upon request and free of charge, you have the right to reasonable access to and copies of all documents,
records, and other information relevant to your claim for benefits.
If the determination of the appeal is to uphold an initial determination not to cover the service, the
determination may be submitted for an external review. See the subsection entitled "How to File an External
Review."
How to File a Complaint with the Commissioner of Commerce
You or someone acting on your behalf may file a request for review with the Commissioner of Commerce at any
time. You may reach the Minnesota Department of Commerce at 651.296.4026 within the Twin Cities
metropolitan area or call 1.800.657.3602 from outside the Twin Cities.
How to File an External Review
An external review organization is an independent entity under contract with the State of Minnesota to review
health plan complaints. You may request an external review at any time including, if you or someone acting on
your behalf has exhausted the PIC internal complaint and appeal processes, you or your representative may file a
request for external review to the Commissioner of Commerce at the following address:
Minnesota Department of Commerce
Attention: Enforcement Division
85 East Seventh Place
Suite 500
St. Paul, MN 55101-2198
The fee required for an external review is $25. However, the fee may be waived due to hardship. All disputes
and complaints may be submitted for an external review, except cases of fraudulent marketing and agent
misrepresentation. External review decisions are binding on PIC, but not binding on the member.
PIC07-740-R1 (1/09) 78 (PCH10409) 1500.75.2RxF.V
No Guarantee of Employment or Overall Benefits
The adoption and maintenance of this COC does not guarantee or represent that coverage will continue indefinitely
with respect to any class of employees and shall not be deemed to be a contract of employment between the employer
and any subscriber. Nothing contained herein shall give any subscriber the right to be retained in the employ of the
employer or to interfere with the right of the employer to discharge any subscriber, at any time, nor shall it give the
employer the right to require any subscriber to remain in its employ or to interfere with the subscriber's right to
terminate his or her employment at any time not inconsistent with any applicable employment contract. Nothing in
this COC shall be construed to extend benefits for the lifetime of any member or to extend benefits beyond the date
upon which they would otherwise end in accordance with the provisions of the GMC or any benefit description.
Definitions
Bariatric Surgery Surgery related to the treatment of obesity.
Biofeedback The technique of making unconscious or involuntary bodily processes (such as
heartbeat or brain waves} perceptible to the senses in order to manipulate them by
conscious mental control.
Calendar- Year The 12-month period beginning January 1 and ending the following December 31 for
provisions based on a calendar year.
Certificate of coverage The document describing, among other things, the benefits offered under PIC and
(COC) your rights and obligations.
Coinsta~ance A fixed percentage of eligible charges that is paid by you and a separate fixed
percentage that is paid by PIC to the provider for cover°ed services and supplies.
Cainsuranee will be teased on (1) the discounted charge negotiated between PIC and
participating providers; or (2) the PIC Non-Participating Provider Reimbursement
Value for non participating providers.
Combination Drug A prescription drTatg in which two or more chemical entities are combined into one
commercially available dosage form.
Compounded Drttg Drugs which are customized drugs prepared by a pharmacist from scratch using raw
chemicals, pawders and devices according to a phtijsician's specifications to meet an
individual patient need.
Confinement An uninterrupted stay of 24 hours or more in a lzospital, skilled nursing facility,
rehabilitation facility or licensed residential treatment facility.
Continuous Coverage The maintenance of continuous and uninterrupted creditable coverage by an eligible
employee or dependent. An eligible employee or dependent is considered to have
maintained coratintrous eover~age if the individual enrolls in PIC and the break in
creditable coverage is less than 63 calendar days. See waiting period.
Cosmetic Services, medications and procedures that improve physical appearance but do not
correct or improve a physiological function, or are not medically necessary.
Covered Services Services or supplies that are provided by your licensed provider or clinic and covered
by PIC, subject to all of the terms, conditions, limitations and exclusions of PIC.
PtC07-740-R1 (1/09) 79 (PCH10409) 1500.75.2RxF.V
Ci-editable Coverage The health benefits or health coverage provided under any of the following:
1. coverage under group health plans (whether or not provided through an insurer);
2. Medicaid;
3. Medicare;
4. public health plans;
5. national health plans or programs; as well as
6. all other types of coverage set forth in the Health Insurance Portability and
Accountability Act of 1996 (HIPAA).
Custodial Care Services to assist in activities of daily living and personal care that do not seek to
cure or do not need to be provided or directed by a skilled medical professional, such
as assistance in walking, bathing and feeding.
Day Treatment Any professional or health care services at a hospital or licensed treatment facility
Sen~ices for the treatment of mental and substance related conditions.
Deductible The amount of eligible charges that each member must incur in a calendar year
before PIC will pay benefits.
