HomeMy WebLinkAboutContract 22552255
PreferredOne Insurance Company
Group Master Contract
Employer: City of Columbia Heights Employer Group #: PCH10409
Address: as on file with PIC
Effective Date: January 1, 2010
This Grozrp Mastef~• Cor~t~•act ("G,f1C"j is entered into by and between Pr~eferr•edOne h~srn^aiTCe Compa~ay~
("PIC"') and the Ei~loyer. The GMC includes the Certifteate of Coverage ("COC") and Exhibits A and
B, which. are part of t13is C~~1C and incorporated by reference. The Employer accepts this GMC by
remitting the first p~~e»~riunz payment to PIC. In consideration of the monthly pr~efftiitn2 paid by the
Employer PIC will. arrange to provide the benefits described in the COC.
Once accepted, this GMC will be effective and all coves°age under this Ctl1C will begin at 12:01 a.m.
Central Time o» 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 aut}~~ority to determine eligibility for benefits and to interpret and constz•ue 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 January 4, 2010 to take
effect on the effective date stated above.
Ps-efea-redOne Insurance Company
6105 Golden Hills Drive
Golden Valley, MN
(763) 847.401.3
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Bv: 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 ti-audulent act, which is a crime.
PIC07-735-R3 I GMC (LG? 1 Ut01
SERVICES AND PAYMENT
Me~rlber Em'ollnlent and Ternllnation
The Employer will offer to all of its eligible employees the opport~mity to become a subscriher~ Linder this
G~IC. Eligible employees and qualified depe~u~ents may enroll only at such times and under such
conditions as specified in the COC and Exhibit B.
Tlla F'r3trjp~~n:^ u~i]t c»hp~t Prrrpllmerlt and terminatini? illform2_tion to PIC' to a timely 171anner and 111 a
format acceptable to PIC. PIC must receive eligible employees' completed enrollment fol-rns 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 Elrlployer'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.) Errlployer agl-ees to compensate PIC for any fees or fines incul-l'ed by
PIC as a result of Employer's faihu'e to comply with PIC's request.
When the Employer and PIC approve an application as to eligibility, the m~e~rlher'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 tel-nunation of coverage is determined in accordance
with the section entitled "Ending Yor~r Coverage" in the COC.
Pi•errr.ir~na, Billing
PIC will bill the Employer for each fi>71 month of coverage by multiplying the appropriate pr•em~iunz rate
set forth in Exhibit A by the number of persons enrolled. Full P~^errair~nl will be billed for persons who
become members between the first and fifteenth day of the month. No prei~r.irrm 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 amolmt billed.
PIC will reflect additions and deletions in enrollment in the subsequent month's billing. For tern>inatioll
of a person's coverage, the Employer will be el~igl`ble to receive a hr'erfliznrz credit for a maximum period
of three months and in no event will arty pt•ernizrm~ credit be given for a person during a month in which
the person received benefits} described in the COC.
For example, if the request to terminate a m.errrher effective May 31, ?009, is received and processed prior
to the scheduled September 2009 bill nm (done in mid-August}, the Employer will receive firll premium
credit back to Jane 20Q9 (June, Juty, August). However°, if this same request is received and processed
after the scheduled September bill rim, 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.
PiC07-73~-R3 2 GMC (LU) (1/101
Amount and Timing of Payments
PIC must receive premirrrrr payment on or before the due date, which is the first day of each month. The
prer~riurrr rate and scope of coverage provided are guaranteed fora 12 month period after the effective rktte
of this G~IIC.
The Employer has a 20-calendar day grace period to make its monthly ~r•errtiurrt payment. If all or a
portion of the prenaiuna 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 F_,mployer makes a nreryrium 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 Etrrployer's financial institution for subsequent Pr°ern~iuna
payments.
Commission Payments to Brokers
PIC pays certain commissions and other payments to brokers for placement of the Employer's business
with PIC. The amount of eomnzissions and other payments may vary from time to time depending on the
commission sh-uchu-e and the nature of the business placed with PIC At the Employer's request and
without charge, PIC will fw-nish info~7nation regarding the actual commission and other payments (if any)
paid to brokers in comleetion with the Employer's conk°aet with PIC.
Benefit Coverage
In consideration of the prernir~m paid, PIC will an-ange for the provision of benefits described in the COC
to rr~aenabers. hr 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
tinder t11is 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 Inten~al Revenue Code (Code) Section 223 and the regulations thereunder
and Minnesota law regarding health savings accounts, established by a subscr•iber• or the Employer on
behalf of a subscriher° covered under the terms of such. COC.
NOTICE
The Employer 4vi11 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 contnbution funding levels or contribution formulas for its employee coverage tinder
the COC; or
~. Disclostu~e of a Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA)
account offering.
Upon the oeetu~-ence 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.
PIC07-73~-R3 3 GMC (LGI (1/101
TERMINATION OF GMC
This CMC may be terminated as follows:
By the Employer, on at least 30-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 Luitil the last day of that month. For example, if notice is given June
1~, 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 En~lover is
responsible for its payment. V
2. By PIC, on at least 30-calendar days` written notice of termination to the Employer and subscr•ihers,
except that PIC may terminate this GMC effective the end of the mouth in which one of the following
events occurs:
a. Employer fails to pay P~•emiur~7 in a timely manner ~nrder the terms of the GMC and subject to the
notice of ternunation described in the next paragraph;
b. Employer performs an act or practice that constitutes fraud or misrepresentation of material fact;
c. Elnpioyer fails to comply with a material provision relatil~g to contributions or participation;
d. Employer ceases doing business; or
e. Upon renewal, Etr~ployer has less than two enrollees covered under this GMC.
If PIC terminates the GMC for nonpayment of the premium, it will send 30 calendar days' written
notice of ternunation to the Employer and subscr•ihe~~s, 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 su~hscr•ibers is
postmarked June 1, it may advise irtemhers that the notice is effective July 1 and that on that date their
coverage will be cancelled retroactively (60 calendar days) to Apri130`''.
Me~rther-s whose coverage terminates for aiiy of the reasons listed in items 2 and 3 above nay 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. 1f PIC terminates the GMC for nonpayment of premiurft, the notice of cancellation it sends
sitbscriber•s 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 sirhscr•ibers, PIC may rely upon the addresses supplied by the
Employer, which the Employer will update every 12 months while this GMC is in effect.
P1C07-735-R3 4 GMC (LG 1 I 1 i 101
RIGHTS AND OBLIGATIONS UPON TERMINATION.
Upon termination of this G~l1C, neither party has any further obligation to the other parry, provided
however, that such termination will not release either parry of its obligations with respect to obligations
including payment obligations accrued before and up to the termination date.
INCONTESTABILITY
Statements the E12~ployer far a 1'31Fl3itli~i' riulies relating tf) i3isiLrabllity w111 be v^vns3dered a represe.aatzon
and not a warranty. After the GMC has been in effect for two years, its validity cannot be contested,
except for nonpayment of p~°er~zium 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.
PIC07-735-R3 5 GMC (LG1 (1/l0)
EXHIBIT A
Group Master Contract
By and Between
PreferredOne Insurance Company
and
City of Columbia I-(eights
The following terms and provisions are incorporated into and made a part of the above GMC:
1) MONTI-ILY PRE~I~IUM RATE:
15.100.2.V 2500.100.4Rx.V 1500.100.2RxF.V
Employee 5489.40 $289.61 $322.71.
Family 51,125.61 5666.10 5742.23
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 Employers, and not PIC's responsibility to determine
the appropriate Exr~ployer tax treatment of, and fidfill all req~rired En~loyer reporting
requirements for all employees and dependents covered under the COC.
2 j Fr°~fer•r•e~~Orre Insrrr•mace Corrr~any (PIC} collects and remits Employee Assistance Erogra~m
(EAP) service fees to a third parry EAP service provider on behalf of the group.
3) As requested by Employer and agreed to by PIC, PIC collects and remits wellness service fees to
a designated third party wellness service provider on behalf of the Employer and/or rrrerrihers.
4} PIC offers and provides wellness incentives and services to merrrber°s covered under the GMC in
connection with wellness services received from designated third party wellness service
providers.
PiC07-73~-R3 6 GMC (LG1 (1110)
EXHIBIT B
Group Master Contract
By and Between
Prel'erredOne 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 elig~`ble employees and dependents
who have not waived coverage due to coverage under another plan, but no less than 50% of all
eligible employees ~ni~st participate under this GMC or another group health plan sponsored by
Preferr°erlOne Insurance Corrrpany ("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)
3)
4)
5)
CONTRIBUTION REQUIRE1bIENTS: The Employer will contribute at least ~0°~~ of the
employee's total prenritrrrt.
DEFINITION OF ELIGIBLE EMPLOYEES: All full-time employees of Ezrrployer defined as
working a n~iniminn of 40 hours per week, and elected officials.
RETIRED: Retirees are eligible under Minnesota Statute 471.61
t9~AITING PERIOD AND EFFECTI~B DATE OF COVERAGE: None.
Coverage begins first day of the calendar month following oi° coinciding with date of eir~ployment
and completion of required waiting period provided that application foi° coverage is received
within 31 days of the date of eligibility.
Late enr°ollees: 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 nu~st
complete the waiting per•iorl designated above.
REHIRES: Treat as new employee, subject to the waiting period.
PIC07-73~-R3 7 GMC (L,G) (1/10)
s . : ;. ,
6105 Golden H~{Is Dri~re
Ga(den `,/alley, MN 55416
January 4, 2010
City of Columbia Heights
Attention: Linda Magee
590 - 40th Avenue NE
Columbia Heights, MN 55421
Dear Ms. Magee:
Enclosed is a revised Group Master Contract for City of Columbia Heights. This contract is
effective as of your renewal date of January 1, 2010. We encourage you to read the entire
Group Master Contract so that you are familiar with all of its provisions.
Also enclosed are Certificates of Coverage for City of Columbia Heights. They replace all
previously issued Certificates of Coverage. Please file them with your Group Master Contract.
Please review and feel free to call us with any questions. Thank you.
Sincerely,
Compliance Department
PreferredOne Insurance Company
Enclosures
PCH 10409
cc: Johnson McCann Benefits
Attention: Gayle McCann
206 East Little Canada Road
St. Paul, MN 55117-1332 (Copy of GMC & COCs)
(763} 847-4000 ® Fax: (763) 847-4410 ® www.preferredone.com
An Equa! Employment OpportunityCAffirmative Action Employer
PreferredQne °
INSURANCE COMPANY
READ YOUR CERTIFICATE CAREFULLY
CITY OF COLUMBIA H~ICHTS
2.x00. `~ OO.~Rx.V
PIC07-740-R2
PCH10409 2500.100.4Rx.V (1/10)
Questions? Our Customer Services staff is available to answer questions about your
coverage rvionday Through Friday, 7:00 a.m. - 7:00 p.m. Central Standard
Time (CST)
When contacting us, please have your memher 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 provi~Per, 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
w'ebsite ww~w.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-R2 ~ PCH10409 2500.100.4Rx.V (1/10)
This COC issued in 2010 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 member
or the employer on behalf of the eligible rrrerrrber. PIC shall not be required to establish, maintain
or contribute to a health savings account on behalf of an eligible member or the employer.
PIC07-740-R2 PCH10409 2500.100.4Rx.V (1/10)
TABLE OF CONTENTS
Important Member Information .................................................................................................................................1
Member Bill of Rights ................................................................................................................................................ .. 2
Disclosure of Provider Payment Methods ................................................................................................................. .. 2
Member Information for N'on-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
C011tialtlity of Care ...............................................................................................................................................
.. '
.. 4
Medical Eia:er^gericy ................................................................................................................................................ .. 5
Group Master Contract (GMC} ............................................................................................................................ .. 5
Your Identification Card ....................................................................................................................................... ..5
Provider Directory ................................................................................................................................................ .. 5
Changes in Coverage ............................................................................................................................................. ..6
Conflict with Existing Law .................................................................................................................................... .. 6
Privacy ................................................................................................................................................................... .. 6
Clerical Error ........................................................................................................................................................ ..6
Assignment ............................................................................................................................................................ .. 6
Notice ..................................................................................................................................................................... .. 6
Time Limit on Certain Defenses ........................................................................................................................... .. 6
F-•ai~d ..................................................................................................................................................................... .. 6
Medical Technology and Treahnent 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 .............................................................................................................................................. 16
Pre-existing Condition Limitation ............................................................................................................................ 49
Exclusions .................................................................................................................................................................. 49
Ending Your Coverage ................................................................................................................................. ....... 56
Leaves of Absence ..................................................................................................................................................... 57
Family and Medical Leave Act (FMLA} ............................................................................................................... 57
The Uniformed Services Employment and Reemployment Rights Act of 1994 (USE } ................................ 57
Continuation Coverage ............................................................................................................................................. 59
Your^ Rigltt to Convert Coverage ............................................................................................................................... 69
Subrogation and Reimbursement ............................................................................................................................. 70
Coordination of Benefits ........................................................................................................................................... 71
How to Submit a Bill if You Receive One for Covered Services ................................................................................ 75
Initial Benefit Determinations of Post-Service Clairns .............................................................................................. 75
Complaint and Appeal Procedures ........................................................................................................................... 76
No Guarantee of Employment or Overall Benefits ................................................................................................... 78
Definitions ................................................................................................................................................................. 78
PIC07-740-R2 PCH10409 2500.100.4Rx.V (1/10)
Important Member Information
Covered Services: Services will be covered by PreferredOne Insurance Company (PIC). Yoz{a^ Cea°tificate 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 providea°s. When a
provider is no longer participating with PIC, yoaz must choose among remaining PIC participating providers.
Contact Customer Service for the most recent listing of PlCproviders.
Emergency Services: Emergency services from nova participatitag providers will be covered only if proper
p,-n p ~~ g _ y
ivCCdUTCS are followed. 1 viii'' C'OC~ ex lainS tree °iOCedure5 gild venelitS aSSvciated with en'aer-eaaC' Care froili
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 ail individual contract or continue coverage under certain circumstances.
These continuation and conversion rights are explained in your COC.
Termination: Youa• coverage may be terminated by yoaz or PIC only under certain conditions. Yoaa~ COC
describes all reasons for termination of coverage.
Prescriptio~i Drugs and Medical Equipment: Enrolling in PIC does slot 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 Applicat~le To Small Employer Groups: Minnesota law requires this disclosure. This plait 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 naernbers,
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 oil the fu st calendar day of the plan year.
Small employer plans are guaranteed renewable as long as the employer remains eligible for a small employer
plan.
PIC07-740-R2 1 PCHI0409 2500.I00.4Rx.V (l/10)
Member Bill of Rights
The laws of the State of Minnesota grant members certain legal rights.
As a PIC member, yorr have the following rights and responsibilities.
Merrrbcrs have the right to:
1. available and accessible services, including emergency services 24 hours a day, 7 days a week;
2. be inf~i_rped of hPaltr prnblenis and re~Pive information regardinsD treatment alternatives and risks that are
sufficient to assure informed choice;
3. refuse treatment recommended by PIC or airy provider;
4. privacy of medical or dental and financial records maintained by PIC and its pur°ticipatirrg providers, in
accordance with existing law;
file a complaint with PIC and the Conunissioner 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 1.800.6573602 and request information.
I~iscimsure ~f d's°ovr~der Payment 1l~Iethods
PIC contracts with participating provider's 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
nrernber 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 pr°ovider type and contract (i.e. per service, per
event, pei° day, by diagnostic related group or percent of charge}. The deductible and coinsurance amounts are
based on the fee schedule amount.
A pcu°ticipating pr°ovider may contractually age°ee to a r°isk~ callor~~arrce. 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, rr~renrber satisfaction, and/or, the financial situation of PIC. The method by which
the r°isk allowcrrrce is repaid may differ by provider type/specialty and therefore may vary among participating
providers. Mcrrrbers are not responsible for payment of any risk alloih~ance. Factors such as the quality,
efficiency and cost effectiveness of care that7~~articipating providers deliver may also affect future contract terms
between PIC and participating providers.
Post-ser°vice cluirrrs submitted to PIC for non participating pr°ovic~ler° benefits are paid on a fee for-service basis.
PIC determines rrrember° benefits based on the PIC Non-Participating Pirovider Reimbrrrsernerrt Lcdue.
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
undei-utilization. Utilization management decision making is based only on appropriateness of care and. service
and existence of coverage.
PIC07-740-R2 2 PCH10409 2500.100.4Rx.V (1/10)
Member Information for Non-Participating Provider Benefits
Covered Services: PIC covers services from rrorr 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 norr 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-R2 3 PCH10409 2500.100.4Rx.V (1/10)
PreferredOne Insurance Company (PIC'}
Introduction to Your Coverage
This COC describes your PIC health care coverage. PIC may not cover all of yorrr~ 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 yorr a complete understanding of the coverage described under
this COC. PIC has discretionary authority to determine eligibility for benefits and to interpret and construe
terms, conditions, limitations and exclusions of this COC and the GMC. 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 subscr-iher~ and the enrolled dependents, if any, as
named on the subscriber's eiuollment application.
Services Received in a Participating Provider Facility from aNon-Participating Provider
For services obtained through a purticipatirrg pr^ovider facility, such as ancillary services, services from an x-ray
technician, and services of an errrcrgerrcv room physician, the participating pro~~ider level of benefits applies as
shown in the "Berreft Schedule". Yorr will be responsible for any charges that may exceed the PIC Non-
Participating Pr-uvider Reinrbrrrsernent 1'ahre.
Standing Referrals to Non-Participating Specialists:
Services provided by anon-participating specialist as a result of a starulirrg 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 yozrr condition. Yorr may apply for, and if appropriate, receive a standing refer°r•al 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 plrysiciarr, 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-tlu-eatening mental or physical illness;
3. Second or tlvrd 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 rrrenrber's death. Continuity of care may also apply to rrrernber-s
PICU7-740-R2 4 PCH10409 2500.I00.4Rx.V (1/10}
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.
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 norz 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 prroviders or the non par-ticipatirrg provider :r regular fee for such services;
2. Follow PIC's pre-certification requirements; and
3. Provide PIC :x~itl: all necessa ;~ medical information related to the care provided to tl~e rsrernber.
Requests for continuity of care will be denied if medical records and other supporting documentation are not
submitted to PIC. PZC'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
You should be prepared for the possibility of a medical en~rer°geracy by knowing ti~ozzr participating provider's
procedures for "on call" and after regular office flours 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 yor.rr
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 yorrr° 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 Grorrp Master Contract (GMC} combined with this COC, any amendments, t13e 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 yorz 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-sen~ice
clairrrs or bills for your health care may be delayed or temporarily denied. Yorr will be asked to present your ID
card whenever vorr receive services.
Provider Directory
You may request fiom PIC a provider directory that lists facilities and individuals who are participating
providers and are available to yorz. Yorz may also find participuting provicler-s 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 pr°ovider.
You may want to vel-ify that a provider° yorz choose is a participating pr°ovider by calling Customer Service.
PIC07-740-R2 5 PCN10409 2500.100.4Rx.V (1/10)
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. Airy change in
coverage is subject to PIC approval If a change in coverage is requested by you~~ employer, it is effective on the
date mutually agreed to by yoicr 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 ("NIPAA") Privacy Rule. In
accordance with the NIPAA 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. Yoz~ will receive a copy of PLC's Notice of Privacy
Practices (which summarizes PIC 's NIPAA Privacy Rule obligations, you~~ NIPAA Privacy Rule rights, and how
PIC may use or disclose health information protected by the NIPAA Privacy Rule) with yoa~ti~° em-ollment packet.
Yc~u may also call Customer Service to receive one. YoTtr failure to provide authorization or requested information
may result in a denial of you~~ claim.
Clerical Error
You will not be deprived of nor receive coverage under the GMC because of a clerical error by PIC. Ynu will not
be eligible for coverage beyond the scheduled teniiination 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
i~~aernbers.
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 from the effective date of the member's coverage
due to a claim or disability. This time Limit does not apply to fraudulent misstatements.
Fraud
Coverage maybe tei-~ninated, if a r~ter~x~her falsifies then- 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-R2 6 PCHI0409 2500.100.4Rx.V (1/10)
Medical Technology and Treatment Review
Depending on the focus of the technology or treatment, one of tln-ee committees (MedicaUSurgical Quality
Subcommittee, Behavioral Health Quality Subcommittee or the Pharmacy and Therapeutics Quality
Subcommittee) determines whether new and existing medical treahnents 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 ?l~Ia.~agement Committee that is made up of independent community plrysiciasas, a
consumer representative and PIC staff.
Recommendations by Health Care Providers
In some cases, y=our provic~eJr may reconnnend or provide written authorization far 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 until at least 60 days after the proof of loss has been provided or after the
expiration of three years after the time written proof of loss is required to be provided.
PIC07-740-R2 7 PCH10409 2500.100.4Rx.V (1/10)
Eligibility and Enrollment
Eligibility
To be eligible to enroll for coverage, you must be a:
1. ,full-tune employee; or
2. depe~rde~lt.
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 ernoll far 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 clepender~t. 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
depende~7ts of either parent, but not both.
Eligible dependents include a subscz°iber-'s:
1. lawful spouse as defined under Minnesota Statute 517.01;
2. unmarried children, from birth tlu-ough age 24, including:
a. natural children;
b. legally adopted children or children placed with the subscriber for legal adoption (date of placement
means tl.~e 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 subscriber who reside in the subscriber's home ill an on-going parent/child
relationship that is intended to continue to adulthood;
d. grandchild(ren) who reside in yoar~r 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 defimed 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 determil>jng whether or not a
medical. child support. order is a valid QMCSO. You 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 disabled dependents after reaching age 25, provided they are:
a. incapable of self-sustaining employment because of~laysiccrl disability, developmental disability, mental
illness or mental health disorder that is expected to be ongoing for a continuous period of at least two
years from the date the initial proof is supplied to PLC; and
b. dependent on the subscriber for a majority of financial support and maintenance.
PIC07-740-R2 8 PCH10409 2500100.4Rx.V (1/10)
Proof of incapacity must be provided with the sz~zbscriber's application for coverage with PIC within 31
calendar days of the date the dependent reaches age 25.
After this initial proof and determination of disabled dependent status by PIC, PIC may request proof again
two years later, and each year after.
If the dependent is disabled and 25 years of age or older at the time of the szd~scriber's enrollment or initial
employment, and such dependent through szzbscribez° enrolled for coverage with PIC, the subscriber must
provide PIC with proof that the dependent meets requirements a. and b. above within 31 calendar days of the
initial date of employment or enrollment.
The disabled deperzderzt shall be eligible for coverage as long as he or she continues to be disabled and
dependent on the sazbscriber, unless coverage otherwise terminates under the GMC.
Enrollment
Initial Enrollment. Eligible employees must make written application to enroll, and such application must be
received ~~~ithin 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 acquu-ed 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.
ilew~orn Enrollment. I'~ewborn infants, including the subscz°iber's newborn grandchildren and children newly
adopted or placed for adoption, who were born, adopted or placed for adoption while the .cubsez-ibez° 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 bil-th, 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 anal the
,cz.zbscriher must be covered under this COC in order- for the newboi7i infant to be covered.
Military Duty. Employees returning fiom 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, yoac may ern-oll 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:
PIC07-740-R2 9 PCH10409 2500.100.4Rx.V (1/10)
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
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 Depende~zts Only. New dependents may enroll subject to the 12-month
pre-existing condition 1_i,nitatian if all the following conditions are met:
1. a gl-oup 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 emplayee, and. in the case of birth, adoptian, placement for adoption
or the legal guardianship of a child; the employee may enroll and the spouse of the employee maybe enrolled
as a dept=rrderrt of the employee if such spouse is otherwise eligible far 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 eiuolled, if
otherwise eligible far coverage; and
4. application must be received within 31 calendar days of the date the employee first acquires the dependent
and coverage slxall begin on the later o£
a. the date deperzderrt 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.
Special Enrollment Period for Medicaid and Children Health Insurance Program (CIIIP} Members. If
an eligible emplayee and/ar his/her eligible dependents are covered under a state Medicaid plan or a state
CHIP and that coverage is terminated as a result of loss of eligibility, then the eligible emplayee may request
em-ollment in the Plan on behalf of lrim/hersehf and/or his/her eligible dependents. Such request must be
made within 60 days of the date the employee's and/or his/her dependent's coverage is terminated from such
state plans.
If an eligible employee and/or his/her eligible dependents become eligible for apremium-assistance subsidy
under the Plcln through a state Medicaid plan or a state CHIP (if applicable), then the eligible employee may
request enrollment in the Plar~r on behalf of him/herself and/or his/her eligible dependents. Such request must
be made within 60 days of the date the employee and/or his/her ~lependerzts are determined to be eligible for
the subsidy under such state plans.
NOTE: Other dependents (such as siblings of a newbonl child) are not entitled to special enrollment rights upon
the birth or adoption of a child.
PIC07-740-R2 10 PCH10409 2500.100.4Rx.V (1/10)
Schedule of Payments
You are required to pay any deductible and coinsur^arzce 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 rzor7 participating provider r^eirrzburserzzent value when you use a uou-
participatingprovider and receive rrorz participating provider benefits.
NOTE: Yottt^ coverage is either "subscriber only" or "family." Therefore, only one of the following sections
"Subscriber only" or "Family" applies to yott. If you have questions about which section applies to yott, contact
PIC.
If you have subscriber only coverage, oil the date that the coverage for your eligible dependent(s) becomes
effective, yotr and your new dependent(s) become subject to the terms and conditions of family coverage.
This is a Minnesata qualified plan.
Szzbscriber only
Deductible: The subscriber must first satisfy the deductible amount by incurring charges equal to that amount
for eligible services in a cc`rlertdar year before PIC will pay benefits. PIC will not pay benefits for the eligible
charges applied toward the dedttictible. Any amount in excess of the PIC non participating provider
reirnbttrsentertt value will not apply towards satisfaction of the deductible. The subset^iber will not be required
to satisfy the deductible before PlC will pay benefits for the following when received from a participating
provider: prenatal and child health services and one home health care visit for well baby services within 4 days
after the date the newborn was discharged from the lzospitul.
Out-of-Pocket Lirrzit: After the subscriber has met the out-of-pocket lirrtit per calendar year for cvittsa~tirattce and
clecluctibles, PIC covers 100% of charges itteurred for all other eligible charges. The subscriber pays any
amounts beater than the ottt-of-poclret lirrtit if any benefit maximums or the lifetime benefit maximum are
exceeded. It is the subscriber's responsibility to pay any amounts greater than the otrt-of-pocket limits if any
benefit maximums are exceeded. Expenses the st,tbscriber pays for any amount ill excess of the PIC ttort-
pctrticipcitirtg prrovider- reintbursernent vahte will not apply towards satisfaction of the out-of-pacltiet linzit.
Subscriber^ only Participating Provider Network Norz-Participating Providers
Deductible $2,500 per calendar year for eligible services of participating providers
and non participating providers combined.
Dut-of-Pocket Lirrzit $2,500 per calendar year far eligible services of participating providers.
$4,000 per calendar year- for eligible services of participating and rzorz-
participatingproviders combined.
Lifetime Benefit Maximum $3,000,000. The cumulative maxilllum payable or covet^ed sen~ices itacttrred
by you during your lifetime under all health plans with the group
contraetholder. The lifetime benefit maximum does not include amounts
which are your responsibility such as deductibles, coinsurance, copaytttettts or
penalties.
PIC07-740-R2 11 PCH10409 2500.100.4Rx.V (1/10)
Family (Subscriber and Enrolled Dependents}
Family Deductible: The family must first satisfy the family deductible amount by incur°ring 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 reimbrn~scmerrt 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 and one home health care visit for well
baby services within 4 days after the date the newborn was discharged from the hospital.
Family vzri-oJ-Poekei ~inrii: After the family has met the family oui-of~ockei limit per cuienciur year in
eligible charges in a calendar year for coinszrr•arrce and family deductibles, PIC covers 100% of charges
irrcrrr•red for all other eligible charges. The family must pay any amounts greater than the family orrt-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 ~articipccting provider r•eirnbrrr°serraerrt value and will not apply towards
satisfaction of the family orrt-of-pocket lirrrit.
Family (Subscriber and Participating Provider Network Nou-Participating Providers
Dependents)
Family Derluetible $5,000 per calendar year for eligible services of participating providers
and norr ~m~ticipating pr°oviders combined.
$2,500 maximum deductible amount per family rraenrber.
Out-of-Pocket Linrit $5,000 per caler~7dur y~ar° ($2,500 maximum orrt-of-pocket amount per
family rnerrrber) for eligible services of participating providers.
$8,000 per calendar year ($4,000 maximum out-of-pocket amount per
fan>ily member) for eligible services of participating and rrorz participating
providers combined.
Lifetime Benefit Maximum $3,000,000. The cumulative maxulium payable or covered services incurred
by you during yarm lifetime under all health plans with the group
eontractholder. The lifetime benefit maximum does not include amounts
which are your responsibility such as deductibles, eoinsru°ance, copayrnerrts or
penalties.
Cost Sharing: The coinsru•ance 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
Reinrbrrr°serrrerrt 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 Nord-Participating Provider Reimbursement i~aluc~,
whichever is applicable, then. the coinsurance is applied to the remainder.
PIC07-740-R2 12 PCH 10409 2500.100.4Rx. V (1 / 10)
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 urember~ is eligible for coverage, the fneruber has provided the appropriate
information for those services and the member has met all other terms of the CDC. 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 Nou-Participating Provider
Berzef t
Pre-certification Penalty None PIC will reduce the amount of
eligible charges by the lesser of
$500 or 25%per confinen~aent.
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 yozc and must follow the procedures set forth below. It
is your responsibility to ensure that PIC has been notified by following the procedures set forth below, when noi7-
pcn-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 rzon-~~articipating provider
benefits.
Pre-certification is required for:
I. all inpatient admissions including skilled nursir~gfacility, rehabilitation, hospital, etc.;
2. transplant services;
3. non-enzergencv ambulance and ambulance transfers; and
4. eating disorder treatment services provided by a pahticipating designated eating disorder program.
If yogi have questions about pre-certification and when you are required to obtain it, please contact Custarmer
Service.
PIC07-740-R2 13 PCH10409 2500.100.4Rx.V (1/l0)
Prior Authorization: It is recommended that you or your provider have certain services be 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 by following the procedures set forth below. It is your
responsibility to prior authorize with PIC by following the procedures set forth below, 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. rc>corrstructive 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 drags may require prior authorization before you can have your prescription filled at the
pharnacy. These prescription drugs may include, but are not limited to:
10. prescription drrr~s, 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;
ll. weight loss medications;
12. oral antifungal drugs; and
13. specialty drags.
Procedures. When a participating provider renders services, the provider will notify PIC for you and must
follow the procedures set forth below. It is your° responsibility to ensure that PIC has been notified when rror~r-
participating providers are used. You or the provider must call Customer Service during nornal business hours
and before services are performed. Failure to obtain. pre-certification may result in a reduction of benefits. For
nor? participating providers, you need to follow the procedures set forth below:
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 yore' attending health care professional 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 aI1 the necessary information. If you or your attending provider have not submitted the
request in accordance with these procedures, PIC will notify yoar 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 and your attending provider of its benefit determination within I S
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 may be made to yorn° attending
jn°ovider by telephone.
3. If the initial determination is that the service will not be covered, yorn• attending health care professional,
hospital (if applicable) and your attending prrovider will be promptly notified by telephone within 1 business
day after the decision has been made.
PIC07-740-R2 14 PCH10409 2500.100.4Rx.V (1/10)
4. Written notification will then be provided to yoat, your attending health care professional, hospital (if
applicable} 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.
Haw to Obtain an Expedited Review
Expedited Review: An expedited initial determination will be used if your attending health care professional
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 dine 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 health care professional would subject you to severe pain that cannot be adequately managed without
the care or treatment that is the subject of the pre-se~^~n~ce clamp.
An expedited intial determination will be provided to yoar, your attending health care professional, hospital (if
applicable} and your attending pravider° 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. Yo~~ will then have at least 48 hours to provide the requested information. Yost, your
attending health care professional hospital (if applicable} and your attending provider will be notified of the
deternnation withhi 48 hours after the earlier of PIC 's receipt of the requested information or the end of the time
period specified for yc~u to provide the requested information. If the intial determination would deny coverage,
you or your atteruling health care professional will have the right to submit an expedited appeal.
Note: If yozn~ request is denied, you may appeal that decision. Refer to the section entitled "Complaint and
Appeal Procedures" for details on how to appeal.
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 care, treatments, services, supplies,
reimbursement of expenses, or payments (such as for a member's, or for a member and a companion's out of
town travel, meals, lodging and other expenses essential to and necessary for treatment) of a rne~r2ber's
catastrophic sickness or i~7jury that would not normally be covered or would only be partially covered. PIC and
the member's physician will determine whether any such care, treatments, services or supplies will be covered.
Such care, treatment, services, supplies, reimbursable expenses, or payments will not be considered as setting any
precedent or creatilig any future liability, with respect to that member or any other nzenaber.