Dentist A licensed doctor of dental surgery or dental medicine, lawfully performing dental
services in accordance with governmental licensing privileges and limitations.
Dental Specialist A dentist board eligible or certified in the areas of endodontics, oral surgery,
orthodontics, pedodontics, periodontics and prosthodontics.
Dependent The subscriber's eligible dependent as described in the "Eligibility" section.
Designated A participating provider or group or association of participating providers that has
Electronic/Online been designated by PIC or its designee to provide electronic/online evaluations and
Participating Provider management services for members with specific chronic diseases, as determined by
PIC or its designee. A list of such providers may be obtained by calling Customer
Service.
LLSgtiaied 1'aiisplaiit Airy iiCcnscd iiospitai, iieaitii Car?; prv'vidEY, group :.r a„SCC1atlon of health care
Network Provider providers that has entered into a contract with or through PIC to provide organ or
bone marrow transplant or stem cell support and all related services and aftercare for
a member.
Educational A service or supply:
1. whose primary purpose is to provide training in the activities of daily living,
instruction in scholastic skills such as reading and writing; preparation for an
occupation; or treatment for learning disabilities; or
2. that is provided to promote development beyond any level of function previously
demonstrated, except in the case of a child with congenital, developmental or
medical conditions that have significantly delayed speech or motor development
as long as progress is being made towards functional goals set by the attending
physician.
PIC07-740-R1 (1/09) 80 (PCH10409) 1500.75.2RxF.V
Effective Date The date a member becomes eligible for health care services and completes all
enrollment requirements, subject to any required waiting period.
Eligible Charges A charge for health care services and supplies subject to all of the terms, conditions,
limitations and exclusions of PIC and for which PIC or the member will pay.
Emergency Emergency services provided after the sudden onset or change of a medical condition
manifesting itself by acute symptoms of sufficient severity, including severe pain,
such that the absence of immediate medical attention could reasonably be expected
by a prudent layperson to result in:
1. placing the member's health in serious jeopardy;
2. serious impairment to bodily functions; or
3. serious dysfunction of any bodily organ or part.
Enrolhnent Date With respect to an individual, the date of enrollment in the health benefit plan or, if
earlier, the first day of the waiting period for enrollment under PIC.
Fee for-Service Method of payment for provider services based on each visit or service rendered.
Fee Schedule The amount that the participating provider has contractually agreed to accept as
reimbursement in full for covered services and supplies. This amount may be less
than the provider's usual charge for the service.
Formulary A list, which may change from time to time, of preferential prescription dntgs that is
used by PIC plans.
Full-time An employee working a minimum number of hours per week as specified by the
employer.
Group Master Conb~act The legal contract between the employer and PIC relating to the provisions of health
(GMC) care services.
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ttuucec~uieve ir~eruyy iu~.iaYy pryvv7ueu ~o u~.rvavy ,,.~ f7a m.,..., .r___a_.-, ~
activity or speech.
Homebound When you are unable to leave home without considerable effort due to a medical
condition. Lack of transportation does not constitute homebound status.
Hospital A facility that provides diagnostic, medical, therapeutic, and surgical services by or
under the direction of physicians and with 24-hour registered nursing services. The
hospital is not mainly a place for rest or custodial care, and is not a nursing home or
similar facility.
Incurred Services and supplies rendered to you. Such expenses shall be considered to have
been incurred at the time or date the service or supply was actually purchased or
provided.
bzjury Bodily damage other than sickness including all related conditions and recurrent
symptoms.
PIC07-740-R1 (1/09) 81 (PCH10409) 1500.75.2RxF.V
Investigative As determined by PIC, a drug, device or medical treatment or procedure is
investigative if reliable evidence does not permit conclusions concerning its safety,
effectiveness, or effect on health outcomes. PIC will consider the following
categories of reliable evidence, none of which shall be determinative by itself:
Whether there is a final approval from the appropriate government regulatory
agency, if required. This includes whether a drug or device can be lawfully
marketed for its proposed use by the United States Food and Drug
Administration (FDA); if the drug or device or medical treatment or procedure
the subject of ongoing Phase I, II, or III clinical trials; or if the drug, device or
medical treatment or procedure is under study or if further studies are needed to
determine its maximum tolerated dose, toxicity, safety or efficacy as compared to
standard means of treatment or diagnosis; and
2. Whether there are consensus opinions or recommendations in relevant scientific
and medical literature, peer-reviewed journals, or reports of clinical trial
committees and other technology assessment bodies. This includes consideration
of whether a drug is included in the American Hospital Formulary Service as
appropriate for its proposed use; and
3. Whether there are consensus opinions of national and local health care providers
in the applicable specialty as determined by a sampling of providers, including
whether there are protocols used by the treating facility or another facility, or
another facility studying the same drug, device, medical treatment or procedure.