Other care, treatments, services or supplies must meet both of these tests:
1. determined. in advance by PIC to be medically necessary and cost effective in meeting the long term or
intensive care needs of a naenaber in connection with a catastrophic sic~-~7ess or injury.
2. charges inca~r°red would not otherwise be payable or would be payable at a lesser percentage.
PIC07-740-R2 IS PCH10409 2500.I00.4Rx.V (I/10}
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 an 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 see°vice.
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 Lfer~e~t 1Von-Participating Pravider I~e~ie~t
PIC pays: PIC pays:
Note: For rtan participatirtgproviders,
in addition to any deda~~ctibles and
coinsurance, yoir pay all charges that
exceed the PIC Non-Pctrticiputing
Provider Reimbuf°serneut T/ahre.
Ambulance Services
Ambulance services for an 100% of eh~gible charges after the Same as participati~~g~~~rovider benefit
emergency. Note: Non- deductible. for ei~~aerger7cy services.
emergeJ~cy transportation
must be pre-certified in 80% of eligible charges after the
advance by PAC. deductible for non-e»zergencv
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 eruerger2cv. Air ambulance is covered only when the condition
is an acute medical emergency and is authorized by a physician.
PIC covers eruerger~cv ambulance (air or ground) transfer from a hospital not able to rendei the ~~aedically
necessary care to the nearest Iospital or medical center able to render the medically necesscx~y care only when
the condition is a critical medical situation and is ordered by a plrysicica~z and coordinated with a rreeeiving
physici~cn.
Ambulance services for anon-emergency. Non-er~aergeucy ambulance service, from hospital to hospital when
care for your condition is not available at the hospital where yoa~~ were first admitted. Transfers from a hospital
to other facilities for subsequent covered care or from home to plzysiciau offices or other facilities for outpatient
treatment procedures or tests are coves°ed if medical supervision is required enroute and when pre-certified.
PIC's medical director or designee must pre-certify non-ei~zetgertcy services in advance.
Exclusions:
a. Please see the "Exclusions." section later in this COC for all exclusions.
b. Non-emergency ambulance service from hospital to hospital such as transfers and admission to Hospitals
performed only for convenience.
PiC07-740-R2 16 PCH10409 2500.100.4Rx.V (1/10)
Benefit Participating Provider Benefit Non-Pa~•ticipating Provider Benefit
PIC pays: PIC pays:
Note: For non participating providers, in
addition to any deductibles and
coinsan•ance, you pay all charges that
exceed. the PIC Non-Participating
Provider Reimburse~~nerzt IraZue.
Chiropractic Services 100% of eligible charges after the 80% of eligible charges after the
deductible. deductible.
Limited to a maximum of 15 visits per
calenda~° yeas°.
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.
Exclusians:
a. Please see the "Exclusions." section later in this COC for all exclusions.
b. Services primarily educational in nature.
e. Vocational rehabilitation.
d. Self-care and self=help training (non-medical}.
e. plealth 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 licensed acupuncture
practitioner or a pr°ovider 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.
PIC07-740-RZ 17 PCH10409 2500.100.4Rx.V (1/10)
Benefit Participating Provider Berrefrt Norr-Partiepatirrg Provider Benefit
PIC pays: PIC pays:
Note: For norr par°ticipcrting providers,
in addition to any deductibles and
coinsurance, yorr pay all charges that
exceed the PIC Nan-Participating
Provider Reimbursernerrt Valare.
Dental Services
Accidental Dental 100% of eligible charges after the 8U% of eligible charges after the
Services deductible. deductible.
Nate: Treahnent and repair must be completed within twelve months of the
date of the injury.
Medically Necessary 100% of eligible charges after the 80% of eligible charges after the
Outpatient Dental Services deductible. deductible.
and Hospitalization for
Dental Care
This provision does not provide coverage far preventive dental procedures. PIC considers dental procedures to
be services rendered by a dentist or deirtal 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 i~rjarry. 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 fitnetion for at least one year. Primary
(baby) teeth must have a life expectancy of one year before loss.
2. Medically lOrecessary €3ntpatient 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 irurr,rred by a rrre~nber who: (1) is a child under age S; (2) is severely disabled; or (3}has
a medical condition unrelated to the dental procedure that 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->siclusive, of medical conditions that play require hospitalization for dental services: severe
asthma, severe airway obstruction or hemophilia. Care must be directed by a physicicru or by a dentist or
dental speeia~list.
Exclusions:
a. Please see the "Exclusions." section later in this COC for 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.
PIC07-740-R2 18 PCH10409 2500.100.4Rx.V (1/10)
£ 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 c~e~2tist unless in com7ection with dental procedures covered by PIC.
j. Dental services related to periodontal disease.
PIC07-740-R2 19 PCH10409 2500.100.4Rx.V (1/10)
Benefit Pay^ticipati~7g P~~ovider Benefit No~z-Participati~T~g Provider Benefit
PIC pays: PIC pays:
Note: For nonhar•ticipatirrg prroviders,
in addition to any deductibles and
coirrsrn~ance, you pay all charges that
exceed the PlC Non-Par-ticipatirzg
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 80% of eligible charges after the
deductible. dedrrc~•tible.
Prosthetics 100% of eligible charges after the 80% of eligible charges after the
deductible. deductible.
Hearing aids for nac~mber°s 100°io of E°ligible clear°ges after the 80% of eligible clzcn~ges after the
under age 19 for hearing deductible. dedzrctible.
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 80°,/0 of eligible charges after the
resultu7g from alopecia deductible, deductible.
areata are limited to a
inaxi~num PIC payment of
$3S0 per calendar year.
Limited coverage for 100% of eligible charges after the 80% of eligible charges after the
special dietary infant deductible. deductible.
formulas and electrolyte
substances that are
consumed orally and treat
phenylketonuria or other
inborn errors of
metabolism
Special. dietary infant
formulas and electrolyte
substances are covered
only when 1) they treat
phenylketonuria (PKU) or
other inbonl errors of
metabolism, 2) are
consumed orally, 3) are
ordered by a physician.,
PIC07-740-R2 20 PCH10409 2500.100.4Rx.V (1/10)
physician's assistant or
nurse practitioner, and 4)
are rrzedically necessary.
Limited coverage for 100% of eligible charges after the 80% of eligible charges after the
amino-acid based deductible. deductible.
elemental formulas that are
consumed orally and treat
cystic fibrosis or certain
other metabolic and
n~alabsol-ption errors.
Amino-acid based
elemental formulas are
covered only when 1) they
are consumed orally, 2) are
ordered by a physician,
physician's assistant, or
nurse practitioner for a
person who is five years or
younger, 3) are medically
necessary, and 4) treat the
following metabolic and
other malabsorption
conditions that have been
diagnosed by a specialist:
a) cystic fibrosis; b)
amino acid, organic acid
and fatty acid metabolic
and malabsorption
disorders; and c) IgE
mediated allergies to food
proteins, d) eosinophilic
esophagitis (EE), e)
eosinophilic gastroenteritis
(EG), and f} eosinophilic
colitis.
Enteral feedings when they 100% of eligible charges after the 80% of eligible circrrges after the
are prescribed by a deductible. deductible.
physician, physician's
assistant or nurse
practitioner and are
required to sustain life.
PIC'07-740-R2 21 PCH10409 2500.100.4Rx.V (1/10)
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.
100% of eligible charges after the 80% of eligible charges after the
deductible. deductible.
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 rrledically rrecessrrry for treatment of keratoconus. Members must pay for
lens replacement. .
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 ar 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 l~or its medical director or designee to deter-rnine 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 "Exclusions." section later in this COC for all 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 sinular items.
g. Items that are prima171y edrrcatiarz~rl 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, cormnmiication board, or computer or electronic
assisted communication.
j. Household. equipment, household fixtures and modifications to the sh-ucture 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 merrzber-s with diabetes or peripheral
vascular disease.
PIC07-740-R2 22 PCH10409 2500.100.4Rx.V (1/10)
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 far activities beyond activities of
daily living (.ADCs).
q. Wigs for conditions other than alopecia areata.
r. 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-R2 23 PCH10409 2500.100.4Rx.V (1/10}
Benefit Participating Provider Benefit Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For non participating pr°oviders,
in addition to any deductibles and
coinsurance, yorr pay all charges that
exceed the PIC Non-Participating
Provider Reirrrbrrrsetner7t Value.
Emergency Room Services 100% of eligible charges after the Same as the participcztirzg provider
deductible. benefit.
You should be prepared for the possibility of a medical emergency by knowing yoz~rr par°ticipatirrg provider's
procedures for "on call" and after regular office hours before the need arises. Determine the telephone number
to call, which hospital yaru• participating provider- uses, and other information that will help yorr act quickly and
correctly. Keep this information in an accessible; location in case a medical errrergerrcv arises.
If ynu have an errrergencv situation that requires immediate treatment, call 911 or go to the nearest emergency
facility. If possible under the circumstances, you should telephane your physician or the participating clinic
where yore normally receive care. A physician will advise you how, when and where to obtaili the appropriate
treatment.
Note: Non-errrergeney services received in an emergency room are not covered. If you choose to receive non-
emergency health services iu an emergency room, you are solely responsible for the cost of these services. See
enrergerrcv under "Definitions".
Covered hospital services are subject to all of the benefit limitations set forth ill 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 tl~e "Exclusions." section later in this COC far all. exclusions.
b. Non-emergency services received in an emergency room.
PIC07-740-R2 24 PCH10409 2500.100.4Rx.V (1/10)
Benefit Participati~ig Provider Berzefit Non-Participati~7g Provider Be~zefif
PIC pays: PIC pays:
Note: For no~~z participating providers,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
Provider Reirnbursen2ent Value.
Home Health Services Note: For non ~articipatingpi°ovider
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 80% of eligible charges after the
alternative to hospital deductible. deductible.
co~~fi~7ement or skilled
nursing facility care.
One well-baby Name visit 100% of eligible charges. 80% 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
newbornz 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 well-
baby's discharge from the
hospitah
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 plrysiciat~i. for the care and treatment of the rnernber's sickness or
injury and rendered in the member's home.
You must be homeboa.md 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 i11 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, wiihout the dil-ect 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-R2 2S PCH10409 2SOO.I00.4Rx.V (1/IO)
Exclusions:
a. Please see the "Exclusions." section later in this COC for all exclusions.
b. Companion and. home care services, unskilled nursing services, services provided by your farm}y or a person
who shares ~~our 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 yoa~r home due to lack of transportation.
h. Cusiodictl ccxre.
i. Services at any site other than your home.
j. Recreational therapy.
PIC07-740-R2 26 PCH10409 2500.100.4Rx.V (1/10)
Benefit Participating Provider Berzef%t 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 Nara-Participating
Provider Reirnbursernerat tialue.
Hospice Care 100% of eligible charges after the 80% 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. Member°s 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. Merraber°s 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 iu the home
hospice program.
Eligibility. In order to be eligible to be enrolled in the home hospice program, a rnernber° 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 raacnaber may withdraw from the home hospice progr am 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 rnerr~zber"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 rnember•'s home or in a setting that provides day care for
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, ar home health aide, during a period of crisis in order to
maintain a terminally ill patient at home.
c. rnedicirlly raecessur y 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 n2enabers 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 em-olled in the hospice
program.
e. medically necessary medications for pails and symptom management, if prior authorized by PIC's
medical director or designee.
f. Taospitul beds and other durable medical equipment when medically necessary and should be prior
authorized by PIC's medical director or its designee.
Exclusions:
a. Please see the "Exclusions." section later in this COC for all 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.
PICU7-740-R2 27 PCH10409 2500.100.4Rx.V (1/10)
Benefit Participating Provider Benefit Non-Pa~^ticipati~ag Provider Be~zefit
PIC pays: PIC pays:
Note: For norz participating providers,
in addition to any deductibles and
coinsrn•ar2ce, 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
possible.
Inpatient 1ospital i GO% of eligible char°ges after the 80% of eligible charges after the
Services deductible. deductible.
Note: Each rrrernber's Coverage for confinements in non-
corrfirrernerrt, ii~ch~ding participati~~g hospitals and sh-illed
that of a newborn child, is mn°sing_facilities are limited to a
separate and. distinct from combined maximum of 120 calendar
the confinement of any days per ealerrdcrr° 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
fan>ily coverage.
Outpatient Hospital 100% of eligible charges after the 80% of eligible char°ges after the
Services, Ambulatory Care deductible. dc:~chrctible.
or Surgical Facility
Services
Rehabilitation Services in 100% of eligible charges after the 80% of eligihle charges after the
a Day Hospital Program dcduc•tible. deductible.
Injectable drugs that are 100% of eh~gible charges after the 80% of eligihle charges after the
not specialt}~ drugs, deductible. deductible.
excluding insulin.
Eating Disorder Treatment 100% of eligible charges after the 80% of eligihle 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-R2 28 PCI-I10409 2500.100.4Rx.V (1/10)
Medically necessary genetic
testing determined by PIC to
be covered ser~~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
y°orr are diagnosed with a
specific sickness by a
physician.
• Genetic testing services if
yorr are considered to be
high risk for a specific
sickness as determined by
%curr.
100% of eligible chat°ges after the ~ 80% 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 dr~args 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 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 nudwives (CNM), or a
physician.
PIC covers asemi-private room, unless a physicicrrr 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.
Outpatient Hospital, Ambulatory Care or Surgical Facility Services. PIC covers the following services
and supplies, for diagnosis or treahnent of sich~ress or injrny on an outpatient basis:
a. use of operating rooms or other outpatient departments, rooms or facilities;
PIC07-740-R2 29 PCH10409 2500.100.4Rx.V (1/t0)
b. the following outpatient services: general nursing care, anesthesia, radiation therapy, pr°escr~iption
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. plrysiciari and other professional medical and surgical services rendered while an outpatient;
e. physician directed weight loss programs only when r~~r.edically 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 haspital 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 rehabilitutiti=e care u7 connection with a sich~~ess or injrny.
Lating Disorder Treatment Program. PIC covers the treatment of eating disorders provided by a PIC
designated participating eating disorder treatment program.
Eaaaer~eaacy Services at a Hospital that leads to an Inpatient Admission
You need to provide notice to PIC of an emergency hospital admission. However, if yore are incapacitated iii a
manner that prevents yora from providing notice of the admission within 48 hours or as soon as reasonably
possible, or if yora are a minor and your parent (or guardian} was not aware of your° achnission, 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} yorr are physically or mentally unable to provide
the required notice; and (2) yorr 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 I,~roup health insurance coverage as
specified below naay not restrict benefits for any hospital length of stay in eom7ection 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 pr•ovic~ler (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 newboni than any earlier portion of the stay.
In addition, a group health plan or health issuer may not, under federal law, require that a physicicrrr or other
health care prohider 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
obtaili pre-certification as described in the pre-certification provisions of the Schedule of Payments.
PIC07-740-R2 30 PCH10409 2500.I00.4Rx.V (1/IO)
Exclusions:
a. Please see the "Exclusions." section later in this COC for all exclusions.
b. Travel, transportation, other than ambulance transportation, or living expenses.
c. Hospitalization, transportation, supplies, or medical services, including physicians' services fm•nished by
the United States Govermment 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.
£ Services and/or drugs to treat conditions that are eosm~etic 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 sich~zess 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 clu onic pain program and rendered by a licensed acupuncture
practitioner or a p~~ovider licensed or trained in acupuncture.
1. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease.
m. Autopsies.
n. Bczr°iat~~ic siirgerie,c.
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 confr,~~zement;
2. for the diagnosis anal treatment of diabetes or an eating disorder; or
3. a rraembe~• has been diagnosed with a chronic medical condition by a physician.
In all cases, except corz~inernent, nutritional counseling must be provided in a plwsiciarz's office, clinic
system or hospital setting.
r. Treatment of eating disorders, except as shown in the Eating Disorders Treatment Program benefit.
PIC07-740-R2 31 PCH10409 2500.100.4Rx.V (1/10}
Benefit Pay^ticipating Pr^ovider &enefit Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For raon participating prroviders,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC No~~-Participating
Provider Rein~~bur^se~rtent Value.
Infertility Services 100% of eligible charges after the Same as participatir~ag provider benefit.
Note: Limited to diag~~ostic deductible.
services oniy.
PIC covers professional services for the diagnosis of infertility and treatment of an underlying medical
condition, tests, facility charges and laboratory work related to coves°ed ser~~ices (such as, but not limited to,
diagnostic radiology, laboratory services, semen. analysis and diagnostic ultrasounds).
Exclusions:
a. Please see the "Exclusions." section. later in this COC for 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 (NI).
j. Donor sperm.
k. Oral and injectable drugs for infertility.
PIC07-740-R2 32 PCH10409 2500.100.4Rx.V (1/10)
Benefit Participatizg Provider Benefit Nozz-Participating Providez° Bezzefit
PIC pays: PIC pays:
Note: For norz participatirzg provides°s,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
Pfrovider Reimbursement Value.
Mental and Substance-Related Disorder Services
Office Visits 100% of eligible charges after the RO°% of eligible charges after the
dedzctible. deductible.
Inpatient Services 100% of eligible charges after the 80% of eligible charges after the
deductible, deductible.
Coverage for confinements in non-
participating hospitals and drilled
nursing, facilities is limited to a
combined maximum of 120 calendar
days per calendar year.
Outpatient Hospital, 100% of eligible charges after the 80% of eligible charges after the
Partial Hospital and Day dededctihle. deductible.
Treatment .Servic•es
Each two calendar days of partial
hospital or day tr°eatment sen~ices 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 Case. PIC 's medical du•ector or designee must authorize in advance any services received in your
home.
2. Office Visits. PIC covers:
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
Diagnosis and treatment of substance-related disorders, including evaluation, diagnosis, therapy and
psychiatric services.
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 rrzedically necessary. These
services may have to be authorized by a provider who is a mental health professional or his or her designee.
PIC07-740-R2 33 PCH10409 2500.100.4Rx.V (1/10}
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 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 n~zedically necessar y
for a sich-rzess or injzrry or it is the only option available at the admitted facility. If you choose a private
room when it is not n~zedically 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.
~. Outpatient Ioospital, hartiai Hospital, and l3ay Treatment ,~~ervices. PIC covers such services in a hospitczi
or licensed treatment facility. These services must bepre-certified by PIC's medical director or designee.
Hospital or Licensed Residential Treatment Facility Care for Emotionally Disabled Children. PIC covers
rnedicully necessar~> uzpatient treatment for emotionally disabled children as diagnosed by a physiciar~z 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 licensed residerzticzl treatrnerzt
facility, inpatient coverage for emotionally disabled children is the same as the inpatient benefit. The child
through age 18 years of age must be an eligible deperzderzt according to the teens of the COC.
Court-Ordered Services. PIC covers mental health and/or substance related evaluations and treatment ordered
by a Mizn~esota 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 proti=idea or other provider as
required bylaw and the provider- is a licensed psychiatrist, or doctoral level licensed psychologist.
2. The treatment is provided by a pcn•ticipating pr°ovider^ 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 1°estrictive envii-omnent.
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 "Exclusions." section later in this COC for 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 abave.
c. Marital counseling, relationship counseling, fanuhy 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.
h. Home-based mental or behavioral health services, unless authorized by PIC 's medical director or designee.
i. Biofeedback.
j. Developmental disabilities or mental conditions that, according to generally accepted. professional
standards, are not amenable to favorable modification, except for initial evaluation, diagnosis or crisis
intervention.
k. Services provided by a licensed residential tr~ecrtrnent facility, except as authorised in advance by PIC 's
medical director or designee.
PIC07-740-R2 34 PCH10409 2500.100.4Rx.V (1/1.0)
Benefit Participating Provider Benefit Non-Participati~zg Provider Benefit
PIC pays: PIC pays:
Note: For faorz-~urticipating providers,
in addition to any deductibles and
coinsurance, yo¢s pay all charges that
exceed the PIC Nora-Participating
Provider Reimbursement Tlaltre.
Office Visits and Urgent Care Center Visits
Siclaress or ifl1Trry -offioo 1(~0% of eligihle chc~rg~s after the 80% of eligihle c~h~rges a$er t1~e
and rrr°gerrt care center deductible. deductible.
visits related to diagnosis,
care or treatment of a
condition, sicla~ress or
l1r.JZdr'rv.
Electronic/online 100% of eligible charges after the 80% of eligible char°ges after the
evaluation of chronic dedrretible. dedrretible.
conditions; limited to 6
evaluations per member
per calendar year.
(In order to be covered, the
evaluation must be
conducted by a designated
electrorziciorrlirae
participating provider only
for established patients
with specific chronic
diseases, such as diabetes
or heart disease, as
determined by PIC` or its
designee.)
Medically necessary genetic 100% of eligihle clzcu~ges after the 80% of eligible cllurges 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 rnernber's pregnancy.
• Genetic testing services if
you are diagnosed with a
specific sicl,~rzess by a
p11ySICZaT1.
• Genetic testing services if
voec are considered to be
high risk for a specific
sicL~ress as determined by
a physician.
PIC07-740-R2 35 PCH10409 2500.100.4Rx.V (1/10)
Implantable and insertable 100% of eligible char°ges after the 80% of eligible charges after the
drug delivery devices for deductible. deductible.
birth. control.
Allergy injections 100% of eligible charges after the 80% of eligible charges after the
deductible. deductible.
Port wine stain -treatment 100% of eligible charges after the 80% of eligible charges after the
to lighten or remove the deductible. dedr~rctible.
discoloration
Postnatal care 100% of eligible charges after the 80% of eligible charges after the
dedr~rctible. deductible.
Preventive Health Care 100% of eligible charges. 80% of eligible charges after the
Services Not subject to the deductible. deductible.
Immunizations (over
age 18)
Laboratory tests,
pathology and
radiology
Preventive health
physicals
Cancer screening
(including routine
PSA tests, pap
smears, ovarian and
colorectal tests, and
mammograms)
Routine preventive eye
examinations, limited
to one exam per
member per calerular
vear°.
Well-baby/child health 100% of eligible charges. 80% of ~>ligible charges after the
services up to age 6. Not subject to the deductible. deductible.
Immunizations up to
age 18.
Prenatal care.
Injectable drugs that are l 00% of eligible charges after the 80% of eligible charges after the
not specicdty drugs, deductible. deductible.
excluding insulin.
PIC covers the professional medical and surgical services of licensed: physicians, health care providers and
nurses.
Services are provided for the following:
a. Office and urgent care center visits relating to the diagnosis, care or treatment of a condition, sickness
ar r71JrlJ"}~.
b. Treatment of diagnosed L}nne disease.
PIC07-740-R2 36 PCH10409 2500.100.4Rx.V (1/10)
c. Contact lenses prescribed as medically necessa~~y 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. Includes associated physicia~~a 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
pa~e~~PratiUe health care exam diagnosis.
a. Routine screening procedures for cancer, including mammo~ams, pap smears, ovarian anal colorectal
tests and prostate specific antigen (PSA).
b. Immunizations as recommended by your physicia~z and as shown in the schedule above.
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.
APhysicia~7 will counsel you as to how often health assessments are needed based on yozu• age, sex and
health status.
e. Prenatal care.
£ Well baby and child health supervision services to age 6 including pediatric P~°e~~entive health care
services, 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
craluomandibular disorder (CMD), that is medically necessary. TMD splints and adjustments are
covered if yoz~r primary diagnosis is TMD. Dental services required to directly treat TMD or CMD are
eligible.
S. Treatment of cleft lip and eie$ 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 elefl. Dental services required for the treatment of cleft Iip or cleft palate
are covered. If a covered dependent quid is also covered under a dental plan, which includes orthodontic
services, that dental plan shall be considered prhnaiy for the necessary orthadantic 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 exanunation 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 prrovider designated by PIC. Limited to
participation in one program in a 12-month period.
14. OB/GYN services for a pregnancy. Female rn~embet•s may obtain the obstetric and gynecologic services
from obstetricians and gynecologists in the Participating provider network without a referral from, or prior
apps°oval through, another physician, PIC, or its designees.
Exclusions:
a. Please see the ``Exchisions." section later in this COC for all exclusions.
b. Services, seminars, or programs that are primarily edarcational in nature.
c. Health education, except when provided during an office visit.
d. Smokilig cessation programs, except as provided ul this COC.
PIC07-740-R2 37 PC1-110409 2500.100.4R~c.V (1/10)
e. Weight loss programs, including, but not limited to, consultations, laboratory services,
and food supplements, and weight loss drugs when not being treated for obesity, exc
necessary as determined by PIC's medical director or designee.
f Nutritional counseling, except when:
1. provided during a confznenzerrt;
2. for the diagnosis and treatment of diabetes, or an eating disordei; or
3. a member^ has been diagnosed with a chronic medical condition by a physr~ciarz.
g•
h.
k.
m.
n.
o.
p•
q~
testing, nutritional
ept when medically
In all cases, except conf nenrent, nutritional counseling must be provided in a physician ~s office, clinic
system or hospital setting.
Recreational therapy.
Professional sign language and fereign language interpreter services in a pr~~aide; 's office, except as
provided in the Continuity of Care provision.
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.
Charges for duplicating and obtaining medical records from rror~ par°ticipating pro~~ider°s unless requested
by PIC.
Genetic testing and associated services when done as a screening test to predict whether yoga may be a
eai-Tier of a specific sickness when yoza are not diagnosed with a specific sickness by a physician or you are
not at high risk for the specific sic7ti-rress as confirmed by a physician.
Homeopathic medicine; hypnosis; chelation therapy, except chelation therapy will be covered when
medically necessary for the treatment of heavy metal poisoning.
Acupuncture, except for treatment in a cln•onie pain program and rendered. by a licensed acupuncture
practitioner or a pr•ovider^ licensed or trained in acupuncture.
Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease.
Treatment of cleft lip and cleft palate, except as otherwise provided in this COC.
Vision therapy/orthoptics.
Services provided by an audiologist that are not provided in an office setting.
Biofeedback.
Routine hearing exams.
PIC07-740-R2 38 PCH 10409 2500100.4Rx. V (1 / 10)
Benefit Designated Transplant Non-Designated Transplant
Net-vork Provider Nerivork Provider
Organ and Bone Marrow ~ Office visits 100% of eligible Office visits: 80% of eligible
Trarzsplarrt Services charges after the deductible. charges after the deductible.
Hospital Services: 100% of eligible Hospital Services: 80% of eligible
charges after the deductible. charges after the deductible.
PIC covers eligible tr•arrsplcrrrt services that PIC's n~edieal 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 tr-crnsplant services for therapeutic treatment and safety. This evaluation continues at
least annually or as new information becomes available anal it results in specific guidelines about benefits for
transplant services. Yorr 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 defilution of an eligible ehczrge, is nrediecrlly necessary, and not
investigative, are available for the following eligible transplants:
Bone marrow transplants and peripheral stem cell transplants.
Heart transplants.
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 roam 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 "Exclusions." section later in this COC for 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.
e. Non-emergency ambulance service from hospital to hospital such as transfers and admission to hospitals
performed only for convenience.
PIC07-740-R2 39 PCH10409 2500.100.4Rx.V (I/10)
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.
PIC07-740-R2 40 PCH10409 2500.100.4Rx.V (1/10)
Benefit Participating Provider Benefit Norz-Participating Provider Benefit
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any deductibles and
coinsurance, yor~r pay all charges that
exceed the PIC Non-Participating
Provider Reimbursernerrt Value.
Physical Therapy, 100% of eligible charges after the 80% of eligible charges after the
Occupational Therapy And deductible. deductible.
Speech 'T'herapy
Sensory integration Coverage is limited to a maximum of 8 visits
therapy for the treatment per merrrber per calendar year-.
of feeding disorders
100% of eligible charges after the 80% of eligible charges after the
deductible. deductible.
PIC covers outpatient physical therapy (PT}, occupational therapy (OT} and speech therapy (ST} for
r-ehabilitutive care rendered. to treat a medical condition, sickness or irrjurv. 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 orderedby 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 lrabilitative 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. Ple~se~ see the "Exclusions.'" section later in this COC for all exclusions.
b. Custodial care ar maintenance ease.
e. Recreational, educational, or self-help therapy (such as, but not limited ta, 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 Z
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.
PIC07-740-R2 41 PCH10409 2500.100.4Rx.V (I/10}
Benefitsx Drugs obtained at a pharmacy Drugs obtained at a pharmacy that is
that is a participating provider. not a participating pr•ovirler. PIC pays:
PIC pays: See "Pre-certification" section.
Note: For Holz ~articipcrh~rzg providers,
in addition to any dedrectibles and
coinsru-artce, you pay all charges that
exceed the PIC Non-Participating
Provider Reimbursement ti'alue.
Prescription Drug Services
NOTE: Benefits for specialty drugs are as described iil this section,
regardless of the place of service where the specialty drug is dispensed or
administered.
1. Prescription drugs that For°rrrulary drugs: Formulary and non formulary drugs:
can be self-administered 100°% of eligible clrcrrges after the 60% of eligible cl2arges after the
for up to a 31-calendar deductible. deductible.
day supply.
2. Up to a 31-day supply for Non formulary drugs: 1.00% of
one type of insulin. eligible charges after the
3. Oral contraceptives for deductible.
a 1-month supply.
4. Contraceptive devices and
delivery methods, other
than oral contraceptives
and injectable
contraceptives, available
from a pharmacy.
5. C~OlnpolnldG'd drZlgS.
• Mail order prescription Formulary drugs: Not covered.
drugs for ?gyp to a 93 100°% of eligible charges after the
calendar day supply. deductible.
Nonforrrrulary drugs: 100% of
eligible charges after the
dcdt~cctible.
Diabetic supplies 100% of eligible charges after the 80% 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 necessa~~~, if
yoet have gestational
diabetes, type I diabetes,
or type II diabetes.
PIC07-740-R2 42 PCH10409 2500.100.4Rx.V (1/lU)
Prescr°iptiorr dr-r~rgs and For~nlulary drugs: Formulary and non foY>,iulary drugs:
over-the-counter (OTC} 100% of eligible charges after the 60% of eligible charges after the
items used in connection deductible. deductible.
with smoking cessation for
up to 31 calendar days per Nan formulary drugs: 100% of
prescription and limited to eligible charges after the
a 93 calendar day supply dedrretible.
per calendar year.
Specialty drugs 100% of eligible charges after the 80°l0 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
phanziacy.
d. A list of these
specialty drags 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.
117jectable drugs that are 100% of eligible charges after the 80% of eligible charges after the
not specialty drags, deductible. deductible.
excluding insulin.
Over-the-Corrrrter (OTC} 100% of eligible charges after the deductible.
Drugs
(Only includes OTC
drugs on the PIC OTC
drag list).
Limited up to a 30
calendar day supply per
prescription.
PIC uses its drug for~rrr~rrlary and the preference of dispensing to determine which ~.~rescriptiorr drr-rgs, including
then- 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. Tlus is known as step therapy. Merrrbers in a step
therapy program will need to meet the requu-ements of that program prior to receiving the second line drug.
Step therapy can apply to fornrrrlrny or non-forrr2trlarw drugs and brand or generic drugs. The Step Therapy List
is subject to periodic review and modification by PIC.
PIC07-740-R2 43 PCH10409 2500.100.4Rx.V (1/10)
Some dispensed prescr-iptiorc 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-
form~tclacy 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
coiusccrauce for quantities received that are in excess of the quantity 1ilnit.
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 youc° prescription at a participating pharmacy counter. You will st11 be responsible for
applicable coinsurance or deductible amounts.
Yocc or your provider may request an exception to the drug fot°rrr¢~lacy. If an exception applies, the non-
fornudac~y drugs that are approved as an exception will be covered at the same level as forc~~uulary drugs.
Exceptions to the drug,forcm~ulacy are available as follows:
When a ~~~hysiciau designates that the prescription for an antipsyehotic drug must be dispensed as
communicated and certifies in writing to PIC that the physiciacc has considered all equivalent drugs in the
.forn~cularv and has deternned that the di°ug prescribed will best treat yocrr condition.
2. If yaac received a preset~iption do°ug to heat 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 forr~ar4laJ-v or you change health plans and become covered under this COC, provided the drug has been
shown to effectively treat your 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,for^rrrrdary or a change in
your health plan,
b. Yora~ physiciccrr designates that the prescription must be dispensed as communicated, and
c. Your pl~vsician certifies il~ writing to PIC that the prescription drug will best treat your condition.
An exception is valid for up to one year. Yoau- physician may request the exception amlually, following the
procedure described above. The exception does not apply if PIC removed the drug from the , for-rrrulcrr-y for
safety reasons. Contact Customer Service for a copy of the written guidelines and procedures ar for assistance
in requesting an exception.
When prescription dregs from a non par-ticipcrtir~ig provider pharmacy are coves°ed, eligible charges include
only the PIC uor~ ~~ar•ticipatirrg pr-ovider r-eirnbr~rsernent vuhce. The PIC Waco ~articipatiug provider
r^eirnbur-ser~~zerrt valise is the cost of the generic equivalent of the prescription dr°ug and the dispensing fee, or if a
generic equivalent does not exist, the charge that PIC determines is to be customary for such prescr-iptiorr drug.