In addition to the above, PIC must determine, on a case-by-case basis, that a drug,
device or medical treatment or procedure meets the following criteria:
I. Reliable evidence preliminarily suggests a high probability of improved
outcomes compared to standard treatment (e. g. significantly increased life
expectancy or significantly improved function); and
2. Reliable evidence suggests conclusively that beneficial effects outweigh any
harmful effects; and
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proposed use; and
4. Reliable evidence suggests the drug, device or treatment is medically appropriate
for the member.
When PIC determines whether a drug, device, or medical treatment is investigative,
reliable evidence will also mean published reports and articles in the authoritative
peer-reviewed medical and scientific literature; the written protocols or protocols
used by the treating facility or the protocol(s) of another facility studying
substantially the same drug, device or medical treatment or procedure, which
describes among its objectives, determinations of safety, or efficacy in comparison to
conventional alternatives, or toxicity or the written informed. consent used by the
treating facility or by another facility studying substantially the same drug, device or
medical treatment or procedure.
Reliable evidence shall mean consensus opinions and recommendations reported in
the relevant medical and scientific literature, peer-reviewed journals, reports of
clinical trial committees, or technology assessment bodies, and. professional
consensus options of local and national health care providers.
PIC07-740-R1 (1/09) 82 (PCH10409) 1500.75.2RxF.V
Late Enrollee An eligible employee or dependent who enrolls under PIC other than during:
I. the first period in which the individual is eligible to enroll under PIC; or
2. the special enrollment period.
Maintenance Care Care that is not habililtative or rehabilitative therapy and there is a lack of
documented significant progress in functional status over a reasonable period of time.
Medically Necessary/ Diagnostic testing, preventive health care services, and medical treatment consistent
Medical Necessity with the diagnosis of a prescribed course of treatment for member's condition, which
PIC determines and will use its discretion on a case-by-case basis are consistent with
the medical standards and accepted practice parameters of the community and
considered necessary for member's condition; and
1. help to restore or maintain member's health; or
2. prevent deterioration of member's condition; or
3. prevent the reasonably likely onset of a health problem or detect a problem that
has no or minimal symptoms.
Member A subscriber or dependent who is enrolled under the GMC.
Non-Participating A licensed provider not under contract as a participating provider.
Provider
Non-Participating Coverage for services provided by licensed providers other than:
Provider Benefits 1. participating providers; or
2. the provider to which the participating provider has referred the member.
With non participating provider benefits, there is member financial responsibility of a
deductible, coinsurance, and any amount in excess of the PIC Non-Participating
Provider Reimbursement Value.
Out-of Pocket Limit The maximum amount of money you must pay in coinsurance and deductible before
PIC pays your eligible charges at 100%. If you reach benefit or overall maximums,
yot~ are responsible for amounts that exceed the ozzt-of-pocket limit.
Over-the-Counter Those drugs that are available without a physician's prescription being legally
(OTC) Drzzgs required.
Participating Proi%ider
Participating Provider
Benefits
A licensed clinic, physician, provider or facility that is directly contracted to
participate in the PIC provider network
Participating Providers may also be offered from other Preferred Provider
Organizations that have contracted with PIC.
Coverage for health care services provided through participating providers.
PIC07-740-R1 (1/09) 83 (PCH10409) 1500.75.2RxF.V
Physical Handicap A condition caused by a physical injuy or congenital defect to one or mare parts of
the member's body and thereafter the member is incapable to self-sustaining
employment and is dependent on the subscriber for a majority of financial support
and maintenance.
Physician A licensed Doctor of Medicine (M.D.}, Doctor of Osteopathy (D.O.), Doctor of
Podiatry (D.P.M.), Doctor of Optometry (O.D.) or Doctor of Chiropractic (D.C.).
PIC PreferredOne Insurance Company.
PIC Non-Pm~ticipatirrg The amount that will be paid by PIC to a non pm•ticipating provider for a service is a
Provider percentage of the lesser of the:
Reimbursement Value 1. non participating provider's charge;
2. amount based on prevailing reimbursement rates or marketplace charges, for
similar services and supplies, in the geographic area; or
3. amount agreed upon between PIC and the nonparticipating provider.
If the amount billed by the non participating provider is greater than the PlC non-
participating provider reimbursement value, you must pay the difference. This
amount is in addition to any deductible or coinsurance amount you may be
responsible for according to the terms of this COC.
Post-Service Claim A claim related to services.
Premium The payment PIC requires to be paid by an individual or employer on behalf of or for
members for the provision of the covered health care services listed in this COC.
Prescription Drug A drug approved by the Federal Drug Administration for use only as prescribed by a
physician.