If the member requests a brand name drug when a generic drug alternative is available, the n~renrber 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 coirrsrrrarrce costs the r~nern~ber° incurs. When the rrr~ember has reached the out-of-pocltiet limit, t11e
rnerrrber still pays the difference in the allowed amount between the brand name and the generic drug, even
though the mermber is no longer responsible for the prescription drug coinsurance.
Corrrpourrded drugs will be covered provided that at least one active ingredient is a prescriptiorr drug. Payment
for a corrrporcnded drug that has a convnercially prepared product available that is identical to or similar to the
compounded product, will be considered for coverage after documented failure of the conunercially 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.
PIC07-740-R? 44 PCH10409 2500.100.4Rx.V (1/10)
Conzpouruled dz-zzgs will be covered according to the nzeznbez•'s pharmacy network benefits. If a non-
paz-ticipating pz~ovider pharmacy is used to obtain the compounded prescription, the non participating pzrovidez^
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. It is recommended that yoaz or your provider have certain pz~escription drzcgs prior
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. It is your responsibility to prior authorize
with PIC when non participating providers are used. If you have questions about prior authorization, you 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 "Exclusions." section later in this COC for 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 dz~zrgs that are equivalent or similar to OTC drugs, except as provided in this COC.
e. OTC home testing products, except as provided ui 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 rzeeessczrv to treat obesity.
i. Prescriptioz 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 cosm.ctic purposes.
1. Unit dose packaging.
m. Homeopathic medic>11e, including dietary supplements.
u. Prescription dz°ugs for the treatment of infertility.
o. Topical or oral acne treatments for rneznbers 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 drr~zgs if purchased by mail order through a program not admministered by PIC's pharmacy
vendor.
s. Prescription drugs for the treatment of erectile dysfunction.
t. Preseriptiozz dr~r~zgs are excluded that have a similar OTC drug (on the PIC OTC list) which has an identical
strength, identical route of adnunistration, identical active chemical ingredient(s), and identical dosage
form.
u. Off-label use of specialt~~ drzcgs.
v. Certain conzbincztion drugs and other drugs, regardless of formulaz~t~ 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-R2 45 PCH10409 2500.100.4Rx.V (1/10)
Benefit Participating Prrovider Be~zefit Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For zaoz~t par°ticipating providers,
in addition to any deductibles and
coiazsurmzce, you pay all charges that
exceed the PIC Non-Participating
Provider Reirnbursem.e~it Value.
Reconstructive Surgery 100% of eligible charges after the 80% of eligible charges after the
deduciible. dedacctihle.
PIC covers medically raeeessu~y recoi~2stratic°tive surgery due to sich-uess, accident or congenital anomaly.
Eligible charges include eligible hospital, plrysician, laboratory, pathology, radiology and facility charges.
Contact Customei Service to determine if a specific procedure is covered.
ReconsZ~°uctiz~e surgeryfollowii2g a n~tastectoi~zy includes the following:
1. reconstruction of the breast on which the mastectomy has been perfarzned;
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 "Excusions." section later in this COC for all exclusions.
b. Services and/or drugs to treat conditions that are cosmetic in nature.
PIC07-740-R2 46 PCH10409 2500.100.4Rx.V (I/10)
Benefit Pazticipating Provider Bezzefit Non-Participating Pzrovider Benefit
PIC pays: PIC pays:
Note: For norz participating providers,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
Provider Rei~~nbursernent T~alc~e.
Skilled Nursing Facility Care
Skilled rehabilitation, 100% of c>ligible charges after the 80% of eligible clzaages after the
including room and board deductible. deductible.
Coverage for confinements in non-
participating hospitals and skilled rzursin
facilities is limited to a combined
maximum of 120 calendar days per
cale~ldar year.
Daily s~-illed care as an 100°% of eligible charges after the 80% of eligible charges after the
alternative to hospital dedt~etible. deductible.
con firtements
PIC covers the eligible skilled nursing facility services for post-acute treatment and rehabilitative care of
sick~~ess or injury. These services must be directed or referred by a physician and pre-certified by PIC 's
medical director or designee.
S"billed ~~~ursing, facility services include room and board, daily skilled nursing and related ancillary services.
PIC covers a semi-private room unless a plzysicic7n recommends that a private room is rnedicaTly 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,
FIC'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 "Exclusions." section later in this COC for all exclusions.
b. Hospitalization, transportation, supplies, or medical services, including physicians' services furtlished by
the United States Government or by an institution operated by the United States Govennzlent, unless
payment is required in accordance with applicable law.
c. Private room, except when medically necessarv or if it is the only option available at the adnvtted facility.
d. Respite or custodial care.
PIC07-740-R2 47 PCH:10409 2500.100.4Rx.V (1/10)
Specified Novi-Farticipatirag 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 hcizefits. Ynz~c are not required to receive these services from a
participating provider°. For example, an office visit, (whether by a participating provider or a non-
participatirrg prnvider) 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 "Exclusions." section later in this COC for all. exclusions.
PIC07-740-R2 48 PCH10409 2500.100.4Rx.V (1/10)
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 f"~rst eligible for coverage, a
pre-existing condition is excluded from coverage until the end of 12 months from the erzrollnzent date. For
those that enroll under the Special Etu°ollment 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 rnernber had corrtimzons
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 exclnsions or limitations specified in this C®C, PIC` will not cover charges
iz~zcurrezl for any of the following services:
1. Services or supplies that PIC determines are not rnediccrlly necessary.
2. Invc>sti,gative procedures and associated expenses.
3. Charges for services determined to be duplicate services by PIC.
4. Personal comfort or convenience items.
S. Procedures that are always cosmetic, or for convenience or comfort reasons, as listed on PIC 's Cosrrzctie
Procedures Policy. This policy maybe obtained by calling PIC Customer Service.
6. Qrthognathic 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 tlu•ough 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.
I1. Charges that exceed the PIC Norz-Par•ticipatirrg Provider Reirnbrrrsement halue for services or supplies
received from norzharticipating providers, including non-participating phainiacies.
12. Services prohibited by law or regulation, or illegal under applicable laws.
PIC07-740-R2 49 PCH]0409 2500.100.4Rx.V (1/10)
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 ]aw.
14. Services under this plan that are paid under Medicare Part B but only to the extent: (i) yozz 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 inezrrr°ed outside the United States if the rrzernber 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
suUscr-iber or of the subscriber's spouse) or anyone who customarily lives in the suhscr•iber~'s household.
19. PIC or the rnember~ 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, daulas, and personal trainers and others who have not completed
professional level education and licensure as deterimined by PIC.
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 coirrsur~arrce 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
mannnograms, 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 airy loss to which a contributing cause was the member's cormnission of or
attempt to conmiit a felony or to which a contributing cause was the rrzernber's being engaged. im an illegal
occupation.
32. Travel, transportation or living expenses.
PIC07-740-R2 50 PCH10409 2500.100.4Rx.V (1/10)
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 aII 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-en~efgency ambulance service from hospital to hospital such as transfers and admission to
hospitals performed only for convenience.
34. Chiropractic Services:
a. See all exchusions.*
b. Services primarily educutiofzal ill nature.
e. 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. Chu-opractic therapy other than for treatment of acute musculoskeletal conditions.
i. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture
practitioner or 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 exelusions.*
b. Dental services covered under yorar- 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.
£ 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. Dzuable Medical E-quipment (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 edircatio~7al in nature or for vocation, comfort, convenience or recreation.
PIC07-740-R2 51 PCFI10409 2500.100.4Rx.V (1/10)
h. Hearing aids, devices to improve hearing and related fittings (except as provided in the Durable
Medical Equipment (DME), Services and Prosthetics provision).
i. Conununication 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-taunter 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. Upgrades to or replacement of any items that are considered eligible char^ges 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 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-pa~edical person or self administered.
e. Home health aides.
f. Services provided in your home for convenience.
g. Services provided in your harne 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 your 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 Unted States Govermnent or by an institution operated by the United States Govermnent, 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.
£ Services and/or drugs to treat conditions that are cosmetic ul natLUe.
PIC07-740-R2 52 PCH10409 2500.100.4Rx.V (1/10)
g. Orthoptics and refractive surgery (i.e. lasik} for opthalmie conditions that are correctable by contacts or
glasses.
h. Services and/or surgery and associated expenses for gender reassignment unless determined to be
nrediccally 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 yoga are not diagnosed with the specific sick~ress by a plrysiciar7 or
yoga are not at high risk for the specific sickness as confirmed by a physicimr.
j. Homeopathic medicine; hypnosis; chelation therapy, except chelation therapy will. be covered when
medically necessary far the treatment of heazy metal poisoning.
k. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture
practitioner or a provider licensed or trained in acupuncture.
1. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease.
m. Autopsies.
n. Bariatr°ic 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 eorrfinement;
2. far the diagnosis and treatment of diabetes or an eating disorder; or
3. a rnernber has been diagnosed with a chronic medical condition by a physician.
In all cases, except eortfiraerraent, 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. (I[TI).
j. Donar sperm.
k. Oral and injectable chugs for infertility.
42. Mental and Substance-Related Disorder Services:
a. See all exclusions.*
b. Counseling, studies, services or corzfincments ordered by a court or law enforcement officer that are not
determined to be medically rrecessarw 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 tra>17ing services.
d, Substance or mental health related conditions that according to generally accepted professional
standards caimot be improved with treatment, except as stated in this COC.
e. Services to hold or confine a rnember° under chemical influence when no medically ncccssary services
are required, regardless of where the services are received (e.g. detoxification centers).
f. Early behavioral interventions for children including 'but not linuted to Lovaas therapy, applied
behavioral analysis, discrete trial training, and intensive intervention programs.
g. Private room, except when rrredically necessary or if it is the only option available at the admitted
facility.
PIC07-740-R2 53 PCH10409 2500.100.4Rx.V (1/10)
h. Home-based mental or behavioral health services, unless authorized by PIC's medical director or
designee.
i. Biofeedback.
j. Developmental disabilities or mental conditions that, according to generally accepted professional
standards, are not amenable to favorable modification, except for initial evaluation, diagnosis or crisis
intervention.
k. Services provided by a licensed residential treatment fzciliry, except as authorized in advance by PIC's
medical director or designee.
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 prob -ams, except as provided in tlus 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 menrher has been diagnosed with a chronic medical condition by a Physician.
In all cases, except confirremerzt, 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 norr ~~articipatirrg Provider°s unless
requested by PIC.
k. Genetic testing and associated services when done as a screening test to predict whether yorz may be a
carrier of a specific sicl~ress when you are not diagnosed with a specific sickness by a Physician or you
are not at Ivgh risk for the specific sicb~ress as confirmed by a Physician.
1. Homeopathic medicil~e; hypnosis; ceesation therapy, except ceesation therapy will be covered when
medically zecessary for the treatment of heavy metal poisoning.
m. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture
practitioner or a Provider- licensed or trained in acupuncture.
n. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease.
o. Treahnent 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 Man•ow Transplant Services:
a. See all exclusions.
b. Services related to organ, tissue and bone mal-r-ow 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-R2 54 PCH10409 2.500.100.4Rx.V (1/10)
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 cordlumbilical cord blood.
i. Travel expenses related to a covered transplant.
45. Physical Therapy, Occupational Therapy and Speech Therapy:
a. See all exelusions.*
b. Ca~stodial cure or ma~intenarzce care.
c. Recreational, educational, or self-help therapy (such as, but not limited to, health club memberships or
exercise equipment).
d. Therapy provided in yoiu~ 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-coi-rectu~g.
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. Pr°escription Drug Services:
a. See all exclusions.
b. Replacement of a prescriptio~i drz~rg due to loss, damage, or theft.
c. Drugs available over-the-counter (OTC} that by applicable law do not requi-e a prescription, except as
provided in this COC.
d. Prescription drugs that are equivalent or similar to OTC dr°ugs, 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 dncgs and OTC drugs for smoking cessation, except as provided in this C~'OC.
j. Prescriptions written by a dentist unless i1 connection with dental procedures covered under this Plan.
k. Drugs used for cosmetic purposes.
1. Unit dose packaging.
m. FIomeopathie medicine, ilehtding dietary supplements.
n. P~°escription drugs for the treatment of il2fertility.
o. Topical or oral acne treatments for rnemhers 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 admilistered as part of a drug manufacturer's study.
r. Prescription drags 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 ingredients}, and identical
dosage form.
u. Off-label use of specialty dt•trgs.
v. Certain cornbinution dn~igs and other drugs, regardless of .frn°muluiy 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-R2 55 PCH10409 2500.100.4Rx.V (1/10)
47. Recorastr•aactive Surgery:
a. See all exclusions.*
b. Services and/or drugs to treat conditions that are cosmetic in nature.
48. Skilled Ntcr•sing Facility Care:
a. See all exclusions.*
b. Hospitalization, transportation, supplies, or medical services, including plrysiciaras' 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 medical/y r~aecessary or if it is the only option available at the adnutted
facility.
d. Respite or custodial care.
49. Specified Nola-Participating Provider Services:
a. See all exclusions.*
Ending Your Coverage
Coverage of the subscriber and/or his or her deperaderats will terminate on the earliest of the following dates,
except that coverage may be contimied or converted in some instances as specified in tl~e "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.
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
c~~ependent, unless the eligible dependent is disabled.
For the subscriber and dependents, termination will be retroactive to the last calendar day for which the
subscriber°'s contribution towards prerniacrn has been received.
7. For the subscriber and dependents, the date you have preformed au 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.
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 em-olled as a participant (including the date the applicable naernber- ceases
to be enrolled for continuation coverage (COBRA) in a HRA plan.
PIC07-740-R2 56 PCH10409 2500.100.4Rx.V (1/10)
Extension of Benefit if Health Plan or Carrier Replaced
If you are confined on the effective date of this coverage, the prior carrier is responsible for all eligible charges
until your final discharge from the inpatient facility or until contract maximums have been met.
An extension of benefits will be provided under this COC to a rner~abei° who is confimed in a hospital or skilled
nursing facility on the date the naerraber's employer terminates its GMC with PIC and replaces group medical or
health coverage with another health plan or insurance carrier, If the employer replaces PIC coverage with
another group health plan or insurance carrier, PIC will pay benefits while the naeaaaber is confined as described in
this section, until discharge, upon receipt of due proof of the following:
1. the rai~eanbei° incurred eligible charges while confined,•
2. the eligible charges are related to the siclti'zaess or injury which caused the nienzber to be confined; and
3. the eligible charges would have resulted in a valid post-sen~ice china 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 intei•rnption 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
COT a tl"llJZl tlOTI S.
If you do not return after an approved leave of absence, coverage may be continued under the "Contim~ation
Coverage" section, provided you elect to continue under that provision. If the ntenaber returns to work
immediately following lus 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 ul~ifonned services and/or their
covered dependents may continue coverage pursuant to USERRA for up to 24 months after the date the
subscriber- is fn-st absent due to uniformed service duty.
EIigibility. 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 conmlissioned corps of the Public Health Service. Duty includes absence for active duty,
active duty for trai~ung, 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 subscr•ib~r's covered
absence are eligible to elect continuation under USERRA.
Upon the sz~tbscribea^'s return to work immediately following his or her leave under USERRA, no ~ti~aiting
periods orpre-existing condition limitations will apply.
Contribution Payment. If continuation of coverage is elected under USERRA, the sz~tbscriber 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 sa~abscriber would otherwise pay for coverage. For
PIC07-740-R2 57 PCH10409 2500.100.4Rx.V (1/10)
absences exceeding 31 calendar days, the cost may be up to 1.02% of the cost of coverage under PIC. This
includes the stibscr°iber's share and any portion previously paid by the employer.
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 sirbsc.riber's court-martial or
dishonorable discharge from the uniformed services; or
4. the date on which the GIL2~C is terminated.
The continuation available under USERRA runs concurrently with continuation available under "Continuation
Coverage." Srrbscribef'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 dVork 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 retunl home safely and an eight hour rest period.
2. 31 to 1.80 days: The employee must apply far reemployment no later than 14 days after completion of
military service.
3. 181 days or mare: 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.
PI:C07-740-RZ 58 PCH10409 2500.100.4Rx.V (1/10)
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 anal maintained by the employer, then you~° right to continue coverage under this COC is not
conditioned upon yoatr 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 subsea°zber
and/or covered member is not required to elect, enroll or be em-olled for, or maintain continuation coverage under
the employer's HRA program. Notwithstanding the foregoing, the employes°'s HRA program may condition the
right to continue coverage under such HRA program upon the subscriber's and/or covered men~~ber's election,
concurrent em-oihnent for, and maintenance of continuation coverage (COBRA) under this COC. A failure to
elect and maintain continuation coverage under this COC may terminate yoz~y- 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, yozt must make a timely separate election to
continue coverage under this COC and timely pay separate continuation premiums far 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 c~epe~~de~zts under this COC that is non-continuation coverage shall be coordinated
with and conditioned upon enrollment and coverage under the HRA pi°ogram offered. and. maintained. by the
employer.
PIC' shall not be required to establish, maintain or contribute to a HRA on behalf of an eligible rne~~~~ber• or the
employer.
PIC07-740-R2 59 PCH10409 2500.100.4Rx.V (1/10)
The subscriber, lus 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 your family elect continuation coverage. A subscriber and a covered
spouse may elect continuation coverage on behalf of each other and/or their covered deperrderrt 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 dependent children may continue coverage when coverage
would normally end;
3. Coverage will be the same as that for other sinular 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 lZight to
Convert Coverage" section following this "Continuation Coverage" section for yozu- conversion rights.
For additional information about yotn~ rights and obligations under the GMC and/or state or federal COBRA
continuation law, you should contact the employer.
Qualifying Events
1. Loss of coverage under the GMC by the subscriber due to one of these events:
a. Voluntary or involuntary ternnation of employment of the szrhscriber for reasons other than "gross
i111SCOi1dUCt."
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.
£ ~Tota~l clisczbility of the szrbscr-iber 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 em-olled il~ Medical°e.
h. Divorce or legal separation of the subscr°iber°.
i. Death of the subscriber.
PIC07-740-R2 60 PCH10409 2500.100.4Rx.V (1/10)
3. Loss of coverage under the GMC by the covered depende~~t 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.
Tlu-oughout 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 r~aer~zbers. You 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 only if you provide timely, written notice to the
employer. Fort 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 rnenzber is eligible to
continue coverage according to applicable laws;
2. Notify persons of the unavailability of continuation coverage;
3. Notify the rr~.errzbet• 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 merr~ber of the prer~iu~na contribution required to continue coverage and how to pay the p~°e~niunz
contribution; and
Notify the ruember 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. Yozr 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. Fou must notify the employer in writing of a covered deperade~xt 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 withiiZ the 60 day timeframe, as explained
previously in Item #1 and #2, using the employer's approved 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;
PIC07-740-R2 61 PCHI0409 2500100.4Rx.V (1/10}
b. the name and address of the subscriber or former szzhscriber ;
c. the names and addresses of all applicable deperzderzts;
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
£ the name, address, and telephone number of the individual submitting the notice. This individual can be
a szrbscr-iber, former srzbscr~iber, or his or her dependent(s); or a representative acting on behalf of the
employee or dependeut(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 writia~g, 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 rrzerrzber's coverage ends, or the date the employer notifies the nzenzber• 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. (You may obtain a copy of the
approved form from the employer.) This election must be submitted in writilig to the employer; and
5. You must pay continuation prerriiurzz contributions:
a. The pr•erniurzz contribution to continue coverage is the combined employer plus subscrrber• 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 disul~ilzty of the szzbscr^iber° while employed}. For a member receiving an
additional ll months of coverage after the initial 18 months due to a continuation extension for Social
Security disability, the pr-enu'ann 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 your° continuation
prerrziurrz, contribution rate(s).
b. The first pr°erzzium 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 nzenrber~'s monthly payments are
due and payable by check at the beginning of each month for which coverage is continued.
c. The rrzeruber must pay subsequent pr~errziurrz contributions by check on or before the required due ct~~te,
plus the 30-calendar day grace period required by law, and if authorized by PICs 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 yore 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 of:
a. the date of the Social Security AdministY•ation'sdlsability determination;
b. the date of the subscriber's teri~iation 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
PIC07-740-R2 62 PCH10409 2500.100.4Rx.V (1/10)
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 #l, and before the end of the 18"' month of yoza~ 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 your continuation coverage;
e. the name of the disabled rrrernb~r-;
f. the date the nr~rnber became disabled;
g. the date the Social Security Adn>inistration 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 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 ar~d specified time period for submitting, in writing, all required information
and supporting documentation.
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
4. You must pay continuation pr•errriurn contributions:
a. The prenrizzrrr 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 rnenrber
receiving an additional 11 months of coverage after the il~itial 18 months due to a continuation
extension for Social Security disability, the prenzizcna 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 prenziura~r contribution rates}.
b. The first prenrizcm contribution must be paid by check within 45 calendar days after electing to
continue the caverage. Thereafter, the nrenzber^'s monthly pa}n~nents are due and payable by check at
the beginning of each. month for which coverage is continued.
c. The rnenrber must pay subsequent prenrizn~z 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 Dependents Only:
If you are cui7-ently enrolled in continuation coverage under this GMC and the szcbscr°ibcr- dies, or in the
case of divorce or a legal separation of the subscriber, or a covered dependent child loses eligibility, then
yozc may request an extension of coverage provided that yocer cun-ent continuation coverage resulted. fiom
the subscriber's leave of absence, retirement, reduction in hom°s, layoff or his/her termination of
employment for reasons other than gross misconduct or resulted from a Social Security Admuiistration
disability determination. To request an extension of continuation, you must notify the employer in
writing within 60 calendar days after the later of:
PIC07-740-R2 63 PCF310409 2500.100.4Rx.V (t/10)
a. the date of the second qualifying event (death, divorce, legal separation, loss of depe~zderlt 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 depertde~~t children. This
extension is not available when a subscriber becomes enrolled in Medicare.
You must subnut your written notice of a second qualifying event within the 60 day timeframe, as
previously described in Item #1, 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 subn~tted to the employer
in writing and must include the following:
a. the name of the employer;
b. the name and address of the szrbscriher or fornler subscriber;
c. the names and addresses of all applicable depe~zdents cui~ently 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;
£ documentation pertauiing 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 dependents}; or a representative acting on behalf of
the employee or deper~de~~~t(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 infor~i~ation
and supporting documentation.
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 #l and #2, and submitting the employer's approved form; and
4. You must pay continuation prei~aiz~»~, contributions:
a. The pi•er~~,i~urrt contribution to continue coves°age is the con~l7ined employer plus subscriber rate
charged under the GMC, plus the employer may charge an additional 2% of that rate. For a me»zber
receiving an additional 11 months of coverage after the initial 18 months due to a continuation
extension for Social Security disability, the premiacr~a contribution for those additional months maybe
increased to 150% of the employer's total cost of coverage. The election form will set forth your-
continuation premi2m2 contribution rates.
b. The first prernit~~m 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 ~~~zembei° must pay subsequent premir~~m 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.
PIC07-740-R2 64 PCH10409 2500.100.4Rx.V (1/10}
Additional Notices You Must Provide: Other Coverages, Medicare Enrollment and Cessation of
Disability
You must also provide written notice of (1) yolrr other group coverage that begins after continuation is elected
under the GMC; (2) your Medicare enrollment (Part A, Part B or both parts) that begins after continuation. is
elected under the GMC; and (3} the ~nei~2ber-, 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 yoza 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
ilicluds the following:
1. If providing notification of other coverage that began after continuation was elected, the name of the »~enaber
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 rn~ember that became enrolled
in Medicare, and the date ofthe Medicare enrollment.
3. If providing notification of cessation of disability, the name and address of the formerly disabled n2ember, 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-R2 65 PCH10409 2500.100.4Rx.V (1/10)
CONTINUATION CHART
If coverage under this GMCis lost Who is eligible to Coverage may be continued until...
because this happens... continue...
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 srda,ccriber. Covered spouse The earliest of the following occurs:
and covered 1. Coverage begins under another group
Menrher must provide notice of such deper~der7t 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 d1e Covered former The earliest of the following occurs:
subscriber. spouse and 1. Coverage begins under another group
covered health plan after continuation coverage is
Merrrber must provide notice of such de~~erulent 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
dcperrderrt began.
Mer~aher 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 die subscriber- n~ Covered spouse The earliest of the following occurs:
Medicare within 18 months before the and covered L 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 ~-oup
other than gross misconduct. health plan after continuation coverage is
elected under the GMC.
Mc nrher 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 r~~ernber 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 earlest of die 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.
PIC07-740-R2 66 PCH10409 2500.100.4Rx.V (1/10)
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 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 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. depende~zt
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 depervderzt 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 die employer for health plan after continuation coverage is
reasons other than gross misconduct. elected tinder 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 rraenrber 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 subscr-fiber, covered spouse or covered deper~rderrt 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 amlual
em°ollment), the Special Enrollment h'eriod provisions of this COC as referenced in the section which.
describes eligibility and em-olhnent 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 newboni
children or newly adopted children (as described in the eligibility and enrollment section) that are acquired
by a strhscr•iber 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.
M 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, you may be entitled to
the special enrollment rights upon acquisition of a new dependent through marriage, birth, adoption,
placement for adoption, or legal guardianslvp, as referenced in the section entitled. Special Enrollment
Period for New Dependents Only.
P1C07-740-R2 67 PCH10409 2500.100.4Rx.V (1/10)
Special Rule for Pre-Existing Conditions
A subscriber, his or her covered spouse or covered depef7der7t 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 ~nei~zber, may choose to remain on continuation coverage under the GMC for the
remainder of lus or her continuation period for coverage of apse-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 e~:perience 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 you 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 »:e»rber, covered
spouse or covered dependent children for purposes of continuation coverage must be submitted in
•vriting to the employer at the employer's address. You must follow the employer's requirements far
submitting written notices.
Public Sector Eligible Retirees
A covered eligible retired employee of certain public or govermnental entities of the State of Mimlesota and
covered depei2c'lettts of such retiree, who are enrolled for dehendeiit coverage as of the date the retiree
terminated employment, may be eligible to continue such coverage upon retirement pursuant to Milnlesota
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, withi2i the deadline required by law, of intent to continue coverage. An eligible retired. employee
who does not elect to continue coverage does not have a right to re-enter or re-enroll for coverage at a later
date.
PIC07-740-RZ 68 PCH10409 2500.100.4Rx.V (1/10)
Youf^ Right to Convert Coverage
Your employer must notify yoT~~ 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. You are eligible for Medicare;
3. Coverage terminated due to the member's failure to pay, when due, any required coiltribzrtian toward
premium;
4. Coverage terminated due to fraud;
5. You are or could be covered. under a continuation of coverage provision under the GMC or under a group
health plan of a "successor employer" (within the meaning of COBRA continuation of coverage) to the
employer.
If you are eligible for and timely apply for a conversion contract as described below, then coverage for you and
all yoa~{r enrolled dE~~er~r.dcnts will be effective on the first calendar day following termination of coverage under
the GMC. There will be no gap in coverage.
Vt~hat you must do:
1. Contact Customer Service for conversion information;
2. Select a qualified conversion plan;
3. Submit a written application and prc~~~~iim2 payment for a conversion contract within 31 calendar days after
your coverage under the GMC ends.
PIC07-740-R2 69 PCH10409 2500.100.4Rx.V (1/10)
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 yoau~ medical claims are ultimately paid by the party that should 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 finds.
2. PIC's subrogation interest is the reasonable cash value of any benefits received by yoir. PIC's subrogation
and/or reimbursement interest applies only after you have received a full recovery far yoarr szckrress or z~~jiny
from another source of compensation for yoitir sick-rzess or inja~ry.
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 cast in the same geographical local
where the loss arises, and. costs yoT~~ pay hz obtaining yoi~ir- recovery.
4. If the health carrier and covered person cannot reach agreement on allocation, the health cai~ier 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
Yoar must provide timely written notice to PIC of the pending claim, if lroa~ make a claim against a thud party far
damages that include repayment far medical and medically related expenses z~2ct~r°i-ed for yotir• benefit. Not
withstanding any tither law to the contrary, the statute of limitations applicable to PZC's rights for reimbursement
or subrogation does not commence to run until the notice has been given.
PIC07-740-IL 70 PCH10409 2500.100.4Rx.V (1/IO)
Coordination of Benefits
As a rnernber~, 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. Yoz~ 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 rrrernber or the
ruerrrber°'s representative, each rrreruber claiming benefits under PIC must provide any facts needed to pay the
claim. If the information camzot 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, coinsurance or
copaynients, 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 acalendar- yeas°. 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 gn•oup, the separate policies are considered parts of the
same plan and there is no Coordination of Benefits among those policies.
a. group, blanket, fianchise, closed panel or other forms of group or group type
coverage (insured or uninsured);
b. hospital indenulity benefits in excess of $200 per day;
c. medical care components of group long-teen 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 govei-~Zinental 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-R2 71 PCH10409 2500.100.4Rx.V (1/10)
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-terns care policies;
c. school accident-type coverages;
d. Medicare supplement policies;
e. Medicaid policies and coverage under other governmental plans, unless
pernnitted 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 deternination 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
prunary. Exception: Group coverage designed to supplement a part of a basic package of benefits may provide
that tine 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 detei-~nhles 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 soup type plan covering the person is the prinnary 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, srrbscr°iber, or retiree, is the primary plan; and the plan that covers the person as a depenc/erat 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 deperrdertt; 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-R2 72 PCH1.0409 2500.100.4Rx.V (1/10)
Child Covered Under More Than One Pian: 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 i£
• 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 specifyi~lg 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 cf 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. Tlus rule does not apply if the rule under para~m-aph 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 deternuned under the rule labeled 2.
Continuation Coverage: If a person whose coverage is provided under a right of continuation provided by
the federal of state law is also covered under another plan, then:
a. the plan covering the person as an employee, r~7emher•, satbsci-iber-, or retiree (or as a depef~def~t of an
employee, ~ne~~~~he~; .ci~hscriber, 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 detenzune 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 ec}ual 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: Cei-fain facts about health care coverage and
services are needed to apply Coordination of Benefit rules and to deternine 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 clainung
benefits. PIC need not tell, or get the consent of, any person to do this. Each person claiming benefits lender PIC
PIC07-740-R2 73 PCH10409 2500.100.4Rx.V (1/10}
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 PAS"MENT: 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 "pa}nnent made" includes providing benefits in the form of services. Tn 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 PlC to the
771C'7111~CJ'.
The "amount of pa}n~ients made" iiichides the reasonable cash. value of any benefits provided in the form of
services.
H. CG®RDINATING Vt'ITH MEDICARE: Tl1is section describes the method of payment if Medicare pays as
the primary plan.
If a j91°oi~ider 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 Nor1-ParticzPatzrlg Prrovl~dc~1~
Reir11b1rrsement L'talare 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 n1e1~11~er who is eligible for Medicare has not enrolled with
Medicare, then PIC will pay as the primary plan.
Renal Failure. If yo11 begin to have services related to renal failure, 1ti~e request that volt sign up far Medicare.
PIC07-740-R2 74 PCH10409 2500.100.4Rx.V (1/10)
How to Submit a BiTI if You Receive One far Covered Services
Sills from Participatitzg Providers
When yoa~ present your identification card at the time of requesting services from participating providers,
paperwork and submission of post-service Maims relating to services will be handled for you 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 yorr 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 pr°ovider• 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 roust 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-ser~~ice claims received. after the deadline will be
denied.
dills from l~ozz-Participatitzg Providers
Claim Submission. ~or~r must subnut 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-sen~ice claims received after the deadline will be denied.
Payment of Past-Service Claims. Post-service claims far 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 Fost-Service Claims
Post-service claims are claims that are fled for payment of benefits by PIC after medical care has been received
and submitted in accordance with PIC 's post-sern~ice claim filing procedures.
If youa° attending provider submits a pvst-ser~~ice cluirra on yorr~r 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 pr•ovi.dcr was acting as
your authorized representative. Your direction will apply to any remaining appeals.
If yoz~r 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 ilutial benefit determination, it may
request the necessary information from you or a tl~°d party. You or the t1~-d 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 yor.r 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 tray, 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-R2 75 PCH10409 2500.100.4Rx.V (1/10)
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 supportnlg documents.
I. 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' compiailzt
already is resolved.
PIC will notify yorr of its decision within 30 calendar days from the date that it receives yor+r complaint.
111 certain circumstances, PIC may take up to 14 additional calendar days to notify yorr of its decision. 111
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 follow>llg time
periods:
If you are requesting benefits that require pre-certification (a pre-service claim), your request will be handled
ui accordance with the pre-certification section of this COC. If yoar° complaint is about a claim for benefits for
services received (a post-service china.) your complaint must be submitted to PIC within 180 calendar days
following denial of the initial determination. A decision on your post-service clairrr complaint will be made
wit1~130 calendar days from receipt of your complaint. Tl>is time period maybe extended if you agree.
How to Request an Appeal
If after the first Ieve1 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
yore 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 pr°ovider within the time periods set forth below for deciding an appeal, yozrr
request will be denied.