Pre-Service Clairn A claim related to services that have not yet been received, and require a request for
pre-certification thhat is made by a member or his or her authorized representative in
$ccoruance `v`v'Ith the procedures descr2bed In th2s COC.
Preventive Health Health supervision including evaluation and follow-up, im2nunization, early disease
Care detection and educational services as ordered by a provider.
Provider A health care professional or facility licensed, certified or otherwise qualified under
state law to provide health care services.
Reconstructive Surgery to restore or correct:
1. a defective body part when such defect is incidental to or follows surgery
resulting from injury, sickness, or other diseases of the involved body part; or
2. a congenital disease or anomaly which has resulted in a functional. defect as
determined by a physician; or
3. a physical defect that directly adversely affects the physical health of a body part,
and the restoration or correction is determined by PIC to be medically necessary.
PIC07-740-R1 (1/09) 84 (PCH10409) 1500.75.2RxF.V
Reconstructive Surgery Coverage far members receiving covered services under PIC in connection with a
Following a mastectomy and who elects breast reconstruction in connection with such
Mastectomy mastectomy will include:
1. reconstruction of the breast on which the mastectomy has been performed;
2. surgery and reconstruction of the other breast to produce symmetrical
appearance;
3. prostheses; and
4. treatment of physical complications at all stages of mastectomy, including
lymphedemas.
Services and supplies will be determined in consultation with the attending physician
and patient. Such coverage will be subject to coinsurance and other plan provisions.
Rehabilitative Care Skilled restorative service that is rendered for the purpose of maintaining and
improving functional abilities, within a predictable period of time, (generally within a
period of six months) to meet a patient's maximum potential ability to perform
functional daily living activities. Not considered rehabilitative care are: skilled
nlrrsing facility care; home health services; chiropractic services; speech, physical and
occupational therapy services for chronic medical conditions, or long-term
disabilities, where progress toward such functional ability maintenance and
improvement is not anticipated.
Risk Allowance A percentage of the reimbursement to a participating provider that is held back by
PIC. The amount withheld generally will be less than 20% of the fee schedule
amount.
Service Area The geographic area in which PIC is approved by the appropriate regulatory
authority to market its benefit plans.
Sickness Presence of a physical or mental illness or disease.
Skilled Care Nursing or rehabilitation services requiring the skills of technical or professional
medlCa7 perSOnnel t0 r~rnyida rare nr accPCg vnttr chan~tng COndltlOri. LOrig term
..- o
dependence on respiratory support equipment does not in and of itself define a need
for skilled care.
Skilled Nursing A Medicare licensed bed or facility (including an extended care facility, hospital
Facility swing-bed and transitional care unit) that provides skilled care.
Specialist Providers other than those practicing in the areas of family practice, general practice,
internal medicine, OB/GYN or pediatrics.
Specialty Drugs Injectable and non-injectable prescription drugs having one or more of the following
key characteristics:
1. frequent dosing adjustments and intensive clinical monitoring are required to
decrease the potential for drug toxicity and to increase the probability for
beneficial outcomes;
2. intensive patient training and compliance assistance are required to facilitate
therapeutic goals;
3. there is limited or exclusive product availability and/or distribution; or
4, there is specialized product handling and/or administration requirements.
PIC07-740-R1 (1/09) 85 (PCH10409) 1500.75.2RxF.V
Standing referral A process by which a member may access covered services from a specialist for a
period of time. The referral is subject to conditions specified in this COC. The
referral must be designated in writing and in advance by PIC and is only valid for the
designated specialist (not to exceed one year).
Stepchild(ren) A natural or adopted child of the szrbscriber's lawful spouse.
Subscriber The person:
1. on whose behalf contribution is paid; and
2. whose employment is the basis for membership, according to the GMC; and
3. who is enrolled under the GMC.
Total Disability Disability (i.e., due to injzrry, sickness, or pregnancy) that requires regular care and
attendance of a physician, and in the opinion of the physician renders the employee
unable to perform the duties of his or her regular business or occupation during the
first two years of the disability, and after the first two years of the disability, renders
the employee unable to perform the duties of any business or occupation for which
he or she was reasonably fitted.
Transplant Sen~ices Transplantation (including retransplants) of the human organs or tissue, including all
related post-surgical treatment and drugs and multiple transplants for related care.
Urgent Care Center A licensed health care facility whose primary purpose is to offer and provide
immediate, short-term medical care for minor immediate medical conditions not on a
regular or routine basis.
Waiting Period The period of time that an individual must wait before being eligible for coverage
under PIC. Awaiting period will not:
1. apply towards a period of creditable coverage, or
2. be used in determining a break in contirzuozrs and creditable coverage.
Yozr% Yorrr
Refers to member.
PIC07-740-R1 (1/09) 86 (PCH10409) 1500.75.2RxF.V