Pre-Sen~ice Claims. If the appeal concerns acute services, yourr may request an expedited review. Within 72
hours of receipt of such request, a decision on your appeal will be made. PIC will notify yore, your atterrdirrg
Ire~rlth care pr°ofessional and your 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, yoar attenc~irrg health care professional and your attending provider within one business day
of the determination, or sooner if yoar medical condition requires. If the appeal concerns non-acute services,
a decision on your appeal will be made and communicated in writing to you, yoar• attending 17ealth care
professional and your attending provider within 30 calendar days. This time period lnay be extended for up
to 1.5 calendar days if yorr agree. This appeal must be submitted to PIC within 180 calendar days following
denial of the ii>itial determination. When you appeal the initial determination for medical reasons, PIC will
al•range for review of the clinical material by a physician in the same or similar specialty who did not make
the initial determination.
PIC07-740-R2 76 PCH10409 2500.100.4Rx.~ (1/10)
2. Post-Service Clairrzs. If your complaint is not resolved to your satisfaction or if you received services after
your- request for pre-certification was denied or after yoar failed to seek pre-certification for services for which
pre-certification was required, yoar may contact PIC and request a written appeal or a heari~ig within 60
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 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 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 yorn~ 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 extei-na1 review organization is an independent entity under contract with the State of Minnesota to review
health plan complaints. I'ou may request an external review at any time including, if vorr or someone acting on
your behalf has exhausted the PIC internal complaint and appeal processes, yore or your representative may file a
request for external review to the Commissioner of Commerce at the following address:
Minnesota Department of C`ammerce
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 rr~~ernber.
PIC07-740-R2 77 PCH10409 2500.100.4Rx.V (1/10)
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 subscr~iber. 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 subscribes-, 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
Attending Health Care The health care professional providing care within the scope of the professional's
Pr-nf'essioncrl practice and with primary responsibility for the care provided to a naenabe~^.
Attending health care professional shall include only physicians; chiropractors;
dentists; mental health professionals; podiatrists; and advanced practice nurses.
Bariatric Szcrgerv 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 nnental control.
Calendar Year The 12-month period begilming January 1 and ending the following December 31 for
provisions based on a calendar year.
Cortif'zcate of coverage The document describing, among other things, the benefits offered under PIC and.
(COC) your rights and olnligations.
Coinstn-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 covered se~^~~ices and supplies.
Coinsurance will be based on (1}the discounted charge negotiated between PIC and
participating pi°oviders; or (2) the PIC Non-Participating Provider Reimbzrf-sernent
l ~tltre for ~~ror~ ~urticipatittg providc~~ s~.
Combination Drug A prescription drug in which two or more chemical entities are combined into one
commercially available dosage form.
Conzporrnded Dn~~g Drugs which are customized drugs prepared by a pharnnacist from scratch using raw
chenicals, powders and devices according to a physician's specifications to meet an
individual patient need.
Confinc~nent An uninterrupted stay of ?4 hours or more in a d~ospital, skilled nursing facility,
rehabilitation facility or licensed residential treatment facility.
Cantinr.rous Coverage The maintenance of corrtirudoiis and uninterrupted creditable coverage by an eligible
employee or dependent. An eligible employee or dependent is considered to have
maintained continuoz~s cover^age if the individual em•olls in PIC and the break in
creditable coverage is less than 63 calendar days. See waiting per-sod.
Cosmetic Services, medications and procedures that improve physical appearance but do not
correct or improve a physiological function, or are not medically necessmy.
P1C07-740-R2 78 PCH10409 2500.100.4Rx.V (1/10)
Covered Sern~ices 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 t}pes of coverage set forth in tl~e 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 Tr°eatrnent Any professional or health care services at a hospital or licensed treatment facility
Services far the treatment of mental and substance related conditions.
Deductible The amount of eligible charges that each rnerrrber° must rarcrn- 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 Specr'alist A dentr'st board eligible or certified in the areas of enrodontics, oral surgery,
orthodontics, periodontics, periodontics and. prosthodontics.
Dependent The subscriber^'s eligible dependent as described in the "Eligibility" section.
Designated A pcrrticipatbtg provider or group or association of purticipatirrg pr°oviders that has
ElectroniciOnline been designated by PIC or its designee to provide electronic/online evaluations and
Pur-ticipating Provider management services for rrrenrbers with specific chronic diseases, as determined by
PIC or its designee. A list of such providers may be obtained by calling Customer
Service.
Designated Trmrsplarrt Any licensed hospital, health care pr°ovider, group or association of health care
Nettivor°ls 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,
inch°uction in scholastic skills such as reading and writing; preparation for an
occupation; or treatment for leanling 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 prob -ess is being made towards functional goals set by the attending
physician.
PIC07-740-R2 79 PCH 10409 2500.100.4Rx. V (1 / 10)
Effective Date The date a rr~errrber becomes eligible for health care services and completes all
enrollment requirements, subject to any required waiting period.
Eligible Clrar°ges A charge for health care services and. supplies subject to all of the terms, conditions,
limitations and exclusions of PIC and far which PIC or the rnen2ber will pay.
Ernergerzev Enaergerrcy 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 rrzerrrber's health in serious jeopardy;
2. serious impairment to bodily functions; or
3. serious dysfunction of any bodily organ or part.
Enrollrnerrt Dute 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 pc`u-ticipcatirrg provider has contractually agreed to accept as
reimbursement in full for cover°ed services and supplies. This amount may be less
than the provider 's usual charge for the service.
Forrrzulary A list, which may change from time to time, of preferential prescription drugs that is
used by PIC plans.
I'rrll-tune 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.
Ha~bih~tative Therapy Therapy provided to develop lllitial functional levels of movement, strength, daily
activity or speech.
Horrr~ehortrrd When vorr are unable to leave home without considerable effort due to a medical
condition. Lack of transportation does not constitute lzorrr~ehoruld 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
Iaospital is not mainly a place for rest or custodial care, and is not a nursing home or
similar facility.
Incra•r°ed Services and supplies rendered to yourr. Such expenses shall be considered to have
been incurred at the time or date the service or supply was actually purchased or
provided.
brjrny Bodily damage other than siclL~t~ress including all related conditions and recm-r-ent
symptoms.
PIC07-740-R2 80 PCH10409 2500.100.4Rx.V (1/10)
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 is
the subject of ongoing Phase I, II, or III clinical trials; ar 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, P1C must determine, on a case-by-case basis, that a drug,
device or medical treatment or procedure meets the following criteria:
I. Reliable evidence prelinunarily 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 Iikely far its
proposed use; and
4. Reliable evidence suggests the drug, device or treatment is medically appropriate
for the member.
When PIC determines whether a chug, 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 chug, device or medical treatment or procedure, which
describes ansong 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 conunittees, or technology assessment bodies, and professional
consensus options of local and national health care providers.
PIC07-740-R? 81 PCH10409 2500.100.4Rx.V (1/10)
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.
hicensed Residential A facility that provides 24-hour-a-day care, supervision, food, lodging, rehabilitation,
Ti•eatmcnt Facility or treatment and is licensed by the Minnesota Commissioner of Human Services and
the Minnesota Department of Health.
Mainter~iai~ice Care Care that is not hubililtative or rehabilitative therapy and there is a lack of
documented significant progress in functional status over a reasonable period of time.
Medically Necesscny/ Diagnostic testing, preventive health cure 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 nienibei•'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-Purticiputing A licensed provider not under contract as a participating provider.
Provider
Non-Purticiputing Coverage for services provided by licensed providers other than:
Pi°ovider Benefits 1, participating providers; or
2, the provider to which the pas-ticipatis7gprovider-has referred the member.
With non participating pravidei° benefits, there is member financial responsibility of a
deductible, coinsurance, and any amount in excess of the PIC Non-Participating
Provider Reim~bursemertt Valise.
Out-of=Pocket Linsit The maximum amount of money you must pay in coiszsurcmce and deductible before
PIC pays yoin° eligible charges at 100%. I~f yuzs reach be~~le~fit or overall maximums,
you are responsible for amounts that exceed the out-of-pocket limit.
Over-the-Coimter°
(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 PIC provider network.
Purticiputing 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-R2 82 PCH10409 2500.100.4Rx.V (1/10)
Physical Disability A condition caused by a physical ir~rjurv or congenital defect to one or more parts of
the member's body that is expected to be ongoing for a continuous period of at least
two years from the date the il>itial proof is supplied to PIC and as a result the member°
is incapable to self-sustaining employment and is dependent on the strbscr•iber for a
majority of financial support and maintenance. An illness will not be considered a
physical disability.
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-Participating The amount that will be paid by PIC to a nonparticipating provider for a service is a
Provider- percentage of the lesser of the:
Reinabursenrent hulue 1. non participating provider's charge;
2. amount based. on prevailing reimbursement rates or marketplace charges, for
similar services and supplies, m the geographic area; or
3. amount agreed upon between PIC and the non participating provider.
Tf the amount billed by the rzon participating provider is greater than the PIC non-
participatir~rg proti~~ider reimbt~rrsernent vultte, yotr must pay the difference. This
amount is in addition to any deductible or coinsurcnrce amount yoa~r may be
responsible for according to the terms of this COC.
Post-Service Claim A request for payment of benefits that is made by a nzenzber or his or her authorized
representative after services are rendered and in accordance with the procedures
described. in this COC.
Prerrziunr 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 Drrrg A drug approved by the Federal Di~ig 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.
Reconstrrcctive Surgery to restore or correct:
1. a defective body part when such defect is incidental to or follows surgery
resulting from injury, sick~ress, or other diseases of the involved body part; or
2. a congental disease or anomaly which has resulted ili a functional defect as
determined by a physician; or
3. a physical defect that du ectly adversely affects the plrysical health of a body part,
and the restoration or correction is determined by PIC to be medically necesscny.
PIC07-740-R2 83 PCH10409 2500.100.4Rx.V (1/10)
Reconstr•rrctive Surgery Coverage for rnen2ber°s receiving covered services under PIC in comlection with a
Following a mastectomy and who elects breast reconstruction in connection with such
Mastecton?v 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 coinsr~r°arrce 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
rzrrrsirtg facility care; home health services; chiropractic services; speech, physical and
occupational therapy services for chronic medical conditions, or long-teen
disabilities, where progress toward such functional ability maintenance and
improvement is not anticipated.
Risk Allo~n.~ance A percentage of the reimbursement to a purticipating 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 i~our changing condition. Long term
dependence on respiratory support equipment does not in and of itself define a need
for sb~~lled car°e.
Skilled Nursing A Medicare licensed bed or facility (including an extended care facility, hospital
Facility swing-bed and transitional care unit) that provides skilled em°e.
Specialist Pr°ovider°s other than those practicing in the areas of family practice, general practice,
internal medicine, OB/GYN or pediatrics.
Shecialt}~ Drags Injectable and non-injectable prescription drags 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.
PICOT-740-R2 84 PCN10409 2500.100.4Rx.V (1/10)
Standing referral A process by which a n~enr~ber 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 subscri.ber's lawful spouse.
Subscriber The person:
1. on whose behalf contribrrtiorr is paid; and
2. whose employment is the basis for membership, accarding to the GNIC; 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
lac or she was reasonably fitted.
Transplant Ser~~ices~
Urgent Care Center
T~aitirr~ Per~iocl
You/1 ~~ur
Transplantation (including retransplants) of the human organs or tissue, including all
related post-surgical treatment and drugs and multiple transplants for related care.
A licensed health care facility whose primary purpose is to offer and provide
iiiunediate, short-term medical care for minor immediate medical. conditions not on a
regular or routine basis.
The period of time that an individual must wait before being eligible for coverage
under PIC. A tivuitirrg period will not:
apply towards a period of creditable ccwer-age; or
be used in determining a break in continuous and creditable coverage.
Refers to rncrrrber~.
PIC07-740-R? 85 PCH10409 2500.100.4Rx.V (I/10)
READ YO~JR CERTIFICATE CAREFULLY
CITY OF COLUMBIA H~IC HTS
~ v. `~ 00.2,.V
PIC07-760-R2
PCH10409 15.100.2.V (i/IO)
Questions? Our Customer Services staff is available to answer questions about your
caverage 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
iiTumber 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
PIC07-760-122 PCH10409 15.100.2.V (1/10)
TABLE OF CONTENTS
Important Meu~ber Information .................................................................................................................................1
Member Bill of Ri~hts .................................................................................................................................................. 2
Disclosure of Provider Payment Methods ................................................................................................................... Z
Member Information for Non-Participating Provider Benefits ................................................................................. 3
P Y ( ~ ...................................................................................................................
PreferredOne Insurance Com an PI 4
Introduction to Your Coverage ...............................................................................................................................4
g ( ) ..............................................................
Certificate of Covera e 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 Ei~lergency ................................................................................ .................................................................. 5
Group Master Contract (GMC) ............................................................ .................................................................. 5
Your Identification Card ....................................................................... ..................................................................5
Provider Directory ................................................................................ .................................................................. 5
Changes in Coverage ............................................................................. ..................................................................6
Conflict with Existing Law .................................................................... .................................................................. 6
Privacy ................................................................................................... .................................................................. 6
Clerical Error ........................................................................................ .................................................................. 6
Assignment ............................................................................................ .................................................................. 6
Notice ..................................................................................................... .................................................................. 6
Time Lamit on Certain Defenses ........................................................... .................................................................. 6
Fraud ..................................................................................................... .................................................................. 6
Medical 'Technology and Treatment Review ........................................ .................................................................. 7
Recommendations by health Cate Providers ....................................... .................................................................. 7
Legal Actions ......................................................................................... ..................................................................7
Eligibility and Enrollment ........................................................................ ................................................................. 8
Schedule of Payments ................................................................................ ................................................................11
Pre-certification Requirement and Prior Authorization .......................... ................................................................13
Description of Benefits .............................................................................. ................................................................16
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 Com~ert Coverage ............................................................... ................................................................ 71
Subrogation and Reimbursement ............................................................. ................................................................ 7Z
Coordination of Benefits ........................................................................... ................................................................ 73
Haw to Submit a Bill if You Receive One for Caverect Servees ................ ................................................................77
Initial Benefit Determinations of Post-Ser-~~iee Clcrirais .............................. ................................................................ 77
Complaint and Appeal Procedures ........................................................... ................................................................ 78
No Guarantee of Employment or Overall Benefits ................................... ................................................................ 80
Definifiotts ................................................................................................. ................................................................ 80
PIC07-760-R2 PCFI10409 15.100.2.V (1/10}
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 provides°s. 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.
E~rterge~zcy Services: Emergency services from non ~crrticipati~zg providers will be covered only if proper
procedures are followed. Yoan- CDC explains the procedures and benefits associated with emergency care from
participa~tizzg and nonparticipating providers.
Exclusions: Certain services or medical supplies are not covered. Yost should read yozrr COC for detailed
explanation of all exclusions.
Continuation: Yoir may convert to an individual contract or continue coverage under certain circumstances.
These continuation and conversion rights are explained in your COC.
Termination: Yozu• coverage may be terminated by yocr or PIC only under certain conditions. Yotn- COC
describes all reasons for termination of coverage.
Preseriptdon I3rargs and. 1l~edacal Ecluig~ment: Enrolling in PIC does not guarantee that any particular
prescription. d~7rg 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 pre~nii~nz 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 rnembel•s,
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 plan year.
Small employer plans are guaranteed renewable as long as the employer remains eligible for a small employer
plan.
PIC07-760-R2 1 PCH10409 15.100.2.V (1/10)
Me~iber Bill of Rights
The laws of the State of Minnesota grant znenzbers certain legal rights.
As a PIC znembez°, you have the following rights and responsibilities.
Members have the right to:
1. available and accessible services, including emergency services 24 hours a day, 7 days a week;
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 mahltained by PIC and its participatz~ng pz°oviders, 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 z-equest information.
Disclosure of Pe^ovi~'er Payment Methods
PIC contracts with par°ticiputirzg providers to provide health care services to members. Participating provicler-s
submit claims for eligible charges to PIC with their usual charge for the health care services. At PIC, the
rz7enzber 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 coinszzrance amounts are
based on the, fee schedzde amount.
A participating provider may contractually agree to a risk ullou~ance. 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 ullowarzce is repaid may differ by pr~ovider type/specialty and therefore may vary among participating
provider°s. Members are not responsible for payment of any risk allo~a~arzce. Factors such as the quality,
efficiency and cost effectiveness of care that participating providers deliver may also affect future contract teiaus
between PIC and pccr~ticipatirzg providers.
Post-service claims submitted to PIC for norz ~articipatirzg provider benefits are paid on a.fee-for°-service basis.
PIC determines member benefits based on the PIC Non-Par°ticipatirzg Provider Reirnbursemerzt 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
undei-utilization. Utilization management decision making is based only on appropriateness of care and service
and existence of coverage.
PIC07-760-R2 2 PCH10409 15.100.2.V (1/10)
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. Yoirr° 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 yor~u° COC for specific information about the need to
obtain pre-certification.
PIC07-760-R2 3 PCH1040915.100.2.V (I/10)
PreferredOne Insurance Company (PICA
Introduction to Your Coverage
Tlus COC describes your PIC health care coverage. PIC may not cover all of yoacr health care expenses. Read
this COC carefully to determine which expenses are covered. Many provisions are interrelated; therefore,
readilig just one or two provisions may not give you a complete understanding of the coverage described under
this COC. PIC has discretionary authority to determine eligibility for benefits and to interpret and construe
terms, conditions, limitations and exclusions of this COC and the GMC. 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 sa~hscriber and the elrrolled dependents, if any, as
named on the sacbscriber°'s enrollment application.
Services Received in a Participating Provider Facility franc 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 erraergencv room physician, the par^ticipating provider- level of berrefts applies as
shown in the "Berre~t Schedule". You will be responsible for any charges that may exceed the PIC Norr-
Participating Provider Keirnhrrrserrzent l'alr~e.
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 starrdirrg referral for treatment
of one of the following conditions:
1. a chronic health condition;
2. a life-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. Disabl>l1g or cln-onic condition that is in an acute phase.
If the physician certifies that the rrrernher- has an expected lifetime of 180 calendar days or less, services from the
terminating provider will be covered until the nrenrber's death. Continuity of care may also apply to rnernbers
PIC07-76U-R2 4 PCH1040915.100.2.V (1/10)
who require an interpreter or are receiving culturally appropriate services and the provider network does not have
such aprovider- or specialist in its network.
Continuity of care may also be extended to new rnernbers who meet the criteria described above and whose
employer changed health plans. However, in such situations, the rron participating prrovider 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 par°ticipating provider ~s regular fee for such services;
2. Follow PIC's pre-eerkification requirements; and
3. Provide PIC with all necessary medical information related to the care provided to the naernber^.
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 E~7aergency
You should be prepared for the possibility of a medical emergency by knowing yoa~r 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 ii1 an accessible location in case a medical ernergeruy arises.
If the situation is a medical emergency and if traveling to a pcarticipatirzg pravider would delay emergency care
and thus endanger yoru° 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 yo7n- 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 emp(oyer~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 erors. If any ID card information is incorrect, post-service
claims or bills for your- health care may be delayed or temporaz-i1y denied. hou will be asked to present your ID
card whenever vorr receive services.
Provider Directory
You may request from PIC a provider directory that lists facilities and individuals who are par°ticipating
providers and are available to you. You may also fmd participating ~,~roviders 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 par•ticipatir~ig provider.
You may want to verify that a provider you choose is a purticipatirrg provider by calling Customer Service.
PIC07-760-R2 5 PCH10409 15.100.2V (1/10)
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 an a uniform basis among all individuals with the same type of coverage. Any change in
coverage is subject to PIC approval. If a change in coverage is requested by you~° 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 stahrte 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 yozrr PIC health care coverage. You will receive a copy of PIC's Notice of Privacy
Practices (which summarizes PIC's HII'AA Privacy Rule obligations, you~° 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
Yoi~~ 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
rnenzhcrs.
Time Limit an 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 from the effective date of the member's coverage
due to a claim or disability. This time limit does not apply to fraudulent misstatements.
Fraud
Coverage may be terminated, if a rnen~aber falsifies their application for coverage; subnuts fraudulent, altered or
duplicate billings, for their or others personal gain; or allows another party not covered under this COC to use
their coverage.
Ptco~-~60-~ 6 Pct-~io4o91s.roo.2.v tino>
Medical Technology and Treatment Review
Depending on the focus of the technology or treatment, one of three corrnmittees (MedieaUSurgieal 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 p~•ovider may recomm~end or provide written authorization for services that are specifically
excluded by the COC. When these services are referred or recommended, a written authorization from yoztr
provider does not over-ide any specific COC exclusions.
Legal Actions
No legal action may be brought until at least 60 days after the proof of loss has been provided or after the
expiration of three years after the time written proof of loss is required to be pravided.
PIC07-760-R2 7 PCH1040915.100.2.V (1%10)
Eligibility and Enrollment
Eligibility
To be eligible to enroll for coverage, you must be a:
1. full-tine employee; or
2. dependent.
If the employer also sponsors and maintains a health reimbursement arrangement (HRA) plan, the employer may
require that eligibility, em•olhnent and coverage under this COC be coordinated with and conditioned upon
concun-ent eligibility and enrollment for benefits under the HRA plan sponsored by the employer.
If concun-ent eligibility and enrollment is required, then the eligibility requirements under this COC are also
applicable to the HRA plan and yotr must be concurrently enrolled under both programs (i. e., this COC and the
HRA plan) to participate in either program. If yoz~ 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 subscribef° it1 order to enroll his or her dependents. A spouse who is
covered as an ei~nployee of the employer is not an eligible dependent. A child who is covered as au employee of
the employer is not an eligible ~lepeirdent. If both parents are covered as employees, children may be covered as
depet~de~rts 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 srrbscriher 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.};
e. stepchildren of the st~rbsc~°iber who reside ii1 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 fiom 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 (ER1SA) and its implementing regulations ("QMCSO"),
which is enforceable against a subscriber. Yoa~tr employer is responsible for determit~lg whether or not a
medical child support order is a valid QMCSO. YOn may request a copy of the procedures used to make
such determinations fiom yot~n° employer.
f. a child for whom the subscriber has been appointed legal guardian by a cotiu-t of law up to the age stated
in the court appointment if less than age 25.
3. Unmarried disabled dependents after reaching age 25, provided they are:
a. incapable of self-sustaining employment because of physical disability, developmental disability, mental
illness or mental health disorder that is expected to be ongoing for a continuous period of at least two
years from the date the initial proof is supplied to PIC; and
b. dependent on the subscriber for a majority of financial support and maintenance.
PIC07-760-R2 8 PCH10409 15.100.2V (1/10)
Proof of incapacity must be provided with the subscriber's application for coverage with PIC within 3l
calendar days of the date the dependent reaches age 25.
After this initial proof and determination of disabled dependent status by PIC, PIC may request proof again
two years later, and eac11 year after.
If the dependent is disabled and 25 years of age or older at the time of the subscriber's enrollment or initial
employment, and such dependent through subscriber enrolled for coverage with PIC, the sarbscr-fiber must
provide PIC with proof that the dependent meets requirements a. and b. above within 31 calendar days of the
initial date of employment or enrollment.
The disabled dependent shall be eligible for coverage as long as he or she continues to be disabled and
dependent on the subscriber, unless coverage otherwise terminates under the GMC.
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.
1~ewborn Enrollment. Newborn infants, including the subscriber's ncwbonl grandchildren and children newly
adapted or placed for adoption, who were bon1, adapted or placed for adoption while the subscriber is covered
under the COC, will be covered immediately from the date of birth, r-egardtess of when notice is received by PIC.
If you subnut 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.
Military Duty. Employees retunling from active duty with the military and their eligible deperzderrts 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, yorr may enroll for coverage subject
to the 12-month pre-existing condition limitation under- the teens of PIC if all of the following conditions are
met:
1. yore were covered under a group health plan or had health insurance coverage at the tune coverage was
previously offered to the employee or dependent;
2. the eligible employee stated in writing at the time of initial eligribility that cover°age under a group health plan
or health insurance coverage was the reason for declining em•olhnent, but only if the Employer required a
statement at such time and provided the employee with notice of the requn-ement and the consequences of
such requirement at the time;
3. your coverage described in 1. above was:
PIC07-760-R2 9 PCH1040915.100.2.V (1/10)
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
4. the eligible employee requested such enrolhnent 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 depei~de~7ts 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 deper~de~at of an employee;
2. the employee is eligible for coverage under PIC;
3. they become dependc~izts 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
el~rolled 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 may be 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 deperrderrt enrolls for coverage under PIC. h~ the case of
marriage: the employee, the spouse and any new depende~zts 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 depei7dent coverage is made available undei PIC; or
b. in the case of marriage, the date of the marriage as described in 3. above; or
c. iii the case of a depender~tt`s birth, the date of the bil-th as described in 3. above; or
d. ill the case of a dependent's adoption, placement for adoptian 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, adapted children, or children placed for
adoption.
Special Enrollment Period for Medicaid and Children Health Insurance Program (CHIP) Me'~rber~s. If
arl eligible employee and/or his/her eligible deperu~er~2ts are covered under a state Medicaid plan or a state
CHIP and that coverage is terminated as a result of loss of eligibility, then the eligible employee may request
enrolhnent in the Plait on behalf of him/hersehf and/or his/her eligible dependents. Such request must be
made within 60 days of the date the employee's and/or his/her dependent's coverage is terminated from such
state plans.
If an eligible employee and/or his/her eligible dependents become eligible for apremium-assistance subsidy
under the Plan through a state Medicaid plan or a state CHIP (if applicable}, then the eligible employee may
request enrollment in the Plarz on behalf of him/herself and/or his/her eligible dependents. Such request must
be made within 60 days of the date the employee and/or his/her dependents are determined to be eligible for
the subsidy under such state plans.
NOTE: Other dependents (such as siblings of a newborn child) are not entitled to special emollment rights upon
the birth or adoption of a child.
PIC07-760-R2 10 PCH10409 15.100.2.V (1/10)
Schedule of Payments
You are required to pay any copayrnents, deductible and coinsurance amount. Benefits listed in this
Schedule of Payments are according to what PIC pays. Any amount of coirrsurauce 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 copayrueuts, deductibles and coiusuran~ce.
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 copayrrrerrts, coiusrrrartce and deductible,
you also pay all charges that exceed the PIC Wort participating provider reinrbursenrent value when you use a
rrorr participating provider and receive uou participating provider benefits.
NOTE: Your coverage is either "subscriber only" or "family.'" Therefore, only one of the following sections
"Subseriber• only' or "Family" applies to you. If you have questions about which section applies to yoi~~, contact
PIC.
If you have sa~~bscriber 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 srEbsc~°iber must first satisfy the deductible aiuount by uncut°:°ing charges equal to that amount
for eligible services in a cale~zdar yeaf- before PIC wiIl 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
reini~hursernent value will not apply towards satisfaction of the deductible. The subscriber wilt not be required
to satisfy the deductible before PIC will pay benefits for the following when received from a participating
provides : prenatal and child health services and one home health care visit for well baby services within 4 days
after the date the newborn was discharged from the hospital.
Out-of-Pocket Lirrzit: After the sirbscr~iber• has met the out-of-pocket lir7ait per calendar yeaa- for copayrTZe~~its,
c°oits:rrance and deduetil7les, ~'IC covers 1~J0°% of charges it~cut°r-ecl for all other eligible charges. The
subscriber pays any amounts greater than the out-nf=poclzet limit if any benefit maximums or the lifetime benefit
maximum are exceeded. It is the suhser°iber's responsibility to pay any amounts greater than the out-of-pocket
limits if any benefit maximums are exceeded. Expenses the sa~rbscriber pays far any amount in excess of the PIC
noj~ partieipati~~gprovider reimbursement value will not apply towards satisfaction of the out-of=pocket liraiit.
Subscriber only
Deductible
Out-of;Pocket Lirnit
Participating P~°ovider Network ~ Norz-Participating Providers
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
uou participating providers.
Lifetime Benefit Maximum $3,000,000. The cumulative maximum payable or covered services incurred
by you during your- lifetime under all health plans with the group
contractholder. The lifetime benefit maximum does not include amounts
which are your responsibility such as deductibles, coinsttrarace, copaynae~~ts or
penalties.
PIC07-760-R2 11 PCH1040915.100.2.V (1/10)
Fan>uly (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 chur;~es applied toward the fanuly deductible. Any amount in excess of the PIC non participating
provider rcirnbursernerrt 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 and one home health care visit for well
baby services within 4 days after the date the newborn was discharged from the hospital.
Family dart-of-Pocket Liurit: After the family has met the fanuly oret-qf-pocket limit per calendar year in
caigihle charges in a calendar year for copayrnerrts, coirrsrrrar~rce and family deductibles, PIC covers l00% of
charges iru•rrr'red for all other eligible charges. The family must pay any amounts greater than the fanuly out-of-
pack-et limit if any benefit maximums or the lifetime benefit maximum are exceeded. Expenses a member pays
for any amount in excess of the PIC nan par•ticiputirrgprovlder reirrrbursenaerrt. value and will not apply towards
satisfaction of the fatuity out-of=pocket lin7it.
Family (Subscriber and Par°ticipating Provider Network
Dependents)
Family Deductible None.
Non-Participating Providers
$900 per ccdcndar year' for eligible
services of nonparticipating
pl'OVZder's.
$300 maximum deductible amount
per family member.
Out-of-Pocket Lirnit $5,000 per calendar' yecu' for $6,000 per calendar yecrr• for eligible
eligible services of participating services of rzon par~ticipatirrg
providers. providers.
No rnernber' orrt-of=pocket limit within the family oart-of-pocket limit amount.
Lifetime Benefit Maximum $3,000,000. The cumulative maximum payable or saver°ed ser~~ices incrrrr'ed
by you during your lifetime under all health plans with the group
corltractl~lolder. The lifetime benefit maximum does not illchlde amounts
which are your responsibility such as deductibles, coinsurance, copaynrerrts or
pei~lalties.
Cost Sharing: The amount of the flat fee copayrrrents is calculated on pr'ovider• billed charges. The pr°ovider'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, ar the_fee schedule that
PIC has negotiated with the participating provider, or the PIC Non-Par°ticipating Provider Reimbursement L'alue
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 Norr-Participating Provider Reimbursement hcdrre, whichever is
applicable, then the coinsurance is applied to the remainder.
PIC07-7C0-R2 t2 PCH1040915.I00.2.V (1/10}
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 meurber has provided the appropriate
information for those services and the meurber 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 Pat~ticipating Provider Be~7efrt Non-Pm^ticipatirTg Provider
Benefit
Pre-certification Penalty None. PIC will reduce the amount of
eligible charges by the lesser of
$500 or 25% per corr~rremerzt.
Pre-Certification Requirement: Pre-certification is a screelung process that pei-~1uts early identification of
situations where case management would be beneficial or medical management is required. when a participating
provider renders services, the providef° will notify PIC for you and must follow the procedures set forth below. It
is yoarr responsibility to ensure that PIC has been notified by following die procedures set forth below, when ~zora-
participati~~g provides are used. Yozr must call Customer Service during normal business hours and before
services are performed. Failure to obtain pre-certification may result in a reduction of r~tor7 participating provider
hett~ fits.
Pre-certification is required for:
1, all inpatient admissions including s~-illed rrursit~g,fcu~ilzty, rehabilitation, hospital, etc.;
2. transplant services;
3. non-er~zcrgeuy 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-R2 13 PCH10409 15.100.2.V (1/10)
Prior Authorisation: It is recommended that you or yozrr- provider have certain services be 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 by following the procedures set forth below. It is your
responsibility to prior authorize with PIC by following the procedures set forth below, when non-participating
pr•olriders are used. If yozr 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 probnam services;
7. reconstructive surgery;
8. durable medical equipment (DMF.,) 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 yvzr can have yozn~ prescription filled at the
pharmacy. These prescription drugs may include, but are not limited to:
10. prescription dr°zrgs, 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 drzrgs.
Procedures. When a participating provider renders services, the provider will notify PIC for yozr and must
follow the procedures set forth below. It is your responsibility to ensure that PIC has been notified when rzon-
purticipatirzgproviders 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 provic~lers, you need to follow the procedures set forth 'below:
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 atter~zdir~zg health car°e professional 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 infoi7nation. If yozr 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 and yozu- attending provider of its benefit determination within 15
calendar days after the earlier of PZC's receipt of the requested information or the end of the time period
specified for you to provide requested information. The initial determination nay be made to your attending
provider by telephone.
3. If the initial determination is that the service will not be covered, your attending healdz care professional,
hospital (if applicable) and yozrr attending provider will be promptly notified by telephone within 1 business
day after the decision has been made.
PIC07-760-iZ 14 PCH1040915.100.2.V (i/10)
4. Written notification will then be provided to you, your atte~~ding hecdth care professional, hospital (if
applicable) 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 yoi~rr 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 yoan° attending health care professivnal
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
atteruli~zg health care prafessional would subject you to severe pain that cannot be adequately managed without
the care or treatment that is the subject of the pre-service china.
An expedited initial determination will be provided to yoa~, your attending health care professional, hospital (if
applicable) 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. Yoaa will then have at least 48 hours to provide the requested information. Yoar, yot~ar
atteaadirag health care professional, hospital (if applicable} and yoan• attending p~°o~,~ider will be notified of the
determination within 48 hours after the earlier of PICs receipt of the requested information or the end of the time
period specified for yoT~t to provide the requested information. If the initial determination would deny coverage,
you or yoa~4r attending health caa°e pa°ofessional will have the right to submit an expedited appeal.
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.
Case Management
In cases where the naenaber• `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 anal the PIC
health care coverage.
Under certain conditions, PIC will consider as eligible chcn°ges other care, treatments, services, supplies,
reimbursement of expenses, or payments (such as for a member's, or for a member and a companion's out of
town travel, meals, lodging and other expenses essential to and necessary for treatment) of a rneaaaber's
catastrophic siclzness or iaajuay that would not normally be covered or would only be partially covered.. PIC and
the member's physician will determine whether any such care, treatments, services or supplies will be covered.
Such care, treatment, services, supplies, reimbursable expenses, or payments will not be considered as setting any
precedent or creating any future liability, with respect to that aaaembea- or any other naenaber.
Other care, treatments, services or supplies must meet both of these tests:
1. determined in advance by PIC to be medically nc~cessari~ and cost effective iz1 meeting the long term or
intensive care needs of a aaaenaber hi connection with a eatastropluc sicb-raess or injuay.
2. charges iaacaa•rcc~l would not otherwise be payable or would be payable at a lesser percentage.
PIC07-760-R2 15 PCH1040915.100.2.V (1/10)
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.
~. 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 Pravider Peneftt Nan-Prrrticipcrtirzg Pz°ovider° Pezzefit
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 Reimbzrrserrtent Value.
Ambulance Services
Ambulance services for an 80% of eligible char°ges. Same as participating provider benefit
errrer•gerrcv. Note: Non- for crrrergerrcv services.
c rrrergencv transportation
must bepre-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 emergencv. Air ambulance is covered only when the condition
is an acute medical ernergerrcy and is authorized by a physician.
PIC covers emergency ambulance (air or ground} transfer from a hospital not able to rendei the rrredically
necessary 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
physiciun.
Ambulance services for anon-ernergerzcy. Non-emergency ambulance service, from hospital to hospital when
care for your condition is not available at the hospital where you were first adnutted. Transfers fi•om 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 "Exclusions." section. later in this COC for all exclusions.
U. Non-emergency ambulance service from hospital to hospital such as transfers and admission to hospita
performed only for convenience.
PIC07-760-R2 16 PCH1040915.100.2.V (1/10)
Benefit Participati~7g Provider Benefit Mort-Partzerpati~Tg Provider Be~Tefrt
PIC pays: PIC pays:
Note: For non participating providers, in
addition to any deductibles and
coirasurcance, you pay all charges that
exceed the PIC Non-Participating
Provider Reimbursement Vahce.
Chiropractic Services 100% of eligible charges after a 80% of eligible clzarges 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 "Exclusions." sectio~l later in this COC for all exclusions.
b. Services primarily edTrcational in nature.
c. Vocational rehabilitation.
d. Self-care and self-help trauiing (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 prod -am and rendered by a licensed acupuncture
practitioner or a provider licensed or trained in acupuncture.
j. Blood, urine or hair analysis related to chiropractic services.
k. Ultrasound, MRT, 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-R2 17 PCHI040915.100.2.V (1/10}
Benefit Participati~zg Provider Benefrt No~z-Pnrticipatuig Provider Be~zefi~t
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Nort-Participating
Provider Reinzbur•se~~nent L'ahre.
Dental Services
Accidental Dental 100% of eligible ch~cnges. 80% of eligible charges after the
Services deductible.
Nate: Treatment and. repair must be completed within twelve months of the
date of the ir~zjury.
Medically Necessary 100°ro of eligible charges. 80% of eligible charges after the
Outpatient Dental Services 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 der~tisz or de~7tal 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 traluna 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 far treatment of an underlying medical condition, e.g. removal of teeth to complete
radiation treatment for cancer of the jaw, cysts and lesions.
3. Medic~rlly Necesscery Hospitalization for Dental Care: PIC covers hospitalization for dental care. This is
limited to charges i~acacrred by a n~zenaher° who: (1) is a child under age 5; (2) is severely disabled; or (3) has
a medical condition unrelated to the dental procedure that 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 "Exclusions." section later in this CDC for 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.
PIC07-760-R2 18 PCH10409 15.100.2.V (1/10)
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 de~7tzst unless in connection with dental procedures covered by PIC.
j. Dental services related to periodontal disease.
PIC07-760-R2 19 PCR1040915.100.2.V (1/IO)
Benefit Participating Provider Benefit Nora-Participating Provider Be~~efit
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any dedarctibles and
coirasur^arzce, yoi~ pay all charges that
exceed the PIC Non-Participating
Provider Rein2brrrsenter~t T~alere.
Durable Medical Equipment ("DME") Services, Prosthetics, and Orthotics
Limited to a maximum PIC payment of
$1,500 per item and an aggregate
maximum PIC pa}nnent of $3,750 per
calendar year.
DME and Orthotics 80% of eligible charges. 80% of eligible chm•ges after the
deductible.
Prosthetics 80% of eligible charges. 80% of eligible charges after the
deductible.
I-Tearing aids for rnernbers 80% of eligible charges. 80% of eligible charges after the
under age 19 for hearing dedrretible.
loss that is not
correctable by ater
covered procedures.
Coverage limited to once
every tlu-ee years.
Wigs for hair Loss 8G% 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-
vear.
Limited coverage for 80% of eligible charges. 80% of eligible charges after the
special dietary infant dedr.retible.
formulas and electrolyte
substances that are
consumed orally and treat
phenylketonuria or other
inborn. errors of
metabolism
Special dietary infant
formulas and electrolyte
substances are covered
only when 1) they treat
phenylketonui-ia (PKU)
or other inborl errors of
metabolism, 2) are
PIC07-760-R2 20 PCHt0409 15.100.2.V (1/10)
consumed orally, 3) are
ordered by a physician,
physician's assistant or
nurse practitioner, and 4)
are medically necessary.
Limited coverage for 80% of eligible charges. 8d% of eligible charges after the
amino-acid based deductible.
elemental formulas that
are consumed orally and
treat cystic fibrosis or
certain other metabolic
and malabsorption errors.
Amino-acid based
elemental formulas are
covered only when 1 }
they are consumed orally,
2) are ordered by a
physician, physician's
assistant, or nurse
practitioner for a person
who is five years or
younger, 3) are rnedieally
necessary, and 4} treat the
following metabolic and
other malabsorption
conditions that have been
diagnosed by a specialist:
a) cystic fibrosis; b)
amino acid, organic acid
and fatty acid metabolic
and malabsorption
disorders; and e) IgE
mediated allergies to food
proteins, d} eosinophilic
esophagitis (EE}, e)
eosinophilic
gastroenteritis (EG}, and
f} eosinophilic colitis.
Enteral feedings when 80% of eligible charges. 80% of eligible clza>^ges after the
they are prescribed by a deductible.
plrysiciarr, physician's
assistant or nurse
practitioner and are
required to sustain life.
PIC07-760-R2 21 PCH1040915.100?.V (1/l0)
Diabetic supplies
Coverage includes over-
the-comlter diabetic
supplies, including glucose
monitors, s}n-iilges, blood
and urine test strips, and
other diabetic supplies as
medically necessarv, if yozr
have gestational diabetes,
type T diabetes, or type II
diabetes.
80% of eligible charges. ~ $0% of eligible charges after the
deductible.
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. .
Payment is limited to the most cost effective and medically necessary altenlative. When the member purchases
a model that is more expensive than what is considered medically raecesscrry by the PIC medical director or its
designee, the rnerrrbcr 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 nrernber- will
be responsible for the difference in cost.
Exclusions:
a. Please see the "Exclusions." section later in this COC for all 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,
hypoallergeiuc 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.
PIC07-760-R2 22 PCH10~09 15.100.2.V (1/10)
m. Orthopedic shoes and custom molded foot orthotics, except for rnezazbez°s 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. Upgrades to or replacement of any items that are considered eligible clzurges and covered under this
section, unless the item is no longer functional and is not repairable.
PIC07-760-R2 23 PCH1040915.100.2.V (1/10)
Benefit Participating Provider Beneft Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For rzora participating providers,
in addition to any deductibles and
coinsur•arzce, yozr pay all charges that
exceed the PIC Nora-Participating
Provider Reirnbursemerzt Value.
Emergency Room Services 100% of eligible charges after a Same as the participating provider
copayrnerzt of X75 per visit. benef t.
You should be prepared for the possibility of a medical emergency by knowing yozir° participating pr°ovider's
procedures for "on call" and after regular office hours before the need arises. Determine the telephone number
to call, which hospital yozrr pcrr•ticipating provider uses, and other information that will help yozr act quickly and
correctly. Keep this information in an accessible location in case a medical emergency arises.
If you have an errzergerzcy situation that requires immediate treatment, call 911 or go to the nearest emergency
facility. If possible under the circumstances, you should telephone your plrysician or the participating clinic
where you normally receive care. A plzysiciarz will advise you how, when and whereto obtain the appropriate
treatment.
Note: Non-enzergerzcv services received in an etnergeney room are not covered. If you choose to receive non-
emergency health services in an emergency room, you are solely responsible for the cost of these services. See
erzzergericv under "Definitions".
Covered hospital services are subject to all of the benefit linnitations set forth in this COC. To receive
maximum coverage m2der 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 "Exclusions." section later in this COC for all exclusions.
b. Non-cr~zer°geucv services received in an emergency room.
PIC07-760-R2 24 PCH10409 15.100.2.V (1/10)
Benefit Participating Provider Bertefrt Nort-Participating Provider Beraef t
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any deductibles and
coirrsrrrarr.ce, you pay all charges that
exceed the PIC Non-Participating
Provicler^ Reimbrn~sernent Value.
Home Health Services Note: For nonpm•ticipatingpr°ovider
services, coverage of all. home health
services is limited to a maximum PIC
payment of $3,750 per culerrdur- year.
Note: Coverage for all home health services is limited to a maximum PIC
payment of $25,000 per rnerrrber per calendar year.
Home health care as an 100% of eligible charges. 80°/v of eligible charges after the
alternative to hospital dedrrctr'ble.
confinement or skzlJed
nrrr°sing facility care.
One well-baby home visit 100% of eligible cliur°ges. 80% of eligible charges after the
by a registered nurse fora deductible.
mother and. newbonl 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 well-
baby's discharge from the
hoshituJ.
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 rnemher's siclti-rress or
injury and rendered in the me»~ber's home.
You must be horr~aebornrd 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 ho.cpitaJ 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 di1-eet 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.
PIC07-760-R2 25 PCH1040915.100.2.V (1/10)
Exclusions:
a. Please see the "Exclusions." section later in this COC for all exclusions.
b. Companion and home care services, unskilled nursing services, services provided by yoin~ 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 your home due to lack of transportation.
h. Cirstocirir~l c~ar~e.
i. Services at any site other than your home.
j. Recreational therapy.
PIC07-760-R2 26 PCH10409 15.100.2.V (1/10)
Benefit Participating Provider Benefit Non-Par~ticrpatirzg Provider Benefit
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any deductibles and
coirrsur°ance, you pay all charges that
exceed. the PIC Norr-Par°ticipating
Pr°ovider^ Reinibirrsement Value.
Hospice Care 100% of eligible charges. 80% of eligible charges after the
deductible.
PIC covers hospice services for nrenabers who are terminally ill patients and accepted as home hospice program
participants. Merrr,ber~s 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 rrredically necessary as described below. Mer~rber°s who elect to receive hospice services do so
in lieu of curative or restorative treatment for their terminal illness far the period they are enrolled in the home
hospice program.
1. Eligibility. In order to be eligible to be enrolled in the home hospice prot,~ram, a rnemher- must:
a. be a terminally-ill patient with plrysician 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 rnerrrber~ may withdraw from the home hospice program at any tiizie.
2. Covered Services. Hospice services include the fallowing 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 ui the rnenrber'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 rnernber°"s home or in a setting that provides day care for
pain or symptom management, when rr~redically necessary, as determined by PIC's medical director or
dcsigncc. Continuous care is defined as ttvo to twelve hours of service per calendar day provided by a
registered nurse, licensed practical nurse, or home health aide, dur>11g a period of crisis in order to
mainta>zl a terminally ill patient at home.
c. rr~redically 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 PlC's medical director or designee, to give the patient's primacy caregivers (i. e.,
fanuly members or friends) rest and/ar 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 paid 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.
Exclusions:
a. Please see the "Exclusions." section later in this COC for all exclusions.
b. Services provided by yoga' family or a person who shares your legal residence.
c. Respite or rest care except as specifically described in this section.
PIC07-760-R2 27 PCH1040915.100.2.V (1/]0)
Benefit Participating Provzden Benefit Non-Participating Provide~~ Benefit
PIC pays: PIC pays:
Note: For non panticipatizzg pz-ovidez°s,
in addition to any deductibles and
coirasunance, you pay all charges that
exceed the PIC Non-Participating
Pz-ovidez~ Reirrzbza~sen2ent Value.
Hospital Services Notify PIC upon admission to a non participating provider hospital as soon as medically
possible.
hlpatient Hospital l00°io of eligible charges. 80% of eligible changes after the
Services deductible.
Note: Each zzremben's Coverage for confinements in non-
confir~7ement, ineludilg participating hospitals and shzlled
that of a newborn child, is mzrsing.facilities are limited to a
separate and distinct from combined maximum of 120 calendar
flee confinement of any days per calendars year.
other member-.
If you have subscnibez°
only coverage, on the date
of bil-th of a newboi-~i, you
and yours new dependent(s)
become subject to the
terms and conditions of
family coverage.
Outpatient Ho,cpital 100% of eligible changes. 80% of eligible changes after the
Services, Ambulatory Care deductible.
or Surgical Facility
Services
Rehabilitation Services in 100% of eligible changes. 80% of eligible changes after the
a Day Hospital Pro~,~am deductible.
filjectable drugs that are 100% of eligible changes. $0% of eligible charges after the
not specialty drzzgs, deductible.
excluding insulin.
Eating Disorder Treatment 100% of eligible changes. 80% of eligible changes after the
Program dedzzc•tible.
Services must be provided
by a PIC designated
pai~tieipating eating
disorder treatment
programs and pre-certified
by the PIC medical
director or its designee.
PIC07-760-R2 28 PCH1040915.100.2.V (1/10)
-_
Medically necessary genetic 100% of eligible chat°ges. 80% of eligible charges after the
testing determined by PIC to deductible.
be covered sen~ices, as
described below:
• Prenatal fetal or maternal
genetic testing (e.g.,
amniocentesis, chorioruc
vinous sampling} done as
a component of care of
the menrber•'s pregnancy.
• Genetic testing services if
you are diagnosed with a
specific sieh~rress by a
pllySlclall.
• Genetic testing services if
yu11 are considered to be
high risk for a specific
sick-rless as determined by
a plzysiciurl.
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 errler°gency. For non-erlu~rgerrcies, 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 sick-rless or injrny,
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 aventilator-dependent patient, up to 1.20 hours of services, provided. by a private-duty nurse or
personal care assistant, solely for the p~upose of communication or interpretation far 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 physician recommends that a private room is medically necessary
and so orders. In the event a rrrerrlber chooses to receive care in a private room under circumstances ill
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 deteriuine 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 sickfiless or injury on an outpatient basis:
a. use of operating rooms or other outpatient departments, rooms or facilities;
PIC07-760-R2 29 PCH1040915.1002.V (i/10)
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. pla~~siciarz and other professional medical and surgical services rendered while an outpatient;
e. plivsician 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
physician7.
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 Car-e Ce~rter• 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 ccn-e 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
Yoz~ need to provide notice to PIC of an emergency hospital admission. However, if you are incapacitated in a
manner that prevents yott from providing notice of the admission within 48 hours or as soon as reasonably
possible, or if yoz~ are a minor and your parent (or guardian) was not aware of yozrr 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 iilcapaeitated 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 comlection 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 b -oup 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, requu e that a physician or other
health care pr-oi~ider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours).
However, to use certain provider-s 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.
PIC07-760-R2 30 PCH10409 15.100.2.V (1/10)
Exclusions:
a. Please see the "Exclusions." section. later in this COC for all. exclusions.
b. Travel, transportation, other than ambulance transportation, or living expenses.
e. Hospitalization, transportation, supplies, or medical services, including physicians' services furnished by
the United States Government or by an institution operated by the United States Govermnent, unless
payment is required in accordance with applicable law.
d. Private roam, except when medically rzecessa~y 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 far convenience.
£ Services and/or chugs 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 nzedlcally
necessary. These services and associated expenses will be reviewed on a case by case basis and, if
determined to be ~raedzcally 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 yoz~ may be a
carrier of a specific sickness when you are not diagnosed with the specific sick~7ess by a physician or you are
not at high risk for the specific sickness as confirmed by a physiciun.
j. Homeopathic medicine; hypnosis; chelation therapy, except chelation therapy will be covered when
t~nedzcally necessary for the treatment of heavy metal poisoning.
k. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed. acupuncture
practitioner or a provider licensed or trained in acupuncture.
1. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease.
m. Autopsies.
n. Bm°iatrie st~crgeries.
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 confirzenaent;
2. for the diagnosis and treatment of diabetes or an eating disorder; or
3. a rnembet~ has been diagnosed with a chroiric medical condition by a physicim~i.
Iu all cases, except cof~fr,nenaent, nut-itional counseling must be provided in a plrysician's office, clinic
system or hospital setting.
r. Treatment of eating disorders, except as shown in t1~e Eating Disorders Treatment Program bei7e'fit.
PIC07-760-R2 31 PCN10409 15.100.2.V (1/10)
Benefit Pua^ticipatirag Provider Beraefrt Nora-Particzpatirag Prrovider Benefit
PIC pays: PIC pays:
Note: For ~~ao~a participati~ag providers,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participati~~g
Pr~ova~der Reir~ibu~seiraent Value.
Infertility Services 100% of eligible charges. Same as participating provider benefit.
Note: Limited to diagnostic
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 coveted set~~ices (such as, but not limited to,
diagnostic radiology, laboratory services, semen analysis and diagnostic ultrasounds).
Exclusions:
a. Please see the "ExClusions." section later ill this COC for 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. Sui~ogate 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. Orai and injectable drugs for infertility.
PIC07-760-R2 32 PCH]040915.100.2.V (1/10)
Benefit Participati~~g Provider Be~zefit Non Participating Provider Be~zefit
PIC pays: PIC pays:
Note: For nova participating providers,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Norr-Par-ticipatirrg
Provider Rein~ahra-sernent Value.
Mental and Substance-Related Disorder Services
Office Visits 100% of eligible charges after a 80% of eligible charges after the
copayrnerat of $15 per visit. deductible.
Inpatient Services 100% of eligible charges. 80% of eligible charges after the
deductible.
Coverage for confinerrrerrts in non-
participating hospitals and skilled
nur-sing 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 deductible.
7reatrrrcrrt Services
Each two calendar days ofpartial
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 yozra° 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 rrecessurv 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.
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 Iris or her designee.
PIC07-760-R2 33 PCH1040915,100.2.V (1/10)
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 rzecessar y
and so orders. Benefits for a private room are available only when the private room is rncdically necessary
for a sickness or injnr y or it is the only option available at the admitted facility. If yon choose a private
room when it is not rncdically necessary, PIC's payment toward the cost of the room shall be based on the
average semi-private room rate in that facility. PICs 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 lzospitcal
or licensed treatment facility. These services must bepre-certified by PIC `s medical director or designee.
Hospitcd or Licensed Residential Treatment Facility Care for Emotionally Disabled Children. PIC covers
rncdically necessary inpatient treatment for emotionally disabled children as diagnosed by a plrysiciarz 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 licensed residential treatrzzent
facility, inpatient coverage for emotionally disabled 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, 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 far 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 "Exclusions." section later in this COC for all exclusions.
b. Counseling, studies, services or confinements ordered by a court or law enforcement officer that are not
determined to be medically necessarv by PIC. except as specifically covered above.
c. Marital counseling, relationship counseling, fanvly 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 rncdically necessary services are
required, regardless of where the services are received (e.g. detoxification centers).
£ Early behavioral interventions for children including but not limited to Lovaas therapy, applied behavioral
analysis, discrete trial tra>IUng, and intensive intervention programs.
g. Private room, except when rncdically necessary or if it is the only option available at the admitted facility.
h. Home-based mental. or behavioral health services, unless authorized by PIC's medical director or designee.
i. Biofeedback.
j, Developmental disabilities or mental conditions that, according to generally accepted professional
standards, are not amenable to favorable modification, except for initial evaluation, diagnosis or crisis
intervention.
k. Services provided by a licensed residential treatment facilit}~, except as authorized in advance by PIC's
medical director or designee.
PIC07-760-R2 34 PCH10409 15.100.2.V (1/10)
Benefit Participating Provider Bezzefit Notz-Paz~ticipating PYOVidez~ Bezzefit
PIC pays: PIC pays:
Note: For norz participating provides,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Nan-Participating
Provider Rei~nbursefnerzt Valve.
Office Visits and Urgent Care Center Visits
Sich~rzess or irrjzt~y -office 100% of eh~gible charges after a 80% of eligible charges after the
and urgent care center copaymerzt of $15 per visit. deductible.
visits related to diagnosis,
care or treatment of a
condition, sic~~~ess or
injury.
Electronic/onlilie 100% of eligible charges. 80% of eligible charges after the
evaluation of cluonic deductible.
conditions; limited. to 6
evaluations per n2ernbei°
per ealenclcrr year°.
(In order to be covered, the
evaluation must be
conducted by a desiglratecl
eleetl"OP2lC~Onh71C
participating provider only
for established patients
with specific chronic
diseases, such as diabetes
or heart disease, as
determined by PIC or its
desig~aee.)
PIC07-760-R2 35 PCH1040915.100.2.V (1/10)
Medically necessary genetic 100% of eligible charges. 80% of eligible charges after 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 rnerrrber s pregnancy.
• Genetic testing services if
you are diagnosed with a
specific siclaress by a
physicicrrr.
• Genetic testing services if
yore are considered to be
high risk for a specific
sicb~ress as determined by
a physician.
Implantable and insertable 100% of eligible charges. 80% of eligible charges after the
ditilg delivery devices for deductible.
birth control.
Allergy injections 100% of eligible charges. 80% 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 ehcr~rges. 80% of eligible charges after the
deductible.
PIC07-760-R2 36 PCH1040915.100.2.V (1/10)
Preventive Health Care 100% of eligible charges. 80% of eligible charges after the
Services deductible.
Immunizations (over
age 18)
Laboratory tests,
pathology and
radiology
Preventive health
physicals
Cancer screening
(including routine
PSA tests, pap
smears, ovarian and
colorectal tests, and
mammograms)
Routine preventive eye
examinations, limited
to one exam per
nrenrher per calerrdar-
year•.
Well-baby/child heahh 100% of eligible ch.crrges. 80% of eligible charges after the
services up to age 6. deductible.
Immunizations up to
age 18.
Prenatal care.
Injectable drugs that are 100% of eligible charges after a 80% of eligible charges after the
not specialty drugs, copayr~rent of $15 per visit. deductible.
excluding insulin.
PIC covers the professional medical and surgical services of licensed: physiciurrs, health care providers and
nurses.
1. Services are provided for the following:
a. Office and rrrgerrt care center visits relating to the diagnosis, care or treatment of a condition, si.ck~zess
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. Includes associated physician charges.
b. Contraceptive devices and delivery methods, other than implantable drug delivery devices, available in
the p7rysician'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 subnutted by the pro7~ider with a routine
preventive health care exam diagnosis.
a. Routine screening procedures for cancer, including mammograms, pap smears, ovarian and colorectal
tests and prostate specific antigen (PSA).
b. Immunizations as reeonmiended by your plrysician and as shown in the schedule above.
c. Laboratory tests, pathology and radiology.
PIC07-760-R2 37 PCH10409 15.100.2.V (1/10)
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.
f. Well baby and child health supervision services to age 6 including pediatric prevera~tive health care
services, developmental assessments and laboratory services.
g. Routine eye screening and exam.
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
rrecessar-~~ dental services.
b. Surgical and non-surgical treatment of confirmed, existing temporomandibular disorder (TMD) anal
craiuomandibular disorder (CMD), that is rr2edically necessary. TMD splints and adjustments are
covered if yoarr° 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 depender~a~t 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 lizmitations as durable medical equipment.
9. Treatment of diagnosed diethylstilbestrol (DES).
10. Diabetic outpatient self-management training anal education.
11. An ernergerrcv 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 pr-avider designated by PIC. Limited to
participation in one program in a 12-month period.
14. OE/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 plrysiciarr, PIC, or its d~esigmees.
ExcleasaQats.
a. Please see the "Exclusions." section later in this COC for all exclusions.
b. Services, seminars, or programs that are prumarily edtrcatiorral in nature.
c. Health education, except when provided during an office visit.
d. Smoking cessation programs, except as provided in this CDC.
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
r~aeeessary as determined by PIC's medical director or designee.
£ Nutritional counseling, except when.:
1. provided during a confrrernerrt;
2. for the diagnosis and treatment of diabetes, or an eatlllg disorder; or
3. a rrzember- has been diagnosed with a chronic medical condition by a plrysiciar7.
In all cases, except confirrern~ent, nutritional counseling must be provided i11 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 admiiustrative
proceedings or research, except as otherwise covered under this section. or as part of a routine preventive
health examination.
PIC07-760-R2 38 PCH1040915.100.2.V (1/10)
j. Charges for duplicating and obtaining medical records front no~~z ~~af~ticipating pr-ovide~°s unless requested
by PIC.
k. Genetic testing and associated services when done as a screeiung test to predict whether you may be a
carrier of a specific sickness when yott are not diagnosed with a specific sickness by a physician or yozti are
not at lugh risk for the specific sicltiness as confu-med by a physician.
1. Homeopathic medicine; hypnosis; chelation therapy, except chelation therapy will be covered when
naedicully necessary for the treatment of heavy metal poisoning.
m. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture
practitioner or a p~~ovider 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.
Biofeedback.
Routine hearing exams.
PIC07-760-R2 39 PCI-I1040915.100.2.V (1/10)
Benefit Designated Transplant Non-Designated Ti~arzspla~zt
Network Provider Network Provider
Organ and Bone Marrow Off ce visits: 100% of eligible Office visits: 80% of eligible
Tra~aspCant Services charges after a copaynient of $15 per charges after the deductible.
visit.
Hospital Services: 80% of eligible
Hospital Services: 100% of eligible charges after the dedz~ctible.
PIC covers eligible tra»spla~rt services that PIC's medical director or designee pre-certifies and determines in
advance to be ~~icdically necessa~•y and not i~avestigative. If the transplant is a~~edically necessary, but is part of a
clinical trial, then benefits are available only for the tr-a~~asplant sei~~ices that are not part of the clinical trial and
therefore not i~zvestigative. It is recommended that tra~~asplant services be received at a designated traraspla~zt
netwo~°k: provider.
Coverage for organ transplants, bone marrow transplants and bone marrow rescue services is subject to periodic
review. -PIC evaluates tt•a~tsplant services for therapeutic treatment and safety. This evaluation continues at
least annually or as new uzfonnation becomes available and it results in specific guidelines about benefits for
n•ansplunt seavices. You may call PIC at the telephone number listed uiside the cover of this COC for
information about these guidelines.
Benefits, if the transplant meets the definition of an eligible charge, is ~~nedically necesscr~y, and not
investigative, are available for the following eligible transplants:
1. Bone marrow transplants and peripheral stem cell transplants.
2. heart transplants.
3. Heart/lung transplants.
4. Lung transplants.
5. Kidney transplants.
G. 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 u1 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 "Exclusions."' section later in this COC for 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 i~tvestigative.
c. Services, chemotherapy, supplies, drugs and aftercare for or related to human organ transplants not
specifically approved as nzecliccrlly 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.
PIC07-760-R2 40 PCH10409 15.100.2.V (1/10)
e. Non-ef~aergeracy ambulance service from hospital to hospital such as transfers and adnussion 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.
PIC07-760-R2 41 PCH1040915.100.2.V (1/10)
Benefit Particzpati~rg Provider Be~zefit Not-Participati~rg Provider Be~zefzt
PIC pays: PIC pays:
Note: For ~~on participating pt•oviders,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
Provr,"der° Rein~~bur^semerzt Value.
Physical Therapy, 100% of eligible charges after a 80% of eligible charges after the
®cenpati®nal Therapy And copayn~~ent of $15 per visit. deductible.
Speech Therapy
Sensory integration Coverage is limited. to a maximum of 8 visits
therapy for the treatment per nzenzber per calendar yecu•.
of feeding disorders
100% of eligible charges after a 80% of eligible charges after the
copcrynz~ent of $15 per visit. dedr.rctible.
PIC covers outpatient physical therapy (PT}, occupational therapy (OT) and speech therapy (ST} for
rehabilitatil~e care rendered to treat a medical condition, siclti~tess or injury. PIC also covers outpatient PT, OT
and ST habilitutive therc~apy for medically diagnosed conditions that have significantly limited. the successfiil
initiation of noi7nal motor or speech development. Therapy must be ordered by a physiciata, phvsicia~t '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 lil~nited 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 "Exclusions." section later in this COC for all exclusions.
b. Catstodial care or nuzintenance care.
c. Recreational, educational, or self-help therapy (such as, but not 1i11uted to, health club memberships or
exercise oquipment).
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. Ir~westigative 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-R2 42 PCH10409 15.100.2.V (1/10)
Benefits Drugs obtained at a pharmacy Drugs obtained at a pharmacy that is
that is a participating provider. not a par^ticipatirag provider. PIC pays:
PIC pays: See "Pre-certification" section.
Note: For rzora participating prroi~iders,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
Provider Reimbursement Value.
Prescription Dr^ug Services
N®T)F: Benefits for specialty drugs are as described in this section,
regardless of the place of service where the specialty dr•trg is dispensed or
administered.
1. Prescription drags that Generic drugs: 100% of eligible Formulary and non formulary drugs:
can be self-administered charges after a copayment of $10 60% of eligible charges after the
for up to a 31-calendar per prescription or refill. deductible.
day supply.
2. Up to a 31-day supply for Forrrzulary brand drugs: 100%
one type of insulin. of eligible charges after a
3. Oral contraceptives for copayment of $25 per prescription
a 1-month supply. or refill.
4. Contraceptive devices
and. delivery methods, Nan formulary brand drugs:
other than offal 100% of eligible clzczrges after a
contraceptives and copayment of $50 per prescription
injectable contraceptives, or refi11.
available from a
phanllacy.
5. Conzpourrded drags.
• Mail order prescription Generic drugs: I00% of eligible Not covered.
drugs for up to a 93 charges aftei a copayment of $20
calendar day supply. per prescription or refill.
Forrrudary brand drng~s: 100°l0
of eligible charges after a
copuyment of $50 per prescription
or refill.
Non formulary brand drugs:
100% of eligible charges after a
copayment of $100 per
prescription or refill.
PIC07-760-R2 43 PCH10409 15.100.2.V (1/10)
Diabetic supplies 80°io of eligible charges. 60% of eligible charges after the
deductible.
Coverage includes over-
the-counter diabetic
supplies, including ghicose
monitors, syringes, blood
and urine test strips, and
other diabetic supplies as
na~edically necessary, if
yorr have gestational
diabetes, type I diabetes,
or type II diabetes.
Prescription drrr,~s and Generic drugs: 100% of eligible Formulary and non formulary drugs:
over-the-counter (OTC) charges after a copavrnent 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 ForrrruZary grand drugs: 100%
presci°iption and limited to of eligible charges after a
a 93 calendar day supply copuvnzent of $25 per prescription
per calerulur year. or refill.
Non forrrrztlary >3rand drugs:
100% of eligible charges after a
copayrnerrt of $50 per prescription
or refill.
Specialty drugs 80% of eligible clutr^ges, not to 60% of eligible charges after the
a. Up to a 31 day exceed a maximum rnember° deductible.
supply. payment of $200 per prescription
b. Specialty drags may ar refill.
be oral or injectable.
c. Must be purchased
through a specialty
pharmacy.
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.
Injectable drugs that are 80% of eligible chcnges. 60% of eligible clrurges after the
not specialty drags, dec~ltrctible.
excluding insulin.
PIC07-760-R2 44 PCH1040915.100.2.V (1/10}
Over-the-Counter (OTC) 100% of elzglble charges after a copaymettt of $'10 per prescription or refill.
Drugs
(Only includes OTC
drugs on the PIC OTC
drug list).
Limited up to a 30
calendar day supply per
Not subject to the deductible.
PIC uses its drug.fonnttlary 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.
For certain. medical conditions, there is a need to manage the use of specific dnigs before alternative (second
line) drugs are prescribed for the same inedieal condition. This is known as step therapy. Members in a step
therapy program will need to meet the requu-ements of that program prior to receiving the second line drug.
Step therapy can apply to fortnulaty or non-forrnulcrty 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 flat the quantity of each
prescription remains consistent with clinical guidelines. Quantity limits can apply to forntulaty or non-
.fc~rmulaty 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. Yc~u will be responsible for additional
copaynteuts or coinsurance for quantities received that are in excess of the quantity lieut.
Certain drugs available over-the-counter (OTC) are covered by PIC as determined by the PreferredOne
Pharmacy anal Therapeutics Committee. A List of such O.TC drugs is available upon request. Those OTC drugs
that are covered by PIC will require a ~Iaysic°zat~'s prescription. To receive PIC 's payment toward your OTC
drug yutt must present your prescription at a partieipating pharmacy counter. Ydu will still be responsible for
applicable copayment,, coinsurance or deductible amounts.
Yost or yota~ provider may request an exception to the drug fornutlary. If an exception applies, the non-
fortnulaty drugs that are approved as an exception will be covered at the same level as forntttlat°v drugs.
1/xceptions to the drug formulate are available as follows:
When a phvsiciatt designates that the prescription for an antipsyehotic drug must be dispensed as
communicated and certifies in writing to PIC that the physician has considered all equivalent drugs in the
,formtdarv and has determined that the drug prescribed will best treat your condition.
if yott received a prescription drug to treat a diagnosed mental ilhzess or emotional disturbance PIC will
continue to cover the drug, as though it were a.forr~ttttlary drug, for up to one year after it is removed from
the formularv or you change health plans and become covered under this COC, provided the drug has been
shown to effectively treat your illness or disturbance and the following conditions are met:
a. You were treated with the drug for 90 calendar days before a change v1 PIC's forrnttlar~~ or a change in
your health plan,
b. Your physician designates that the prescription must be dispensed as comuiuiucated, 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. Your pllysiciutt may request the exception amlually, following the
procedLU-e described above. The exception does not apply if PIC removed the drug from the fornutlaty for
PIC07-760-R2 45 PCH1040915.100.2.V (1/10)
safety reasons. Contact Customer Service for a copy of the written guidelines and procedures or for assistance
in requesting an exception.
When prescription clrrrgs from a non laarticipatirrg provider° pharmacy are covered, eligible charges include
only the PIC norr ~articipalirrg pr•ovr,'der reinrbursenrent value. The PIC non participating pravider-
rc:irnbursenrerrt value is the cost of the generic equivalent of the prescription drag and the dispensing fee, or if a
generic equivalent does not exist, the charge that PIC determines is to be customary for such prescription dr°ug.
If the nrenrber requests a brand name drug when a generic drug alternative is available, the member will be
required to pay the applicable copayment or coinsrrrar~rce 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 copaynrcnt, deductible or coinsrn-ante costs the nrernber incurs. When the nrenrber has reached the
orrt-of=pocket limit, the nrenrber stiIi pays the difference in the allowed amount between the brand name and the
generic drug, even though the rrrenrber is no longer responsible for the prescription drug copcryrrrent or
co rrrsururrc e.
Conrpourrded drugs will be covered provided that at least one active ingredient is a prescription dr^tzg. Payment
for a compounded dr•rrg 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. Tl1e applicable benefit level will be applied.
Compounded dr-ugs 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.
Corrrpounded drags will be covered according to the nrerrrbcr°'s pharmacy network benefits. If a non-
participating pr-owider pharmacy is used to obtain the compounded prescription, the norr 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 fiom 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 coves°ed.
Prior Authorization. It is recommended that you or your- provider have certain pr•escriptiorr drags prior
authorized im advance to determine medical necessity, by PIC or its designee. When a participating pr°ovider
renders services, the provider will prior authorize with PIC for you. It is your responsibility to prior authorize
with PIC when norz particr'patirzg providers are used. If you have questions about prior authorization, yon may
call PIC at the phone number listed on the inside front cover of t11is COC. These prescription drugs may
include, but are not limited to:
1. prescription drugs, that are over:
a. $I50 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 "Exclusions." section later in this COC for all exclusions.
b. Replacement of a prescr°iption 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. P~°escription drugs that are equivalent or similar to OTC dr-ugs, except as provided in this COC.
e. OTC home testing products, except as provided in this COC.
PIC07-760-R2 46 PCH1040915.100.2.V (i/10)
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 comlection 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. 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
farm.
u. Off-label use of specialty drugs.
v. Certain combination drugs and other drugs, regardless of formzdary 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. Tlus policy is subject to change.
PIC07-760-R2 47 PCH1040915.100.2.V (1/10)
Benefit Participating Provider Benefit Norr-Participating Provider Benefrt
PIC pays: PIC pays:
Note: For norr participating providers,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Partieipatirtg
Provider Reirrrbursenzent Vahre.
Recorrstrrrctive Surgery 100% of eligible charges. 80% of eligible charges after the
deductible.
PIC covers medically necessary reconstructive surgery due to sickness, accident or congenital. anomaly.
Eligible charges >liclude eligible hospital, plavsician, laboratory, pathology, radiology and facility charges.
Contact Customer Service to determine if a specific procedure is covered.
Reconstructive surgery following a mastectomy ilicludes the following:
1. reconstniction 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 lymphedelnas.
Exclusions:
a_ Please see the "Exclusions." section later in this CDC for all exclusions.
b. Services and/or drugs to treat conditions that are cacnaetie ii~1 nature.
PIC07-760-R2 48 PCH1040915.100.2.V (1/10)
Benefit Participating Provider Benefit Non-Paz^ticipatizzg Provider Berzefzt
PIC pays: PIC pays:
Note: For non ~ar-ticipatingproviders,
in addition to any deductibles and
coirrszzr°ance, you pay all charges that
exceed the PIC Non-Paz°ticipatirrg
Provider Reirnbursenrerrt 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 rrzzrsin
.facilities is limited to a combined
maximum of 120 calendar days per
calendar veur.
Daily skilled care as an 100% of eligible chm~7es. 80% of eligible charges after the
alternative to hospital deductible.
core f inernerr is
PIC covers the eligible spilled rrrusing fcrc~ility services for post-acute treatment and rehabilitative care of
siclnaess or injury. These services must be directed or referred by a physician and pre-certified by PIC 's
medical director or designee.
Shrilled nrn~singfacility services include room and. board, daily skilled nursing and related ancillary services.
PIC covers asemi-private room unless a plrysiciarr 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 nrernber° chooses to receive care in a private roam under circumstances in which it is not rrredica~lly necessay,
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 "Exclusions." section later in this COC for all exclusions.
b. Hospitalization, transportation, supplies, or medical services, including physicians' services furnished by
the United States Govermuent or by an institution operated by the United States Govez7~ment, unless
payment is required its accordance with applicable law.
c. Private room, except when medically necc~sscu~>> or if it is the oi~1y option available at tiie admitted facility.
d. Respite or crrstodiczl care.
PIC07-760-R2 49 PCH1040915.100.2.V (1/10)
Specified No~z-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 participati~~lg provider beiaefits. Yoi~ are not required to receive these services from a
participating provider. For example, an office visit, (whether by a participating pr-ovider~ or a nor~a-
participuting provide) for the services listed below will be covered at the participati~~zg 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 diagnlosis 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 "Exclusions." section later in this COC for all exclusions.
PIC07-760-R2 50 PCH1040915.100.2.V (1/10)
Pre-existing Condition Limitation
Pre-Existing Condition Any condition, regardless of the cause of the condition, for wlvch medical advice,
diagnosis, care or treatment was recommended or received, during the 6 month
period immediately preceding the member's enrolbnent date under PIC. Genetic
iliformation 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 em-o11 under the Special Enrollment provision, apre-existing condition is excluded from coverage
until the end of 12 montltis from the enrollment date.
The pre-existing condition limitation is reduced by any period of time during which the nzernber 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
incur~rerl 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 far convenience or comfort reasons, as listed on PIC 's Cosrnetie
Procedures Policy. This policy may be obtained by calling PIC Customer Service.
6. Orthognathic surgery.
7. Services received before coverage under PIC begins or after yozzr coverage under PIC ends.
8. Services or supplies not directly related to yozn° care.
9. Services or supplies thr ough a provider° ordered or rendered by providers that are unlicensed or not certified
by the appropriate state regulatory agency.
10. PIC or the rrrenzber 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 communty, or provided at a frequency other than that accepted by the medical
community as medically appropriate.
ll. Charges that exceed the PIC Non-Participating Provider Reinzbursenzent !%'alue for services or supplies
received from non ~rarticipatirzg providers, ilicluding non-participating pharmacies.
12. Services prohibited by law or regulation, or illegal under applicable laws.
PIC07-760-R2 ~1 PCH1040915.100.2.V (1/10}
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) yoat are eligible to be
covered under Medicare Part B; (ii) yoir 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 m~eci+icully rzeccsscrry 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 sz+bscr•iber's spouse) or anyone who customarily lives in the szsbscriber's household.
19. PIC or the me~~nber are not liable for charges for services performed by certified surgical technicians,
surgical technicians or certified operating room technicians.
20. All services, except em.ergencv services, for ~net~ibers when outside the United States.
21. Services provided by massage therapists, doulas, and personal trainers and others who have not completed
professional level education and licensure as determined by PIC.
22. Sexual devices, services; or supplies or presc~•r~tior~ 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 coznsura~~ce requirement of such a policy.
24. Massage therapy.
25. Telephone consultations.
26. Electronic mail consultations except as covered in Office Visits and Ui°gef7t Cure 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 physiciu~z.
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-R2 52 PCHI0409 15.I00.2.V (1/10)
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-ern~ergency ambulance service from liospital to Izospital such as transfers and admission to
17ospitals performed only for convenience.
34. Chiropractic Services:
a. See all exclusions.
b. Services primarily edrecational 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 far treatment of acute musculoskeletal conditions.
i. Acupuncture, except for treatment ire a chronic pain program and rendered by a licensed acupuncture
practitioner or 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. 1Vlanipula~tian 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.
£ 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 ar destroyed by misuse, abuse or carelessness; (2)
lost; or (3) stolen.
£ Duplicate or similar items.
g. Items that are prunarily edrrcutional in nature or for vocation, comfort, convenience or recreation.
PIC07-760-R2 53 PCH10409 15.100.2.V (1/10}
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, cormmunication board, or computer or
elech-onie 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
cancer.
1. Over-the-counter orthotics and appliances.
m. Orthopedic shoes and custom molded foot orthotics, except for mei~zbers 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 (ADLs).
q. Wigs for conditions other than alopecia areata.
r. Upgrades to or replacement of any items that are considered eligible charges and covered under this
section, ulrless the item is no longer functional and is not repairable.
37. Emergency Room Services:
a. See all exclusions.
b. Non-enaergenev 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 yo2.n- family or a
person who shares yoaa~ legal residence.
c. Services provided as a substitute for a primacy caregiver in the home.
d. Services that can be perfol-n1ed by anon-medical. person or self-administered.
e. Home health aides.
f. Services provided in yo2rr° home for convenience.
g. Services provided in your- home due to lack of transportation.
h. Custodial care.
i. Services at any site other than yoga- home.
j. Recreational therapy.
39. Hospice Care:
a. See all exclusions.*
b. Services provided by yotn~ family or a person who shares yoga- 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' sec°vices fiu•nished
by the Ui>ited States Government or by an institution operated by the United States Govermnent, unless
payment is required in accordance with applicable law.
d. Private room, except when ~~zedically 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.
PIC07-760-R2 54 PCH10409 15.100.2. V (1 / 10)
g. Orthopties 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
yore are not at high risk for the specific sicltirress as confirmed by a physician.
j. Homeopathic medicine; hypnosis; chelation therapy, except chelation therapy will be covered when
medically rrecessar y for the treatment of heavy metal poisoning.
k. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture
practitioner or 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 confnement, 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. Uamete and zygote intrafallopian transfer (GIF"I' and CIF"I') procedures.
£ Sui-r-ogate 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, fanuly 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 requu-ed, regardless of where the services are received (e.g. detoxification centers).
£ Early behavioral interventions for children including but not limited to Lovaas therapy, applied
behavioral analysis, discrete trial trallung, and intensive intervention programs.
g. Private room, except when medically necessary or if it is the only option available at the admitted
facility.
PIC07-760-R2 55 PCH1040915.100.2.V (1/10)
h. Home-based mental or behavioral health services, unless authorized by PIC's medical director or
designee.
i. Bigfeedback.
j. Developmental disabilities or mental conditions that, according to generally accepted professional
standards, are not amenable to favorable modification, except for initial evaluation, diagnosis or crisis
intervention.
k. Services provided by a licensed resr,'dential treatrnerzt.facility, except as authorized in advance by PIC's
medical director or designee.
43. Office Visits and Urgent Care Center- Visits;
a. See all exclusions.
b. Services, seminars, or programs that are primarily educcrtior~al 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 rrredically necessary as determined by PIC s medical director or designee.
£ Nutritional counseling, except when:
1. provided during a confirremerrt;
2. for the diagnosis and treatment of diabetes or an eating disorder; or
3. a mer~~nber- has been diagnosed with a cluonic medical condition by a physician.
In all cases, except confnerrzerrt, 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. 1/xams, 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 examuiation.
j. Charges for duplicating and obtaining medical records from Wort 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 sich~zess when you are not diagnosed with a specific siclcrress by a physician or you
are not at high risk for the specific sickr~ress as confirmed by a physician.
L 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 cln•onic pain program and rendered by a licensed acupuncture
practitioner or 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/oi~thoptics.
q. Services provided by an audiologist that are not provided in an office setting.
r. Bigfeedback.
s. Routine hearing exams.
44. Organ and Bone Marrow Transplant Ser~t~ices:
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 nr~edically 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-R2 56 PCN10409 15.100.2.V (1/10)
e. Non-emez°gency ambulance service from Ia~ospital 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 »zaintenartce care.
e. Recreational, educational, or self-help therapy (such as, but not limited to, health club memberslZips ar
exercise equipment).
d. Therapy provided in yozzr 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 far a reason other than the treatment of feeding disorders.
j. Group therapy for PT, OT and ST.
46. Pr°cscriptiozz Dz•zzg Services:
a. See all. exclusions.*
b. Replacement of a prescription dz•ug 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. Prescriptiozz 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 z~tedicully necessazy to treat obesity.
i. Prescr•iptior~ drugs and OTC dr°ugs for smoking cessation, except as provided in this C`UC`.
j. Prescriptions written by a dezztist unless in connection with dental procedures covered under this Plczn.
k. Drugs used for coszzzetic purposes.
L Unit dose packaging.
m. 1-Iomeopathic medici~le, including dietary supplements.
n. Prescription drugs for the treatment of infel•tility.
o. Topical or oral acne treatments for nzezzzbcrs 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. Pz°escrptiozz drugs if purchased by mail order through a program not administered by PIC's pharmacy
vendor.
s. Pr°eseription drugs for the treatment of erectile dysfunction.
t. Prescriptioza drugs are excluded that have a similar OTC cb•zrg (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 drzzgs.
v. Certain cozubination d~°z-rgs and other drugs, regardless of formulary status, will not be covered
according to the PIC pharmacy policy titled ``Cost Benefit Program." Contact Customer Seavice for a
copy of this policy or a list of the affected drugs. This policy is subject to change.
PIC07-760-R2 57 PCH1040915.100.2.V (1/10}
47. Recorzstructihe Surgery:
a. See ail 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 plrysicimzs' 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 cztstodial care.
49. Specified Non-Particii~ating Provider° Services:
a. See all exclusions. *
Ending Your Coverage
Coverage of the subscriber and/or his ar her depezzder7ts 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 subscriher° 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 subscriher° retires, unless PIC and the
employer have agreed to provide covei°age for retirees under the GMC.
3. For the subscr°iber and dependents, the end of the month in which the subscriber's eligibility under the GMC
ends.
4. For the szthscriber 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 ct dc~perulent, the end of the month in which the child is no longer eligible as a
dependent, unless the eligible dcperzdent is disabled.
6. For the szthscriber and dependents, term111ation will be retroactive to the last calendar day for which the
subscriber's contribution towards prenziurn has been received.
7. For the szthscriber- and dependents, the date you have preformed an act or practice that constitutes fi-aud 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 suh,ccr°iber and dependents including those enrolled for continuation coverage (COBRA),
the date the sub.reriber• ceases to be enrolled as a participant (including the date the applicable n~cmber ceases
to be enrolled for continuation coverage (COBRA) in a HRA plan.
PIC07-760-R2 58 PCH1040915.100.2.V (1/10)
Extension of Benefit if Health Plan or Carrier Replaced
If you are confined on the effective date of this coverage, the prior carrier is responsible for all eligible charges
until your final discharge from the inpatient facility or until contract maximums have been met.
An extension of benefits will be provided under this COC to a r77e7nber who is confined in a hospital or skilled
nursing facility on the date the »7e777ber's employer terminates its GMC with PIC and replaces group medical or
health coverage with another health plan or insurance carrier. If the employer replaces PIC coverage with
another group health plan or insurance carrier, PIC will pay benefits while the rv7en7ber is confined as described in
this section, until discharge, upon receipt of due proof of the following:
t. the 777e7nber i77cu7.7°ed eligible charges while confined,•
2. the eligible charges are related to the siclo7ess or iuju7y which caused the member to be confined; and
3. the eligible charges would have resulted in a valid post-service cluir77 if this benefit had been in effect at the
time expenses were inc7rrred.
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 inten-uption 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. Ya7c are responsible for all required
0072 tY7 bu tT 0715.
If yvu 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 7ne7nber returns to work
immediately following his or her approved FMLA leave, no wuiti77~ periods or pre-existing condition
limitations will apply.
The Uniformed Services Employment and Reemployment Rights Act of 1.994 (USERRA)
Continuation of Benefits. Subscribers who are absent due to service i11 the uniformed services and/or their
covered depende77ts may continue coverage pursuant to USERRA for up to 24 months after the date the
s7~7bscriber is fn-st absent due to uniformed service duty.
Eligibility. A s77bscribe7• 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 traiiung, initial active duty for training, inactive duty training and for the pus-pose of an
examination to determ>Iie fitness for duty.
Covered depe7ulents 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 retm-n to work immediately following his or her leave under USERRA, no waitiu~;
periods orpre-existing condition limitations will apply.
Contribution Payment. If continuation of coverage is elected under USERRA, the subscriber or covered
c~leperzderzt is responsible for payment of the applicable cost of coverage. If the s7~bscriber is absent for not
longei than 3I calendar days, the cost will be the amount the subscriber would otherwise pay for coverage. For
PIC07-760-R2 59 PCH1040915.1002V (1/10)
absences exceeding 31 calendar days, the cost may be up to 102% of the cost of coverage under PIC. This
includes the st~bscT°iber 's share and any portion previously paid by the employer.
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 st.{bsct-iber 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." Sz~bscriber'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.
Keturn 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 begimning 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 far up to two years
for persons who are hospitalized or convalescing.
PIC07-760-RZ 60 PCH1040915.100.2.V (1/10)
Continuation Coverage
Important Note if Employer also Sponsors IIRA 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 you~~ right to continue coverage under this COC is not
conditioned upon your concui-~-ent 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 si~rbscriber's and/or covered n~zember•'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 yaur• right to continue coverage under the
employer's HRA program. Termination of continuation coverage (COBRA) under this COC before expu-ation 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 rnembe~° or the
employer.
PIC07-760-R2 61 PCH1040915.100.2.V (1/10}
The subscriber, his or her covered spouse and covered dependent children may continue coverage under PIC
when a qualifying event occurs. Yotr may elect continuation coverage for yourself regardless of whether the
subscriber or other eligible dependents in your fanuly 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 strbscriber•, lus 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 dependent children may continue coverage when coverage
would normally end;
3. Coverage will be the same as that for other similar nzernbers; 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 coz~ltinuation 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.
Qualifying Events
1. Loss of coverage under the GMC by the subscr°iber° due to one of these events:
a. Voluntary or involuntary termnation 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 srrbsc:ril3er.
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.
e. Layoff of the sr.rbscriber-.
d. Leave of absence of the subscriber.
e. Early retirement of the subscriber.
f. Tatal disability of the subscriber while employed. by the employer.
g. Subscriber becoming enrolled u1 Medicare.
h. Divorce or legal separation of the subscriber.
i. Deat11 of the srrbscr•iber~.
PIC07-760-R2 62 PCH1040915.100.2.V (1/10)
3. Loss of coverage under the GMC by the covered depend~~it 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 members. Yc~u do not need to notify the employer of these
qualifying events. However, for other qualifying events including divorce or legal separation of the subscr-iher
and loss of dependent child status, continuation is available only if yoar provide timely, written notice to the
employer. You 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 merrzbcr^ is eligible to
contimie coverage according to applicable laws;
2. Notify persons of the unavailability of continuation coverage;
3. Notify the rrr~rrrb~r° of his or her rights to continue coverage provided that all required notice and notification
procedures have been followed by the strbscrzbcr, covered spouse andlor covered depertclc~rrt children;
4. Inform the rru>rnber of the premium contribution required to continue coverage and how to pay the pr-errriurrr
contribution; and
Notify the nrernber 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;
You must notify the employer in writing of a covered deper~d~rrt child ceasilig 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;
Yozr 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. (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;
PIC07-760-R2 63 PCI-I1040915.100.2.V (1/10}
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. T1nis individual can be
a subscriber, former subscriber, or lnis or her depender~t(s}; or a representative acting on behalf of the
employee or deper7derat(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.
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 rnernber's coverage ends, or the date the employer notifies the mern,ber of continuation rights,
whichever is later. To elect continuation coverage, youu must complete and submit your written election
within the 60-day timeframe using the employer's approved election form. (You may obtain a copy of the
approved farm from the employer.) Tlnis election must be submitted in writing to the employer; and
5. Yocr must pay continuation premium contributions:
a. The prerrriurrc. 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
additional ll 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 your continuation
prcmiurr~r contribution rate(s).
b. The first preruicnn contribution must be paid by check within 45 calendar days after electilg to continue
the coverage or such longer period as required by law. Thereafter, the merrrber's monthly payments are
due and payable by check at the begimning of each month for which coverage is continued.
c. The member must pay subsequent prer~~ir~crrr contributions by check on or before the required due date,
plus the 30-calendar day grace period. required by law, and if autharized by PIC1 such longer period
allowed by tine employer or required by law.
What you must do to apply for continuation extension:
A. Social Security Disability:
If you are cun-ently enrolled ill 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 cul~ent
continuation coverage resulted from the subscriber's leave of absence, retirement, reduction in hours,
layoff, or lnis or her termination of employment for reasons other than gross misconduct. To request an
extension of continuation, yocr nnust 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 tei~nination of employment, reduction of hours, leave of absence,
retirement, or layoff; or
e. the date on which you would lose coverage under the GMC as a result of the subscriber's
PIC07-760-R2 64 PCH1040915.100.2.V (1/10)
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 #l, and before the end of the 18`i' 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 anal address of the subscriber or former strbsc~-iber;
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 rrae~nbe~ ;
f. the date the nzenzber 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 individual can
be a subscriber, former subscriber, or lus or her depet7dent(s); or a representative acting on behalf of
the err7ployee or dependent(s).
If you do not supply all notice requirements in writing as previously described, then yoct must follow the
employer's requirements and specified time period for submitting, in writing, all required information
and supporting documentation.
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 tilneframes, by following the notification procedure as previously explained in Item
# l and #2, and submitting the employer's approved form; and
4. You must pay continuation prenziz~t~aa contributions:
a. The p~°e~yaiunz contribution to continue coverage is t11e combined employer plus .cath5criber rate
charged under the UMC", plus the employer may charge an additional 2°/0 of that rate. For a rrrcrrabef~
receiving an additional 11 months of coverage after the initial 18 months due to a continuation
extension for Social Security disability, the preniiuna~ 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 prerroaiz~rn contribution rates}.
b. The first prcmiurn contribution must be paid by check within 45 calendar days after electing to
continue the coverage. Thereafter, the r~rernber's monthly payments are due and payable by check at
the beginning of each month for which coverage is continued.
c. The rn~enxber~ must pay subsequent pre~~aium 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 Qualifyin~ Events for Covered Depe~idents Oniy:
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
yoz~r may request an extension of coverage provided that yoin- current continuation coverage resulted from
the subscriber'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:
PIC07-760-R2 65 PCH10409 15.100.2.V (I/10)
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 deperaderrt(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 subsc~~iber 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 yaur• continuation coverage;
e. the description and date of the second qualifying event;
i'_ 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 s~irbscr•iber°, 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.
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; a»d
4. Yau must pay continuation prenrirrnr contributions:
a. The pr•errrirrm 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 rnenrber°
receiving an additional 11 months of coverage after the initial 18 months due to a continuation
extension for Social Security disability, the prenuunr contribution for those additional months may be
increased to l50% of the employer's total cost of coverage. The election form will set forth your
continuation prenriunr contribution rates.
b. The fzi°st pr°ernzunr 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 ~•e due and payable by check at the beginning of each month for which coverage is
continued.
e. The rnernber must pay subsequent premzurn 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.
PIC07-760-R2 66 PCH10409 15.100.2.V (I/10)
Additional Notices You Must Provide: Other Coverages, Medicare Enrollment and Cessation of
Disability
Yost must also provide written notice of (1) yozn• other group coverage that begins after continuation is elected
under the GMC; (2) yoarr- Medicare enrollment (Part A, Part B or both parts) that begins after continuation is
elected under the GMC; and (3) the ~n~ernher, 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:
If providing notification of other coverage that began after continuation was elected, the name of the m~niber
who obtained otter coverage, and the date that other coverage became effective.
If providing notification of Medicare enrollment, the name and address of the r~iernher that became eiu-olled
in Medicare, and the date of the Medicare enrollment.
If providing notification of cessation of disability, the name and. address of the fornierly disabled ~ne~nber-, 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-R2 67 PCH10409 15.100.2.V (1/10)
CONTINUATION CHART
If coverage under this GMCis lost Who is eligible to Coverage may be continued until...
because this ha ens... continue...
The subscriber's leave of absence, early Subscriber, The earliest of the following occurs:
retirement, hours were reduced, layoff, covered spouse 1. 1$ 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
Merr~~ber must provide notice of such dependent health plan after contnluation coverage is
event to the employer in accordance children elected under the GMC.
with the employer's notice procedures 2. Co~>>erage 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 wilder another group
covered health plan after continuation coverage is
Mcnzber 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.
Em•ollment of the subscriber iii Covered spouse The earliest of the following occurs:
Medicare. and covered 1. 36 months after continuation coverage
deperrderrt began.
Mernbea- must provide notice of such children 2. Coverage begins wider 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- ui Covered spouse The earliest of the following occurs:
medicare writnin 1$ mont?1s before uhe and covered 1. 36 months after enrollment of subscriber
subscriber's hours were reduced or deperrderrt in Medicare.
termination of employment for 1°easons 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. Em•ollment, after continuation coverage is
event to the employer in accordance elected wilder the GMC, of the applicable
with the employer's notice procedures menrber° 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-R2 68 PCH l 0409 15.100.2. V (l / 10}
The employer files a voluntary or
uivoluntary 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 continuation for covered
retiree.
2. 36 months after death of covered retiree
for covered spouse and covered
deper2dent 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 srrbscr-iber is absent from work due Subscriber, Coverage would otherwise end under this
to total disability that occurred while the covered spouse GMC.
sarbscr-iber is employed by the employer and covered
and covered under this GMC. depende~rt
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 Admuiistration 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 deper2dent
of absence, early retirement, reduction in child is no longer disabled.
hom-s, 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
contnzuation extensions due to Social GMC.
Security disability.
~pEeiai Enrrcrl~me~ft Ferio~s
If yorr are a srrbscr•r,'ber, covered spouse or covered dependent who is enrolled in continuation caverage 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 cantinuation period requir ed 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 srrbscr-iber~'s continuation period required by federal law, and are enrolled
through special enrollment, are entitled to continue coverage for the maximum continuation period requn-ed
by law.
If the continuation period required by federal law has been exhausted, and yorr are enrolled for additional
continuation coverage pursuant to state law or the eligibility provisions of this COC, hou 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 Em-ollment
Period for New Dependents Only.
PIC07-760-R2 69 PCH10409 15.100.2.V (1/10}
Special Rule for Pre-Existing Conditions
A s~~b,cc~~abei°, his or her covered spouse or covered dependent child who is enrolled in continuation coverage
under this GAMIC and. then obtains other arroup coverage that excludes benefits for pre-existing conditions
applicable to such r~~euibei°, 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 (ar less) and only
during the six months inunediately after their group health plan coverage ended.
If you 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 uzeurbe~•, covered
spouse ar covered dependent children far 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 Mimlesota and
covered dc~pe~idents 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 Muuiesota
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 ar leer
employer, within the deadline required by law, of intent to continue coverage. An eligible retired employee
who does not elect to co~~tinue coverage does not have a right to re-enter or re-enroll for coverage at a later
date.
PIC07-760-R2 70 PCH1040915.100.2.V (1/10)
Your Right to Convert Coverage
Yozrr employer must notify yozc of your right to convert coverage. You are eligible to convert to an individual
conversion plan without proof of good health or waitz~ag~~es~iods on the later of the following dates:
1. You~~ coverage under the GMC ends, or;
2. Upon exhaustion of yoz.f~^ eligibility for continuation coverage under the GMC.
However, yoi~ti will not be eligible for a conversion contract if any of the following are true:
1. Yau 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 ternnated due to the nrembe~~ ~s failure to pay, when due, any required contribartion toward
p~•ervtiztm;
4. Coverage terminated. due to fraud;
5. You are or could. be covered under a continuation of coverage provision under the GMC or under a group
health plan of a "successor employer" (within the meaning of COBRA continuation of coverage) to the
employer.
If you are eligible for and timely apply for a conversion contract as described below, then coverage for you and
all yaicr- enrolled de~e~zde~~ts 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 prem~iurn. payment for a conversion contract within 31 calendar days after
youzn~ coverage under the GMC ends.
PIC07-760-R2 71 PCH1040915.100.2.V (1/10)
Subrogation and Reimbursement
PIC's Subrogation Rights
For tl~~e 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° sickz7ess or zrzjury
from another source of compensation for yoa~r sic•7,~raess or it~zjz~rv.
3. PIC's right to recover its subrogation interest is subject to a pro rata subtraction for actual monies paid for
casts and reasonable attorney fees which shall not exceed the prevailing cost in the same geographical local
where the loss arises, and costs yoer 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 bending arbitration.
5. Nothing in this section shall limit PIC's right to recovery from another source which may otherwise exist at
law.
Notice Requirement
Yost must provide timely written notice to PIC of the pending claim, if your make a claim against a third party for
damages that include repayment for medical and medically related expenses iiacurred for your benefit. Not
withstanding any other law to the contrary, the statute of limitations applicable to PIC 's rights for rPizubursement
or subrogation does not commence to run until the notice has been given.
PIC07-760-R2 72 PCH 10409 15.100.2. V (1/ 10)
Coordination of Benefits
As a rnernber, you agree to permit PIC to coordinate obligations under this COG 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 bi11il1g 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 nzernber 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, coinsurance 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
i°easonable 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 culerrdar 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 ~~leans a parent a Yvarded 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 b •oup, 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 i1lde~nnity benefits in excess of $200 per day;
c. medical care components of group long-teen 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 govermnental 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-R2 73 PCII1040915.100.2.V (1/10}
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-teen 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 DETERMINr~TION 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 primacy plan and may reduce the benefits it pays so
that pa}nnents from all group plans do not exceed 1.00% 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 ather 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 determmines its order of benefits
by using the fu st 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 retn-ee, is the primary plan; and the plan that covers the person as a d~perrdent 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 depenc~'erzt; 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-R2 74 PCH 1.0409 15.100.2. V (1 / 10)
3. 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 u1 the year if:
• The parents are married;
• The parents are not separated (whether or not they ever have been. married); ar
• 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
prunary.
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 claun 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 deper~~dent}. If the other plan does not have this rule, and if; as a result, the plai~7s do not
agree on the order of benefits; then this rule is ignored. Tlis rule does not apply if the rule under para~aph 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, n~~ern~her, satbscrzbei~, or retiree (or as a ciepende~zt of an
employee, r~aemhc>t; ,tiuh,ccr~zl7er, 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 prunary.
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 deter-~nination 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
PIC07-760-R2 75 PCH1040915.100.2.V (1/10)
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 "pa}nnent 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
nicruher•.
The "amount of pa}nnents made" includes the reasonable cash value of any benefits provided iii the form of
services.
II. COORDINATING WITH MEDICARE: This section describes the method of payment if Medicare pays as
the primary plan.
If a proriclc:r 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
Reimhzus~nient I~alue 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 nxe~nber who is eligible for Medicare has not enrolled with
Medicare, then PIC will pay as the primary plan.
Renat Failure. If you begin to have services related to renal failure, tii~~e request that yoar sign up for Medicare.
PIC07-760-R2 76 PCH1040915.100.2.V (1/]0)
Haw to Submit a Bill if You Receive One far Covered Sey°vices
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 cluirns relating to services will be handled for yorz by yozm
par-ticipatirrg provider. Yozr may be asked by your provider to sign a form allowing yorn~ provider to submit
claims on your behalf. If you receive an invoice or bill from your pravider- for services, simply return the bill or
invoice to your provider, noting your enrollment with PIC. Yorrr provider will then submit the post-service claim
with PIC in accordance with the terms of its participation agreement. Your post-service clairrz will be processed
for payment according to PIC guidelines. PIC must receive post-service clairrzs within l5 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 past-service claims is 180 calendar days. Post-service claims received after the deadline will be
denied.
Bills from Non-Participating Providers
Claim Submission. Yorr must submit an iten>ized 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 pravider name and charges. PIC must receive past-service clairrzs within 1S 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 clairus is 180 calendar days, Post-service clairrzs received after the deadline will be denied.
Payment of Post-Service Clazrns. Post-service clairrzs 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 ar 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-Ser^vice Clain~is
Past-scrti~icc: clairzzs are claims that are filed for l~~ayment 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 pravider subnuts apart-service clairrr on yorzr- behalf, the provider will be treated as your
authorized representative by PIC far purposes of such claim and associated. appeals unless yozr specifically direct
otherwise to PIC within ten (10} business days from PIC 's noti~ttcation that an attending provider was acting as
your authorized representative. Your direction will apply to any remaining appeals.
If your post-service clairrr is denied, PIC will communicate such deTUal within 30 calendar days after 1°eceept of a
post-sen~ice 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 yozz of its initial benefit determination witlvn 1.5 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 iazcr.rrred.
PIC07-760-R2 77 PCH1040915.I00.2.V (1/lU)
Complaint and Appeal Procedures
How to Submit a Complaint
You may subunit a complaint by telephone or in writing to PIC. The complaint should include the specific reason
for the eonnplaint and any supporting documents.
1. Complaints About Administrative Operations and Matters Other than Claims. If the telephone
complaint is not resolved to yoatr satisfaction within 10 calendar days after PIC receives your complaint, yoa~
may submit your complaint in writing. Customer Service is available to provide any assistance necessary to
eoml~~lete a written complaint form.
PIC will notify you that it received yoiu• written complaint within 14 calendar days, unless yoau- 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 1.4 additional calendar days to notify you of its decision. In
such cases, PIC wiIl notify yoT~ti, in advance, of the reasons for the extension and the date when you nnay
expect tine final decision.
2. Complaints About Claims. PIC will notify youu of its decision in accordance with the following time
periods:
If you are requesting benefits that require pre-certification (a ~~°e-ser~~ice claim), voar~r request will be handled
ill 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 complaitt 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 you~° complaint. Tlus time period may be extended if yogi agree.
How to I-2equest an Appeal
If after the first Ievei 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
ynTf of its decision in accordance with. the following procedlu-es and tide periods. PIC must ho provided all the
information needed to make a decision. If PIC does not have all information it needs and camiot obtain complete
information front you or your provider within the tinne periods set forth below for deciding an appeal, your
request will be denied.
Pre-Service Clcxims. 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 you, your attending
health care p~°ofessio~zal and yoa~~r- attendil~g provider- by telephone of its determination as quickly as yoarr
medical condition requires, but no later than 72 hours after PIC receives the appeal Written notification will
be sent to you, your attending health care pf°ofessional and your attending provider within one business day
of the determination, or sooner if yozr~• medical condition requires. If the appeal concerns non-acute services,
a decision on yor~r appeal will be made and. communicated in writing to yoar, your attending Izealth care
prgfessioraczl and yoiu- attending provider 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 yon appeal the initial determinnation 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.
PIC07-760-R2 78 PCH1040915.100.2.V (1/10)
2. Post-Ser~~ice Cluirns. 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, you may contact PIC and request a written appeal or a hearing within 60
calendar days of the first level complaint denial. If you want a written appeal, yvrr 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. Yorr 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 an 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 your claim for benefits.
If the determination of the appeal is to uphold an initial deternunation 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 Con~erce at any
time. You may reach the Minnesota Department of Conunerce 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. Yorr may request an exter-r1a1 review at any time including, if your 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 Conuuissioner of Commerce at fl1e 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 subnutted for an external review, except cases of fraudulent marketing and agent
misrepresentation. External review decisions are binding on PIC, but not biliding on the rrrernher.
PIC07-760-R2 79 PCH10409 15.100.2.V (1/l0)
No Guarantee of Employment or Overall Benefts
The adoption and maintenance of this COC does not guarantee or represent that coverage will continue indefinite
with respect to any class of employees and shall not be deemed to be a contract of employment between the employ
and any subscriber°. Nothing contained herein shall give any subscriber° the right to be retained in the employ of t
employer or to interfere with the right of the employer to discharge any subscriber-, at any time, nor shall it give t.
employer the right to require any subscriber- to remain in its employ or to interfere with the subscriber's right
terminate his or her employment at any time not inconsistent with any applicable employment contract. Nothing
this COC shall be construed to extend benefits for the lifetime of any rnemher or to extend benefits beyond the d
upon which. they would otherwise end in accordance with the provisions of the GMC or any benefit description.
Definitions
Attending Health Care The health care professional providing care within the scope of the professional`s
Professional practice and with primacy responsibility for the care provided to a rnenaber.
Attending health care pr-~fessional shall include o1>ly physicians; cluropraetors;
dentists; mental health professionals; podiatrists; and advanced practice nurses.
I3cn°iatric Sugery Surgery related to the treatment of obesity.
Biofecdbuc•k 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 ~'eclr The I2-month period beginning January l and ending the following December 31 for
provisions based on a calendar year.
Certif%cate of coverage The document describing, among other things, the benefits offered under PIC and
(COC) your rights and obligations.
Coirrsrrrarrce A fixed percentage of eligible charges that is paid by you and a separate fixed
percentage that is paid by PIC to the pr•ovider° for covered services and supplies.
Coinsurance will be based on (1}the discounted charge negatiat~ed between PAC and
participating providers; or (2) the PIC Norr-Participating Provider Reirnhur°semerrt
Yw~hrve for r~on ~~articipatingpreviders.
Cnnrbinatiorr Drug Apr°escriptian drug i11 which two or more chen>ical entities are combined into one
commercially available dosage form.
Compounded Drrrg Drugs which are customized drugs prepared by a pharmacist from scratch using raw
chenucals, powders and devices according to a physician's specifications to meet an
individual patient need.
Confirrerrrent An uninterrupted stay of 24 hours or more iu a hospital, skilled nursing.facility,
rehabilitation facility or licensed residential. treatment facility.
Corrtinrrorrs 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 contirruorrs coverage if the individual enrolls in PIC and the break in
creditable coverage is less than 63 calendar days. See waiting perr'od.
Copuyment The fixed amount of eligible charges yore must pay to the provider° for covered health
care services received. The copcryment may not exceed the charge billed for the
covered health care service.
Cosmetic Services, medications and procedures that improve physical appearance but do not
correct or improve a physiological function, or are not medically necessary.
PIC07-760-R2 80 PCFI1040915.100.2.V (1/10)
Covered Ser~~ices Services or supplies that are provided by yorn~ licensed pr-ovidc>r° 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 (HII'AA).
Custodial Car°e 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 Tr-eatr~nent Any professional or health care services at a hospital or licensed treatment facility
Ser~~ices for the treatment of mental and substance related conditions.
Deductible The amount of eligible charges that each rrrernber- must irrerrr in a calendar year
before PIC will pay benefits.
Dentist A licensed doctor of dental surgery or dental medicine, lawfully pcrfornung dental
services in accordance with govermnental licensing privileges and limitations.
Dental Speciczlist A dentist board eligible or eei-tified in the areas of endodonties, oral surgery,
orthodontics, pedodontics, periodontics and prosthodontics.
Dependent The subscriber's eligible dependent as described in the "Eligibility" section.
Designated A par~ticiputing provider- or group or association of par°ticipatirrg providers that has
Electronic/Or~lirre been designated by PIC or its designee to provide electronic/online evaluations and
P'crrticipatingProviderr management services for rnc~rnbers with specific chronic diseases, as determined by
PIC or its designee. A list of such providers may be obtained by calling Customer
.cicr`Jlee.
Desigrratcd Transplant Any licensed hospital, health care provider°, group or association of health care
Network Provider providers that has entered into a contract with or through PZC 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 primacy 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 ease 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-R2 81 PCH1040915.I00.2.V (I/10}
Effective Date The date a rnerzzber becomes eligible for health care services and completes all
enrollment requirements, subject to any required waiting per~iad.
Eligible CJzarges 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 rncrnber 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 rnenzber's health in serious jeopardy;
2. serious impairment to bodily functions; or
3. serious dysfunction of any bodily organ or part.
Erzrallrnerrt 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.
Fec-far~-Service Method of payment for provider services based on each visit or service rendered.
Fee Sclaedz~le The amount that the pw~ticipatirzg provider has contractually as eed to accept as
reimbursement in full for covered services and supplies. This amount may be less
than the prop%ider's usual charge for the service.
For»zerlary A list, which may change from time to time, of preferential prescription drugs that is
used by PIC plans.
Fzrll-time An employee working a minimum number of hours per week as specified by the
employer.
Group Halter Cantract The legal contract between the employer and PIC relating to the provisions of health
(GMC') care services.
Habilitati~~e Tlzer-aPv 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 h~onzeboamd 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 custodiul care, and is not a nursing home or
similar facility.
Incrdr-red Services and supplies rendered to you. Such expenses shall be considered to have
been irzcrrrred at the time or date the service or supply was actually purchased or
provided.
Injure Bodily damage other than sicb~rzess including all related conditions and recurrent
symptoms.
PIC07-760-R2 82 PCH1040915.100.2.V (1/10)
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:
1. 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 far its proposed use by the United States Food and Drug
Administration (FDA); if the drug or device or medical treatment or procedure is
the subject of ongoing Phase I, II, or III clinical trials; or if the drug, device or
medical. treatment or procedure is under study or if further studies are needed to
determine its maximum tolerated dose, toxicity, safety or efficacy as compared to
standard means of treatment or diagnosis; and
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 ill 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 file treating facility or another facility, or
another facility studying the same ds~ug, 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. Rclablc evidence suggests the drug, device or treatment is medically appropriate
for the member.
When PIC detei-mules 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 treatng facility or the protocol(s) of another facility studying
substantially the same chug, 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 commmittees, or technology assessment bodies, and professional
consensus options of local and national health care providers.
PIC07-760-R2 83 PCH10409 15.100.2.V (I/10)
Late Enrollee An eligible employee or dependent who em•olis 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.
Licensed Residential A facility that provides 24-hour-a-day care, supervision, food, lodging, rehabilitation,
Ti•ecrtrraerrt Facility or treatment and is licensed by the Minnesota Commissioner of Human. Services and
the Minnesota Department of Health.
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 naen~aber'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 rnenaber•'s condition; and
1. help to restore or maintain rraerrrber's health; or
2. prevent deter-ioration of rnerraber•'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 srrbscr°iber or dependent who is em-olled under the GMC.
Non-Par°ticipatirag A licensed pr-ovider• not under contract as a participating provider.
Pr°ovicler•
Nora-Participating Coverage for services provided by licensed provider°s other than:
Provider Bene firs 1. participating providers; or
2. the provider to which the participating provider has referred the member.
With nora parti.cipatirag pravider° benefits, there is member financial responsibility of a
deductible, coinsurance, and any amount in excess of the PIC Non-Participating
Pro7~ider• Reimbur°serazerat tiahre.
Out-of-Pocket Linait The maximum amount of money you must pay in copayment.~, coinsarr•cxrrce and
dechrctible before PIC pays your eligible charges at 100%. If yorr reach benefit or
overall maximums, you are responsible for amounts that exceed the vut-of-pacl.:et
limit.
Over-the-Corrnter°
(OTC) Drugs
Participating Provider
Participating Provider°
Beraefr.ts
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 iii 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 tluough participating providers.
PIC07-760-R2 84 PCfl1040915.100.2.V (1/10)
Physical Disability A condition caused by a physical injury or congenital defect to one or more parts of
the mernher^'s body that is expected to be ongoing for a continuous period of at least
two years from the date the initial proof is supplied to PIC and as a result the rnernber
is incapable to self-sustaining employment and is dependent on the srrbscr•iber for a
majority of financial support and maintenance. An illness will not be considered a
physical disability.
Physician A licensed Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.}, Doctor of
Podiatry (D.P.1V1.), Doctor of Optometry (O.D.) or Doctor of Chiropractic (D.C.).
PIC PreferredOne Insurance Company.
PIC Norr-Pcrrticipcrtirrg The amount that will be paid by PIC to a n~orr participating provider for a service is a
Provider percentage of the lesser of the:
Reimbrrrsemerzt tialrre 1. nonparticipatiragprovider'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 nonpar°ticipating provider.
If the amount billed by the nonpurticipatirrg pr°ovider is greater than the PIC rrorr-
participutirrg provider reirnburser~r~erat value, you must pay the difference. This
amount is ill addition to any deductible or coi»sr~rrance amount you may be
responsible for according to the terms of this COC.
Post-Service Claire A request for payment of benefits that is made by a merrzber° or his or her authorized
representative after services are rendered and in accordance with the procedures
described in this COC.
Prerniurrr The payment PIC requires to be paid by an individual or employer on behalf of or for
ruerr~bers 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
phy=sician.
Pre-Ser~~ice Clcrirn A claim related to services that have not yet been received, and require a request far
pre-cel-tification that is made by a nzer~r~ber• or his ar her authorized representative in
accordance with the procedures described in this COC.
Preventive Health Health supervision il~cluding evaluation and follow-up, inununization, early disease
Car°e 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 injauy, sicl~:uess, or other diseases of the involved body part; or
2. a congenital disease or anomaly which has resulted its 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 cor7ection is determined by PIC to be medically necessary.
PIC07-760-R2 85 PCH1040915.100.2.V (1/10)
Reconstructive Suz•gery Coverage for rnenzbez-s 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 coirzsuz-ante 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
nur-sizzgfacilil7~ 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 sclzedzde
amount.
Service Area The geographic area in which PIC is approved by the appropriate regulatory
authority to market its benefit plans.
Sick~raess 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 ils and of itself define a need
for skilled care.
Skzlled 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,
intei7ial medicine, OB/GYN or pediatrics.
Spey°ialty Drugs Injectable and non-injectable prescription dz-azgs 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 islerease the probability for
beneficial outcomes;
2. intensive patient training and compliance assistance are required to facilitate
therapeutic goals;
3. there is linuted or exclusive product availability and/or distribution; or
4. there is specialized product handling and/or administration requil-ements.
PIC07-760-R2 86 PCH10409 15.100.2.V (1/10)
Standing referral A process by which a m,erzzber may access covez~ed sezvices 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 quid of the subscriber's lawful spouse.
Subscz°iber 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 injuzy, 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 Sez~~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 Cer~atcr A licensed health care facility whose primary purpose is to offer and provide
immmediate, short-terra medical care for minor immediate medical conditions not on a
regular or routine basis.
t~aitizzg 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 covet°age; or
2. be used in determining a break in corztizzzzozzs and creditable coverage.
You/Your
Refers to nzenzher.
PIC07-760-R2 87 PCI-I1040915.100.2.V (1/10)
PreferredQne °
INSURANCE COMPANY
PICO'7-740-R2
READ YOUR CERTIFICATE CAREFULLY
CITY OF COLUMBIA I-I~ICHTS
'~ X00. `I 00.2RxF.V
PCH10409 1500.100.2RxF.V (I/10)
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 n:ember 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
~'~'ebsite 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
PIC07-740-122 PCH10409 1500.100.ZRxF.V (1/10)
This COC issued in 201.0 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 member
or the employer on behalf of the eligible »lember. PIC shall not be required to establish, maintain
or contribute to a health savings account on behalf of an eligible nrerrrber or the employer.
PIC07-740-R2 PCH10409 1500.100.2RxF.V (1/10)
TABLE OF CONTENTS
Important Mc>uther Information ................................................................................................................................. l
Meurber Bill of Rights .................................................................................................................................................. 2
Disclosure of Provider Payment Methods .................................................................................................................. . 2
Member Information for Non-Participating Provider Benefits ................................................................................ . 3
p Y ( ~ ..................................................................................................................
PreferredOne Insurance Com an PI 4
.
Introduction to Your Coverage .............................................................................................................................. . 4
Certificate of Coverage (COC) ............................................................................................................................... . 4
Ser~~ices Received in a Participating Provider Facility from aNon-Participating Provider .................................. 4
Standing Referrals to Non-Participating Specialists :............................................................................................. 4
Continuity of Care ...................................................................................................................................................4
Medical Emergency ..................................................................................................................................................5
Group Master Contract (GMC) .............................................................................................................................. 5
Your Identificatian Card ......................................................................................................................................... 5
Provider Directory .................................................................................................................................................. 5
Changes in Coverage ...............................................................................................................................................6
Conflict with Existing Law ...................................................................................................................................... 6
Privacy ..................................................................................................................................................................... 6
Clerical Error ..........................................................................................................................................................6
Assigttmeut ............................................................................................................................................................. . 6
Notice ....................................................................................................................................................................... 6
Time Litnit on Certain Defenses ............................................................................................................................. 6
Fraud ....................................................................................................................................................................... 6
Medical Technology and Treatment Review .......................................................................................................... 7
Recommendations by Ilealth Care Providers ......................................................................................................... 7
Legal Actions ...........................................................................................................................................................7
Eligibility and Enrollment ......................................................................................................................................... 8
Schedule of Payments ................................................................................................................................................ ll.
Pre-certification Requirement and Prior Authorization .......................................................................................... 13
Description of Benefits .............................................................................................................................................. 16
Pre-existing Condition Limitation ............................................................................................................................ 49
Exciusions .................................................................................................................................................................. 49
Ending Your Coverage .............................................................................................................................................. 56
Leaves of Absence ..................................................................................................................................................... 57
Family and Medical Leave Act (FMLA} ............................................................................................................... 57
The L7nflformed Services Employment and Reemployment Rights Act of 1994 (USERRA) ................................ 57
Continuation Coverage ............................................................................................................................................. 59
Your Right to Convert Coverage ............................................................................................................................... 69
Subrogation attd Reimbursement ............................................................................................................................. 74
Coordination of Benefits ........................................................................................................................................... 71
How to Submit a Bill if Yc~u Receive Otte for Covered Ser•viees ................................................................................ 7_5
Initial Benefit Determinations of Post-Service Claims .............................................................................................. 75
Complaint and Appeal Procedures ........................................................................................................................... 76
No Guarantee of Employment or Overall Benefits ................................................................................................... 78
Definitions .....................................................................>.,.....................,................................................................... 78
PIC07-740-R2 PCH104091500.10021ZxF.V (1/10)
Important Member Information
Covered Services: Services will be covered by PreferredOne Insurance Company (PIC). Yo1ir Certifrcate of
Coverage (COC) defines what services are covered and describes procedures yore must follow to obtain coverage.
Providers: ling oiling 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 partrcipatirzg providers.
Contact Customer Service for the most recent listing of PIC providers.
Emergency Services: Emergency services from non participatiizg providers will be covered only if proper
procedures are followed. Your COC explains rile procedures and benefts associated with era~~erge~~cy care from
partzcipati'ng and ~7on participati~~g providers.
Exclusions: Certain services or medical supplies are not covered. You should read yotn- CDC 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 ire your COC.
Termination: Your coverage may be terminated by yoi~ or PIC only under certain conditions. Your COC
describes all reasons for termination of coverage.
Prescription Drrrgs and Medical Equipment: Enrolling in PIC does not guarantee that any particular
prescription di~rg 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 prer~~aiui~i 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 r~u~ei~~~zbers,
and 75 percent for all other small employer b -oups.
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 plan year.
Small employer plans are guaranteed renewable as long as the employer remains eligible for a small employer
plan.
PIC07-740-R2 1 PCH10409 1.500.I002RxF.V (1/10}
Me~nbeN Bill of Rights
The laws of the State of Minnesota grant nrem~bers certain legal rights.
As a PIC member, yorr have the following rights and responsibilities.
Mernber•s have the right to:
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 Connnerce 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 ar 1.800.657.3602 and request information.
Disclosure of P~^ovit,!el^ Payment Methods
PIC contracts with participating providers to provide health care services to merrrbers. Participating providers
submit claims for eligible charges to PIC with their usual charge for the health care services. At PIC, the
rrrenrber benefits are determined for the service and the claims are paid according to the applicable fee schedule.
Tlus may be based on various methodologies, depending on the provider type and contract (i.e. per service, per
event, per day, by diagnostic related to-oup or percent of charge). The deductible and coinsan~ance amounts are
based on the fee schedule amount.
Apartic°iputing provider may contractually agree to a risk. allolvancc. The money withheld fer the risk allowurrce
niay or lnay not be retm-~led to the provider, depending on various cireulnstances, such as quality of care,
efficiency, cast effectiveness, m~ernber- satisfaction, and/or, the financial situation of PIC. The method by which
the risk allowance is repaid may differ by providcr° type/specialty and therefore may vary among pcn•ticipatirrg
providers. Members are not responsible for payment of any risk allotih~arrce. Factors such as the quality,
efficiency and cost effectiveness of care that participating proi~iders deliver may also affect future contract teens
between PIC and pm~ticipating providers.
Post-service claims submitted to PIC for non ~~ar°ticipazing provider benefits are paid on afee-for-ser-~~ice basis.
PIC determines member benefits based on the PIC Norr-Participating Provider- Reirrrbarrsernerat Tlaltre.
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 iii
underutilization. Utilization management decision making is based only on appropriateness of care and service
and existence of coverage.
PIC07-740-R2 2 PCH10409 1500.100.2RxF.V (1/10)
Member Information for Non-Participating Provider Benefits
Covey^ed Sep^vices: PIC covers services from norz par-ticipatifrg prroviders, 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 tlu-ough rzon ~ar-ticipating 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-R2 3 PCH10409 1500100.2RxF.V (1/10)
PreferredOne Insurance Company (PICA
Introduction to Your Coverage
This COC describes yozrr 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 ane or two provisions may not give you a complete understanding of the coverage described under
this COC. PIC has discretionary authority to determine eligibility for benefits and to interpret and construe
terms, conditions, limitations and exclusions of this COC and the GMC. 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 subscribe~° and the em-olled 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 emerget~acy room physician, the participating provider level of benefrts applies as
shown in the "Benefit Schedule". You will be responsible for any charges that may exceed the PIC Non-
Pcrrticipating Provider Rc in~bursen~e~it tialue.
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 rE ferral for treatment
of one of the following conditions:
1. a eln-onic health condition;
2. alife-threatening mental or physical illness;
3. a second or third trimester pregnancy;
4. a degenerative disease ar disability; or
5. any other condition or disease of sufficient seriousness and complexity to require treatment by a specialist.
Continuity of Care
Tf the contract between PIC and your partieipathig physician, participating I~ospital or participating speciulist
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 trimestei° pregnancy;
4. Physical or mental disability defined as an izlability 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 chromic condition that is iii an acute phase.
If the plryciciarr certifies that the nzelnher° has an expected lifetime of 180 calendar days or less, services fi-om the
terminating provider will be covered until the ~raernbc~r's death. Continuity of care may also apply to n~~einbers
PIC07-740-R2 4 PCH10409 1500.100.2RxF.V (1/10)
who require an interpreter or are receiving culturally appropriate services and the provider network does not have
such aprovider- or specialist in its network.
Continuity of care may also be extended to new rnenzbers who meet the criteria described above and whose
employer changed health plans. However, in such situations, the non ~ar~ticipating provider must agree to all of
the following:
Accept as payment in full the lesser of PIC's reimbursement rate for such services when provided by
participating providers or the norr participating provider's regular fee for such services;
Follow PIC's pre-certification requirements; and
Provide PIC with. all necessary medical information related to the care provided to the merrrber.
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 Emerge~zcy
You should be prepared for the possibility of a medical emergency by knowing yor~~r participating provider's
procedures for `on call°' and after regular office hours before the need arises. Determine the telephone number to
call, which Izospital your participating provider uses, and other information that will help yozr act quickly and
correctly. Keep this information in an accessible location in case a medical ernergerzcy arises.
If the situation is a medical emergency and if traveling to a participating pr•ovider° would delay ernergencw care
and thus endanger your health, you should go to the nearest medical facility. However, call PIC or your
participating prof=ides witlun 48 hours or as soon as reasonably possible to discuss your medical condition and to
coordinate any follow-up care. Yoar may authorize someone else to act on your behalf. If the situation is not a
medical emer°gency and if you seek care at a hospital emergency room, coverage for such services maybe denied.
Group Master Contract (GMC}
PIC''s Group Master Contract (GMC') combined with this Cf~C, any amendments, the employer's application, the
individual applications of the subscribcr•s and any other documents referenced in the GMC constitute the entire
contract between PIC and the employer. If you wish to see the GMC, ca~~7tact your employer.
Four Identification Card
PIC issues an identification (ID} card containing coverage information. Please verify the information an 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. You will be asked to present your ID
card whenever you 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 you. Yorr may also find pcn•ticipatir7g 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 provider is a participating provider.
You may want to verify that a provider you choose is a participating provider by calling Customer Service.
PIC07-740-R2 5 PCHI0409 1500.100.2RxF.V (1/10)
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
coverage is subject to PIC approval. If a change in coverage is requested by yoTCr- 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 yoau° 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 sumrnarizes 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.
Yacc 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 ol~ 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 rise the misstatement
to cancel coverage that has been in effect for two years or more from the effective date of the member's coverage
due to a claim or disability. This time liiiut does not apply to fraudulent misstatements.
Fraud
Coverage may be terminated, if a rccember 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-R2 6 PCH10409 1500.100.2RxF.V (1/10)
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 connnittees are made up of PIC staff and independent community physiciaf~s 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 conllnittees carefully examine the scientific
evidence and outcomes for each treatment/teclu~ology being considered. The decisions of the subcommittees are
overseen. by the Quality Management Committee that is made up of independent community physiciu~~s, 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 until at least 60 days after the proof of loss has been provided or after the
expiration of three years after the time written. proof of loss is required to be provided.
PICO'1-740-R2 7 PCH10409 1500.100.2RxF.V (1/10)
Eligibility and Enrollment
Eligibility
To be eligible to enroll for coverage, you must be a:
1. ,frill-tittle employee; or
2. depertdettt.
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 a self employed individual within the meaning
of the HRA plan document and thus, ineligible for the HRA plan, you may em-oll solely in this COC program and
will not be required. to concurrently enroll in the HRA plan.
An employee must enuoll for coverage as the satbs~ct°~ber in order to enroll 1>is 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 subscribet•'s:
1. lawful spouse as defined under Minvlesota Statute 517.01;
unmarried children, from birth through age 24, including:
a. natural. children;
b. legally adopted children or children placed with the subscribet° 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 tatal or partial support.};
c. stepchzldr-ert of the subscriber who reside in the satbsct•ibetr ,r home iu 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 hospitaX 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 strbsct°iber. Your employer is responsible for determining whether or not a
medical child support order is a valid QMCSO. You may request a copy of tale procedures used to make
such determinations from your employer.
f. a child for whom the subset°iber has been appointed legal guardian by a court of law up to the age stated
in the count appointment if less than age 25.
3. Unmarried disabled dependents after reaching age 25, provided they are:
a. incapable of self-sustauung employment because of physical disabilit)~, developmental disability, mental
illness or mental health disorder that is expected to be ongoing for a continuous period of at least two
years from the date the initial proof is supplied to PIC; and
b. dependent on the subscriber for a majority of financial support and maintenance.
PIC07-740-R2 8 PCH10409 1500.100.2RxF.V (1/10)
Proof of incapacity must be provided with the szrbscribc~r's application for coverage with PIC within 31
calendar days of the date the dependent reaches age 25.
After this initial proof and determination of disabled dependent status by PIC, PIC may request proof again
two years later, and each year after.
If the depe~~der~t is disabled and 25 years of age or older at the time of the subscriber°'s enrollment or initial
employment, and such dependent through sicbscriber enrolled for coverage with PIC, the sarbscrzber must
provide PIC with proof that the dependent meets requirements a. and b. above within 31 calendar days of the
initial date of employment or enrollment.
The disabled dependent shall be eligible far coverage as long as he or she continues to be disabled and
dependent on the subscriber-, unless coverage otherwise terminates under the GMC.
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 depe~adent first becomes eligible
subject to the 12-month pre-existing condition limitation. The satbsc~~r~be~~ 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 dc~pef~dents do not enroll within 31 calendar days of
the date they first become eligible they may enroll at a later date subject to fhe 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 accordti~nce with the Special EnroIlment Period provisions listed
below.
New~s€~rn Enrollment. Newbo~;~ infants, including the sa~rbsc~~iber's newborn bn-andchildren and children newly
adopted. or placed for adoption, who were born, adapted or placed for adoption while the sz~bsc~•zber 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 3l days after the date of birth, adoption or placement for adoption, the
newbonl or adopted child will still be covered back to the d~~te 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
subsc~-ibe~~ must be covered under this COC in order for the newbarn 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 Depc~fzderats. If you are an eligible employee or an eligible
depenc~'ent of an eligible employee but not eiuolled for coverage under PIC, you may em-oll for coverage subject
to the l2-month pre-existing condition limitation under the terms of PIC if all of the following conditions are
met:
1. yoi~ 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:
PIC07-740-R2 9 PCH10409 1500.1002RxF.V (1110)
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
the eligible empli~yee 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. blew depertde~rts 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
em•o11ed under PIC as a dependent of the employee, and us 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 depe~ulent 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 withil~l 31 calendar days of the date the employee first acquires the de~,~endent
and coverage shall begin an the later aP:
a. the date dependent coverage is made available under PIC; or
b. in the case of marriage, the date of the man-iage 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 deperTdent'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.
Special Enrollment Period for Medicaid and Children Health Insurance Program (CHIP) Merrrbers. If
an eligible employee and. or his/her eligible dependents are covered under a state Medicaid plan or a state
CHIP and that coverage is terminated as a result of lass of eligibility, then the eligible employee may request
emolhnent in the Plan on behalf of him herself and/or his/her eligible dependents. Such request must be
made within 60 days of the date the employee's and/or his/her dependent's coverage is terminated fiom such
state plans.
If an eligible employee and/or his/her eligible dependents become eligible for apremium-assistance subsidy
under the Plan through a state Medicaid plan or a state CHIP (if applicable), then the eligible employee may
request em•ollment in the Plan an behalf of him/herself and/or his/her eligible dependents. Such request must
be made within 60 days of the date the employee and/or his/her dependents are determined to be eligible for
the subsidy under such state plans.
NOTE: Other depencents (such as sibl>ligs of a newboi7z child) are not entitled to special enrollment rights upon
the birth or adoption of a child..
PIC07-740-R2 10 PCH10409 1500.100.2RxF.V (1/10}
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 cJzarges less the percentage covered by PIC. PIC pay went begins after you have
satisfied any applicable deductibles and coizsurance.
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 zzon participating provider reiuzburseru~ent value when you use a ziozt-
participatingprovider and receive non paz•ticipatiug provider benefits.
NOTE: Your coverage is either "sz~bscriber only" or "family." Therefore, only one of the following sections
"Sz~bscriber only" or "Family" applies to yozti. If you have questions about which section applies to yoi~, 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
Subscriber only
Deductible: The subscriber must first satisfy the dcderctible amount by incurring charges equal to that amount
for eligible services in a cale~~zdaf- year before PIC will pay benefits. PIC will not pay benefits for the eligible
chcn°ges applied toward the deductible. Any amount in excess of the PIC no~7 participating provider
reimburserrzerzt value will not apply towards satisfaction of the deductible. The subscribe~° will not be required
to satisfy the deductible before PIC will pay benefits for the following when received from a participating
pravidez : prenatal and child health services and one home health care visit for well baby services within 4 days
after the date the newborn was discharged from the hospital.
Out-of-Pocket Lizuit: After the subscriber has met the out-of-pocket li~r2it per calendar year for coinsurance and
declrrc.•tibles, PIC covers 1 Fl~% of charges ii~eurred for all other eligible rizarges. The subscriber pays any
amounts greater than the out-of-poc•Icet lzniit 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 linzits if any
benefit maximums are exceeded. Expenses the subscriber° pays for any amount in excess of the PIC non-
participatingprovider ~°ein2burser~~ent valise will not apply towards satisfaction of the out-of=pocket limit.
Subscriber only Participating Provider Network No~z-Participating Providers
Deductible $1,500 per calendar year for eligible services of participatirzgproviders
and non participating providers combined.
Out-of-Pocket Limit $1,500 per calendar year for eligible services of participating providers.
$2,000 per calendar yem• for eligible services of participating and nozz-
participatiugproviders combined.
Lifetime Benefit Maximum $3,000,000. The cumulative maximum payable or covered services i~u~en•r~ed
by you during your lifetime under all health plans with the group
contractholder. The lifetime benefit maximum does not include amounts
which are your responsibility such as deductibles, c:oin,cm•ance, copayments or
penalties.
PIC07-740-R2 ll PCH10409 1500.1002RxF.V (7/10)
Family (Subscriber and Enrolled Dependents)
Family Deductible: The family must first satisfy the family deductible amount by incur°ring 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 r•eirrrbursernent 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 and one home health care visit for well
baby services within. 4 days after the date the newborn. was discharged from the hospital.
Family but-of-Pocket Lirzzit: 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
incur~r-ed 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 norz-participating provider reimbzrrserner~t value and will not apply towards
satisfaction of the family out-of-pocket limit.
Family (Subscriber and Participating Provider Network Nou-Participating Providers
Deperzderzts)
Family Deductible $3,000 per calendar year for eligible services of participating providers
and non ~articipatirrg providers combined.
Na nrernber deductible within the family deductible amount.
Ozct-of-Pocket Limit $3,000 per calendar year for eligible services of participating providers.
$4,000 per culerrdar year for eligible services of participating and non-
participating prov%ders combined.
No member out-of-pocket limit within the family otrt-of-pocket lirnr.'t amount.
Lifetime Benefit Maximum $3,000,000. The cumulative maximum payable or caver-ed sen~ices incurred
by you during yoru° lifetime under all health plans with the group
contractholder. The lifetime benefit maximum does not include amounts
which are your responsibility such as decluctihles, coirrstn-unce, copcrynzerrts or
penalties.
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
Reirnbur-serrrerrt La1ue if PIC does not have an alneement with the provider. If you have a deductible, it is first
subtracted from the billed charge, fee schedule, or the PIC Non-Participating Provider° Reinrhursenzerrt T~crlue,
whichever is applicable, then the coinsurance is applied to the remainder,
P1C07-740-R2 12 PCH10409 1500.100.2RxF.V (1/10)
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 rrrenrber is eligible for coverage, the merrrber has provided the appropriate
information for those services and the rr:ember 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 Nora-Participating Provider
Berrefrt
Pre-certification Penalty None PIC will reduce the amount of
eligible charges by the lesser of
$500 or 25%per corafr~rement.
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 particij~ati~r~
pi•ovidcr renders services, the provider will notify PIC far you and must follow the procedures set forth below. It
is your responsibility to ensure t11at PIC has been notified by following the procedures set forth below, when rrora-
pcarticiputing proi~iders 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 ~ao~z pu~•ticipatirzg provider
bef~refzts.
Pre-certification is required for:
1. all inpatient admissions including skilled m~t~sing facilit3~, rehabilitation, hashitul, etc.;
2. tt•atrsplatzt sewices;
3. non-er~ze~ge~acy 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 obtaili it, please contact Customer
Service.
PIC07-740-R2 13 PCH10409 1500.100.2RxF.V (1/10)
Prior Authorization: It is recommended that you or your provider have certain services be authorized in
advance to determine medical necessity, by PIC or its designee. When a participating provider renders services,
the pr°ovider° will prior authorize with PIC for you by following the procedures set forth below. It is your
responsibility to prior authorize with PIC by following the procedures set forth below, when non participating
providers are used. If yore 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 pr°escription 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:
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. specicrltJ~ dr°ugs.
Procedures. When a participating provider renders services, the provider will notify PIC for you and must
follow the procedures set forth below. It is your responsibility to ensure that PIC has been notified when norr-
participating provider°s 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 ~~ar•ticipating providers, you need to follow the procedures set forth below:
1. A phone call must be made to Customer Service no less than 15 calendar days prior to the date serviees are
scheduled. An expedited review is available if yortr atterrdirrg health care pr°ofessiorral believes it is
warranted.
Yorr 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 maybe 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 notifyyourti and your attending provider 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.
If the initial determination is that the service will not be covered, your attending health car°e professional,
hospital (if applicable) and your attending provider will be promptly notified by telephone within 1 business
day after the decision has been made.
PIC07-740-R2 14 PCH10409 1500.100.2RxF.V (1/10)
4. Written notification will then be provided to you, your attending health car°e professional, hospital (if
applicable) and yozrr attending provider explaining the principal reason or reasons for the determination. The
notification will also include the process to appeal the decision.
Note: If yozrr- 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.
>Eiow to Obtain an Expedited Review
Expedited Review: An expedited initial determination will be used if your attending health care professional
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 yozrr life or health or your- ability to regain maximum function, or in the opinion of your
attending health care professional would subject you to severe pain that cazuiot be adequately managed without
the care or treatment that is the subject of the pre-service claim.
A.n expedited initial determination will be provided to yozr, your° attending health care prgfessiorzal, hospital (if
applicable) 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 pi°ovide the requested information. Yozr, yozrr
attending health care professiorr~al, hospital (if applicable) and yozrr attending pro~~ider 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 intial determination would. deny coverage,
yozr or yozrr atterzdirzg health care professional will have the right to subnut an expedited appeal.
Note: If your request is denied, you may appeal that decision. Refer to the section entitled "Complaint and
Appeal Procedures" far details on how to appeal.
Case Management
Irz cases where the nrerrrber•'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 anal the PIC
health care coverage.
Under certain conditions, PIC will consider as eligible charges other care, treatments, services, supplies,
reimbursement of expenses, or payments (such as for a member's, or for a member and a companion's out of
town travel, meals, lodging and other expenses essential to and necessary for treatment) of a rrzenzber's
catastrophic sic1,-ness or injury that would. not normally be covered or would only be partially covered. PIC and
the nrenrber's physician will determine whether any such care, treatments, services or supplies will be covered.
Such care, treatment, services, supplies, reimbursable expenses, or payments will not be considered as setting any
precedent or creating any future liability, with respect to that member or any other mernber•.
Other care, treatments, services or supplies must meet both of these tests:
1. determined. in advance by PIC to be nr~edically necessary and cost effective in meeting the long term or
intensive care needs of a rnernber iii connection with a catastrophic sich~ness or injury.
2. charges inczu•red would not otherwise be payable or would be payable at a lesser percentage.
PIC07-740-R2 15 PCH10409 1500.100.2RxF.V (1/10)
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. Same rules for obtaining benefits are listed in yozzr 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 necessazy services, unless such services are also covered services,
and received while you are covered under this COC.
Benefit Purticipatizzg Provider Sezzefzt Nozz-Paz~ticipatiug Pzrovider Bezae~t
PIC pays: PIC pays:
Note: For raor7 participating providers,
in addition to any deductibles and
coinsurance, yozr pay all charges that
exceed the PIC No~z-Participating
Provider Reinzbtrrsernent Value.
Ambulance Services
Ambulance services for an 100% of eligible charges after the Sa1ne as participating provider benefit
emergency. Note: Non- deductr'hle. for er~~lergency services.
ernerge~~cy 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 em~e~gency and is authorized by a physician.
PIC covers emerge~~cv ambulance (air or ground} transfer from a Hospital not able to render the medically
neccssczry 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-emergency. Non-emergency ambulance service, from hospital to hospital when
care for yoza° condition is not available at the hospital where yvi-s were first admitted. Transfers from a hospr~tal
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 em-oute and when pre-certified.
PIC's medical director or designee must pre-certify non-emergency services in advance.
Exclusions:
a. Please see the "Exclusions." section later in this COC for all exclusions.
b. Non-emergency ambulance service from 7~ospital to Hospital such as transfers and admission to lzospita,
performed only for convenience.
PIC07-740-R2 16 PCH10409 1500.100.2RxF.V (1/10)
Benefit Participating Provider Benefrt Non-Participating Provider Be~aefit
PIC pays: PIC pays:
Note: For noi~t participating providers, in
addition to any deductibles and
coinszrrance, you pay all charges that
exceed the PIC No~~-Participating
Provider Reimbursement Value.
Chiropractic Services 100% of eligible charges after the 75% of eligible charges after the
deductible. dedaictible.
Limited to a maximum of 15 visits per
calendar year.
Coverage includes chiropractic services to treat acute musculoskeletal conditions, by manual manipulation
therapy. Dia~niostic services are linvited to medically necessafy radiology. Treatment is limited to conditions
related to the spine or joints.
Exclusions:
a. Please see the "Exclusions." section later in this COC for all exclusions.
b. Services primarily echacutioraal uZ nature.
e. 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 licensed acupuncture
practitioner or 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. IVlanipulation under anesthesia related to chiropractic services.
m. I~Iomeopatlve/holistic services related to chiropractic services.
PIC07-740-R2 17 PCH10409 ISOO.I00.2RxF.V (I/10)
Benefit Participati~zg Provider Be~iefit No~z-Partzcipati~Tg Pi^ovirler^ Benefit
PIC pays: PIC pays:
Note: For ~2or1 ~arti~cipatir~g providers,
in addition to any deductibles and
coirtsiu•arzce, you pay all charges that
exceed the PIC Nora-Participating
Provider Reirnb¢rrsen~errt Value.
Dental Services
Accidental Dental 100% of eligible charges after the 75°io 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 l00% 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 follow>Ilg 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
(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 treahnent for cancer of the jaw, cysts and lesions.
Medically Neeesscny Hospitalization for Dental Care: PIC covers hospitalization for dental care. This is
linuted to charges inezr~rred by a member who: (1) is a child under age 5; (2) is severely disabled; or (3) has
a medical condition ui~r elated to the dental procedure that requires hospitalization or general anesthesia for
dental treatment. Coverage is limited to facility and anesthesia charges. Oral sm•geon/derrtist 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 "Exclusions." section later in this COC for 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.
PIC07-740-1Z? 18 PCH10409 1500.100.2RxF.V (1/10)
£ 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-R2 19 PCH10409 1500.100.2RxF.V (1/10)
Benefit Participating Provider Ber:efit Nort-Participating Pr^ovider Benefit
PIC pays: PIC pays:
Note: For non ~articipatingproviders,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
Provider Reinrburserrrent 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 member°s 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 l 00% of eligible charges after the 75% of eligible charges after the
resulting from alopecia deductible. deductible.
areata are lnuited to a
maximum PIC payment of
$350 per calendar yecn~.
Lilluted coverage for 100% of eligible clacuges after the 75% of eligible charges after the
special dietary infant deductible. deductible.
formulas and electrolyte
substances that are
consumed orally and treat
phenylketonuria or other
inborn en•ors of
metabolism
Special dietary infant
formulas and electrolyte
substances are covered
only when 1) they treat
phenylketonuria (PKU) or
other inborn en-ors of
metabolism, 2) are
consumed orally, 3) are
ordered by a physician,
PIC07-740-R2 20 PCH10409 1500.100.2RxF.V (U10)
physician's assistant or
nurse practitioner, and 4)
are medically necessary.
Limited cover°age for 100% of eligible chaF•ges after the 75% of eligible charges after the
amino-acid based ded~~ctible. deductible.
elemental formulas that are
consumed orally and treat
cystic fibrosis or certain
other metabolic and
malabsorption errors.
Amino-acid based
elemental formulas are
covered only when 1) they
are consumed orally, 2) are
ordered by a physiciar~a,
physician's assistant, or
nurse practitioner for a
person who is five years or
younger, 3) are medicalTv
necessary, and 4) treat the
following metabolic and
other malabsorption
conditions that have been
diagnosed by a specialist:
a) cystic fibrosis; b)
amino acid, organic acid
and fatty acid metabolic
and malabsorption
disorders; and c) IgE
mediated allergies to food
proteins, d) eosinophilic
esophagitis (EE'}, e)
eosinophilic gastroenteritis
(EG), and f) eosinophilic
colitis.
Enteral feedings when they 100% of eligible charges after the 75% of eligible charges after the
are prescribed by a deductible. deductr,"ble.
~Irysician, physician's
assistant or nurse
practitioner and are
required to sustain life.
PIC07-740-R2 21 PCH10409 1500.1002RxF.V (1/10)
Diabetic supplies 100% of eligible chat°ges after the 75% of eligible charges after the
dedisctible. dedatictible.
Coverage includes over-
the-counter diabetic
supplies, including glucose
monitors, syrhlges, blood
and urine test strips, and
other diabetic supplies as
naeclically ~zecessa~~~, if yoi~
have gestational diabetes,
type I diabetes, or type II
diabetes.
PIC covers equipment and services ordered by a physiciat7 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 rryaedically rzecessaty for treatment of keratoconus. Il~Iernber°s must pay for
lens replacement. .
Payment is limited to the most cost effective and medically necessary alterlative. When the membe~° purchases
a model that is more expensive than what is considered i~~edically necessary by the PIC medical director or its
designee, the n~~embet- will be responsible for the difference in purchase and maintenance cost. PIC's payment
for rental shall not exceed tl~e purchase price, unless FIC' 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 naenabe~° purchases new equipment or supplies when the PIC medical director or designee determines that
repair costs of the rnen7ber's current equipment or supplies would be more cost effective, then the n~ier~iber- will
be responsible for the difference in cost.
Exclusions:
a. Please see the "Exclusions." section later in this COC for all 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 sinular items.
g. Items that are primarily edi~ca~tiotual 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. Connmunication 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 ~nenabers with diabetes or peripheral
vascular disease.
PIC07-740-R2 22 PCH10409 1500.100.2RxF.V (1/10)
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. 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-RZ 23 PCHI0409 I500.100.2RxF.V (I/10)
Benefit Participating Provider Be~zefit Not-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 Reicrcbccrsement halue.
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 yourparticipatingproyider 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 inunediate 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
treat111ellt.
Note: Non-emergency services received in an emergency room are not covered. If you choose to receive non-
emcc~gec2ev health services in an emergency room, yoac are solely responsible for the cost of these services. See
ernergencv under "Definitions".
Covered hospital services are subject to all of the benefit linutations set forth in this COC. To receive
maximum coverage Linder this part, yoac 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 "Exclusions." section later in this COC for all exclusions.
b. Non-emergency services received in an emergency room.
PIC07-740-R2 24 PCH10409 1500.100.2RxF.V (1/10)
Benefit Participating P~^ovider Benefr,t Norz-Participating Provide~^ Benefit
PIC pays: PIC pays:
Note: For non par°ticipating providers,
in addition to any deductibles and
coinsurance, yoar pay all charges that
exceed the PIC Non-Pm°ticipatirr~g
Provider Reimbursement T~alrtie.
Home Health Services Note: For rron participating provider
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.
corrfzraenumt or skilled
mtirsing fcicility care.
One well-baby home visit 1.00% 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 far the birth of the
newborn was less than 48
hours fallowing a vaginal
delivery or less t11an 96
hours following a
caesarean section. Tlus
visit must occur within 4
days after the date of well-
baby's 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 merrrher°'s sicl~rress or
injury and rendered in the rrrember's home.
You must be horrreboarnd 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 i11 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 suctioiung 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-R2 25 PCH10409 1500.100.2RxF.V (1/10)
Exclusions:
a. Please see the "Exclusions." section later in this COC for ali 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.
PIC07-740-R2 26 PCH10409 1500.100.2RxF.V (1/10)
Benefit Pay^ticipati~ag PYOVider Be~zefit Non-Participating Provider Be~zefit
PIC pays: PIC pays:
Note: For non participating providers,
in addition to any dedz~ctibles and
cairtsurartce, yoe~ pay all charges that
exceed the PIC Non-Participating
Provider Reirnbursen~ent i~ahte.
Hospice Care 100% of eligible charges after the 75% of eligible charges after the
deductible. deductible.
PIC covers hospice services for rnenzbers 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. Men~.be~°s who elect to receive hospice services do so
in lieu of curative or restorative treatment for their terniinal illness for the period they are enrolled in the home
hospice program.
Eligibility, h1 order to be eligible to be enrolled in the home hospice program, a naembe~° must:
a. be a terminally-i11 patient with plrysicia~l 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 mernber may withdraw from the home hospice program at any time.
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 iii the nterrzber's home by an
interdisciplinary hospice team (which may include a phusician, nurse, social worker, and spiritual
counselor) and home health aide services, if prior authorized by plc's medical director or its designee.
b. one or more periods of continuous care in the mcrnber's home or in a setting that provides day care for
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. nz~edically T7ecesscny 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 pi°ima~y caregivers (i.e.,
family rnernbers 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. rra~eclically 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.
Exclusions:
a. Please see the "Exclusions." section later in this COC for all exclusions.
b. Services provided by yore- fanuly or a person who shares your legal residence.
c. Respite or rest care except as specifically described in this section.
PIC07-740-R2 27 PCH10409 1500.100.2RxF.V (1/10)
Benefit Participating Provider Benefit Nort-Participating Provider Benefit
PIC pays: PIC pays:
Note: For nor? purticipatirag providers,
in addition to any deductibles and
coinsurance, yozt pay all charges that
exceed the PIC Nora-Participata~ng
Provider Reimbursement Value.
Hospital Services Notify PIC upon admission to a raon participating provider hospital as soon as medically
possible.
Inpatient Hospital 100% of eligible charges after the 75% of eligible charges after the
Services deductible. deductible.
Note: Each naernber's Coverage for confinements in non-
confinement, including participating hospitals and skilled
that of a newborn child, is nursingfaeilities are limited to a
separate and distinct from combined maximum of 120 calendar
the confinement of any days per calendar year^.
other rnernber.
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, Aiubulatory 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 chugs that are 100% of eligible charges after the 75% of eligible charges after the
not specialty drugs, deductible. deductible.
excluding insulin.
Eatilzg 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-R2 28 PCH10409 1500.100.2RxF.V (1/10)
Medically necessu~y genetic
testing determined by PIC to
be co~~e~•ed set°vices, as
described below:
• Prenatal fetal or maternal
genetic testing (e.g.,
anmiocentesis, chorionic
vinous sampling) done as
a component of care of
the naernber's pregnancy.
o Genetic testing services if
yoa~s are diagnosed with a
specific sickness by a
pl~rysician.
• Genetic testing services if
yoi~s are considered to be
high risk for a specific
,cick~~ress as determined by
a physician.
100% of eligible charges after the ~ 75% of eligible char^ges after the
deda~ctible. dedT~ctible.
When anon-participating hospital is used, notify PIC of an admission to the non-pal-ticipating Iraspitul within
48 hours or as soon as reasonably possible after an emerger~cv. For non-errzergencies, aphone 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 i~~jurv,
that requires the level of care only available in an acute care facility. Inpatient lzospitcal services include, but
are not limited to:
a. room and board;
b. the use of operating rooms, intensive care facilities; newbonz nursery facilities;
c. general nursing care, anesthesia, radiation therapy, physical, speech and occupational therapy,
preseJ~iptiai~ drargs 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 aventilator-dependent patient, up to 120 hours of services, provided by a private-duty nu1-se 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 (IMP}, clinical nurse specialist (CNS}, RN first
assistant, certified registered nurse first assistants (CRNFA), certified nurse midwives (CNM), or a
pIIVSTClall.
PIC covers asemi-private room, unless a physiciut~ recommends that a private room is rnedieally ~~ecessary
and so orders. In the event a menTber• chooses to receive care in a private room under circumstances in
which it is not medically izecessui~t~, 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 n~edicully raecessuiy criteria.
2. Outpatieut Hospital, Ambulatory Care or Surgical Facility Services. PIC covers the following services
and supplies, for diag~losis or treatment of sick~iess or injin~~ on an outpatient basis:
a. use of operating rooms or other outpatient departments, rooms or facilities;
PIC07-740-R2 29 PCH10409 1500.100.2RxF.V (1/10)
b. the following outpatient services: general nursing care, anesthesia, radiation therapy, prescription
drags 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. physicimr 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 cure in connection with a siclti~ress or it jury.
Eating Disorder Treatment Program. PIC covers the treatment of eating disorders provided by a PIC
designated participating eating disorder treatment program.
Erslergeruy Services at a Hospital that leads to an Inpatient Admission
Yon need to provide notice to PIC of an emergency drospitul 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 yore- 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 tln-ough 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. I4owever, the group health plan or health issuer may pay for a shop-ter 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 newbon7 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-hom• (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 pr°ovider obtaili 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-R2 30 PCN10409 1500.100.2RxF.V (1/10)
Exclusions:
a. Please see the "Exclusions." section later in this CDC for 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 necess~ny 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 opthalnuc 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 rrredically 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 sick-rress by a physician or you are
not at high risk for the specific sick~ress 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 licensed acupuncture
practitioner or a pro~~ider 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 rrrernher has been diagnosed with a chroiric 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.
PIC07-740-R2 31 PCH10409 1500.100.2RxF.V (1/10)
Benefit Pcrrticipati~zg Provider Benefit NOn Participating Provider Benefit
PIC pays: PIC pays:
Note: For non participating prroviders,
in addition to any deductibles and
coirzsrrrance, you pay all charges that
exceed the PIC Non-Par°ticipating
Provider Reirnbursenrent iralue.
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 "Exclusions." section later in this COC for all exclusions.
b. Reversal. of voluntary sterilization.
c. Adoption costs.
d. In vitro fertilization.
e. Gamete and zygote intrafallopian transfer (GIFT and ZIFT) procedures.
£ Surrogate pregnancy.
g. Sperm bai~lcing.
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
PIC07-740-R2 32 PCH10409 1500.100.2RxF.V (1/10)
Benefit Participating Provider Benefit Non-Participating Provider Be~zefit
PIC pays: PIC pays:
Note: For rron ~~articipcrting prroviders,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
Provider Reimbursement Value.
Mental and Substance-Related Disorder Services
Office Visits 100% of eligible charges after the 75°,/0 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 lros7~itals and skilled
rrursing.fa~cilities 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 Dcry deductible. deductible.
Tr•eutrrrent Services
Each two calendar days of partial
hospital or day treah~2ent services will
be considered equal to one calendar day
of treatment in a hospital. These days
are part of the 1.20 calendar day
maximum limit listed under "Inpatient
Services."
PIC covers services performed by provider°,s far 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 sigz~ficant disruption of function in yoatr life situatioaa, and has a recognized effective treat~~nent. PIC 's
medical director or designee determines when there is a serious or persistent mental or nervous disorder that
meets criteria far coverage.
Coverage is available as follows:
1. Home Care. PIC's medical director or designee must authorize in advance any services received in yoru-
home.
2. Office Visits. PIC covers:
a. Outpatient professional services for evaluation, diagnosis, crisis intervention, therapy including
rrrediccrlly uecesscrry 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.
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 rrredically r~ecessarv. These
services may have to be authorized by aprovider- who is a mental health professional or his or her designee.
PIC07-740-R2 33 PCH10409 1500.100.2RxF.V (1/10)
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 physicia~~ reconnnends 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. C3utpatient Hospital, Partial Haspitul, and Day Treatment Services. PIC covers such services in a haspital
or licensed treatment facility. These services must bepre-certified by PIC 's medical director or designee.
Hospital or Licensed Residential Ti^eatment Facility Care for Emotionally Disabled Children. PIC covers
medically ~aecessa~y inpatient treatment for emotionally disabled children as diagnosed by a physicica~~ under
the Minnesota Department of Human Services criteria. Tlus care must be authorized by and an-anged
through a mental health professional. For treatment provided by a hospital or licensed residential treatment
facility, inpatient coverage far emotionally disabled children is the same as the inpatient benefit. The child
tlu-ough 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 Miiv~esota court tinder 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, or doctoral level liceitised psychologist.
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 enviromnent.
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 "Exclusions." section later in this COC for all exclusions.
b. Counselil7g, studies, services or confinements ordered by a court or law enforcement officer that are not
determilzed 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 tl•aining 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 m~ernber under chemical influence when no medically frecessa~y 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 trailung, and il7tensive 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, unless authorized by PIC 's medical director or designee.
i. Biofeedhuck.
j. Developmental disabilities or mental conditions that, according to generally accepted professional
standards, are not amenable to favorable modification, except for initial evaluation, diagnosis or crisis
intervention.
k. Services provided by a Icensed residential treatment facility, except as authorized. in advance by PIC's
medical director or designee.
PIC07-740-R2 34 PCH10409 1500.100.2RxF.V (1/10)
Benefit Participating Provider Benefzt Non-Participating Provider Benefrt
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. urgent cm~e center° deductible. deductible.
visits related to diagnosis,
care or treatment of a
condition, sic~7aess or
131Jrrry.
Electronic/online 100% of eligible charges after the 75% of eligible charges after the
evaluation of chronic dedrrctihle. deductible.
conditions; limited to 6
evaluations per member
per calerzdcrr year.
(In order to be covered, the
evaluation must be
conducted by a designated
electronic/anlirre
pczrticipatingln~ovider° only
for established patients
with specific chronic
diseases, such as diabetes
or heart disease, as
determined by I?IC or its
designee. )
Medically necessary genetic 100°0 of eligible charges after the 75°/a of eligible churges after the
testing determined by PIC to dedrretihle. dechrctible.
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 nrernber's pregnancy.
• Genetic testing services if
you are diagnosed with a
specific siclaress by a
physician.
• Genetic testing services if
you are considered to be
high risk for a specific
sick~less as detei-~nined by
a phvsiccrrr.
PIC07-740-R2 35 PCI-I10409 1500.100.2RxF.V (1/10)
Implantable and insertable 100% of eligible charges after the 75% of eligible charges after the
drug delivery devices for deductible. deductible.
birth control.
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 chaYges after the
to lighten or remove the deductible. deductible.
discoloration
Postnatal care 100% of eligible charges after the 75% of eligible chaYges after the
deductible. deductible.
Preventive Healzh Care 100% of eligible charges. 75% of eligible charges after the
Services Not subject to the deductible. deductible.
Immunizations (over
age 18)
Laboratory tests,
pathology and
radiology
Preventive health
physicals
Cancer screening
(including routine
PSA tests, pap
smears, ovarian and
colorectal. tests, and
mannnograms}
Routine preventive eye
exanviiations, limited
to one exam per
rnen2ber° per calendm~
yeaY.
Well-baby!cluld health 100% of eligible charges. 75% of eligible then°ges after the
services up to age 6. Not subject to the deductible. deductible.
Immunizations up to
age 18.
Prenatal care.
Injectable drugs that are 100% of eligible charges after the 75% of eligible charges after the
not specialty drugs, deductible. dedrretible.
excluding insulin.
PIC covers the professional medical and surgical services of licensed: physicians, health care pYOVider•s and
nurses.
Services are provided for the following:
a. Office and urgent care center visits relating to the diagnosis, care or treatment of a condition, sich~ress
or injury.
b. Treatment of diagnosed Lyme disease.
PIC07-740-R2 36 PCH10409 1500.100.2RxF.V (1/10)
c. Contact lenses prescribed as medically rrecessarv 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. 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 fighters 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, ovarian and colorectal
tests and prostate specific antigen (PSA).
b. Immunizations as recommended by yoru~ physician and as shown in the schedule above.
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 to age 6 including pediatric preventive Izealtlr care
services, developmental assessments and laboratory services.
g. Routine eye screening and exam.
7. Surgical services performed iii 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 rnedicully necessary. TMD splints and adjustments are
covered if yorn° primary diagnosis is TMD. Dental services required to directly treat TMD or CMD are
eligible.
S. Treatment of cleft rip a~~zd cleft palate .Tor a covered deperrderri 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 eleff. 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 trailung and education.
1 L An emergency examination of a child ordered by judicial authorities.
12. Prenatal screenng for Cystic Fibrosis when a pregnancy is considered at high risk.
I3. 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 far a pregnancy. Female members may obtailz 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 `Exclusions." section later in this COC for all. 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 ni this COC.
PIC07-740-R2 37 PCH10409 1500.100.2RxF.V (1/10)
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:
I . provided during a confinement;
2. for the diagnosis and treatment of diabetes, or an eating disorder; or
3. a niernber has been diagnosed with a chronic medical condition by a physician.
In all cases, except confinement, nutritional counseling must be provided in a ~~rhysiciarr's office, clinic
system. or hospital setting.
g. Recreational therapy.
h. Professional sign language and foreign language interpreter services in a pr°ovider ~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 par°ticipating pr°ovider~s unless requested
by PIC.
k. Genetic testing and associated services when done as a screening test to predict whether yore may be a
carrier of a specific sickness when yorr~ are not diagnosed with a specific sr'claress by a physician or yon are
not at high risk for the specific sick-rress as confirmed by a physician.
1. I-Iomeopathic medicine; hypnosis; chelation therapy, except chelation therapy will be covered when
nredlcally necessary for the treatment of heavy metal poisoning.
m. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture
practitioner or 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.
PIC07-740-R2 38 PCI310409 1500.100.2RxF.V (1/10)
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 eligible 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 tr°ansplant services that are not part of the clinical trial and
therefore not investigative. It is recommended that tr°arrsplcrnt services be received at a designated tr-arasplarrt
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 amsually or as new information becomes available and it results in specific guidelines about benefits far
t~°ansplant services. You 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 rrecesrary, and not
investigative, are available for the following eli ible transplants:
1. Bone man-ow 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 trausplant-
related treatment provided shall be subject to and in accordance with the provisions, limitations and other terms
of this CDC.
Medical and hospital expenses of the donor are covered only when the recipient is a member and the transplant
has been pre-cei-tified 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 "Exclusions." section later in this COC for all exclusions.
b. Services related. to organ, tissue and bone mai-~-ow transplants and stem cell support procedures or periphei°al
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 mai-row or stem cell transplant.
e. Non-emergency ambulance service from hospital to hospital such as transfers and admission to hospitals
performed only for convenience.
PIC07-740-RZ 39 PCH]0409 1500.100.2RxF.V (1/10)
£ 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.
PIC07-740-R2 40 PCH10409 1500.100.2RxF.V (1/10)
Benefit Participatirg Provider Ber7efzt Norz-Participating Prrovider Be~zefrt
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- Reinrbzu~senrent Value.
Physical Therapy, 100% of eligible charges after the 75% of eligible charges after the
Occupational Therapy And deductible. deductible.
Speech Therapy
Sensory integration Coverage is limited to a maximum of 8 visits
therapy for the treatment per nrenrber° per calendar year.
of feeding 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 care rendered to treat a medical condition, siclL~tress or ir~rjrrry. 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 order°ed 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 witizin 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 "Exclusions." section later in this CUC" for all exclusions.
b. Custodial care or rrraintenance care.
c. Recreational, educational, or self-help therapy (such as, but not limited. to, health club memberships or
exercise equipment}.
d. Therapy provided in yorrr° 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 nifusion 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-R2 41 PCH10409 1500.100.2RxF.V (1/10)
Benefits*
Drugs obtained at a pharmacy __
Drugs obtained at a pharmacy that is
that is a participating provider. not a participatizg provider. PIC pays:
PIC pays: See "Pre-certification" section.
Note: For non ~~m•ticipating providers,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Note-Participating
Provider Reimbursemetrt trahre.
Prescription Drzzg Services
NOTE: Benefits for specialty drugs are as described in this section,
regardless of the place of service where the specicdty drug is dispensed or
administered.
1. Prescription drugs that Fortzzulazy drugs: Forrrzulazy and non forz~zulazy drugs:
can be self-administered 100% of eligible charges after the 75% of eligible charges after the
far up to a 31-calendar deductible. deductible.
day supply.
2. Up to a 31-day supply for Non fornzulazy drugs: 100% of
one type of insulin. eligible charges after the
3. Oral contraceptives for deductible.
a 1-month supply.
4. Contraceptive devices and
delivery methods, other
than oral contraceptives
and injectable
contraceptives, available
from a pharmacy.
5. Comb?otatded 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
eligible charges after the
cleducttble.
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-R2 42 PCH10409 1500.100.2RxF.V (1/10)
Prescription chugs and For~arulary drugs: Formulary and non formulary drugs:
over-the-counter (OTC) 100% of eligible charges after the 75% of eligible chm°ges 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 c7~arges 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.
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.
Injectable drugs that are 100% of eligible charges after the 75% of eligible charges after the
not specialty drugs, deductible. dedrrctihle.
excluding insulin.
Over-the-Counter (OTC) 100% of eligible charges after the deductible.
Drugs
(only includes OTC
drugs on the PIC OTC
drug list}.
Limited up to a 30
calendar day supply per
prescription.
PIC uses its dnig forrnrclary 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.
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-formcdaty drugs and brand or generic drugs. The Step Therapy List
is subject to periodic review and modification by PIC.
PIC07-740-R2 43 PCH10409 1500.100.2RxF.V (1/10)
Some dispensed prescription drugs require the use of quantity linuts, which ensure that the quantity of each
prescription remains consistent with clinical guidelines. Quantity limits can apply to .formulary or non-
forrnulary drugs and brand or generic drugs. A list of those prescription drzrgs 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
coir~srn•ance 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 dnrgs
that are covered by PIC will require a physician's prescription. To receive PIC's payment toward your OTC
c~lr•ug you must present your prescription at a participathlg pharmacy counter. You will still be responsible for
applicable coinsurar~rce or deductible amounts.
You or yoztir provider may request an exception to the drug for-rnrrlary. If an exception applies, the non-
forrnulary drugs that are approved as an exception will be covered at the same level as forrrrulary drugs.
Exceptions to the drug formudary are available as follows:
When a plrysiciarr designates that the prescription for an antipsychotic chug must be dispensed as
communicated and certifies in writing to PIC that the pliysiciarz 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 prescriptian drug to treat a diagnosed mental illness or emotional disturbance PIC will
continue to cover the drug as though it were a for°mulary drug, for up to one year after it is removed from
the for•rnula~ry or you change health plans and become covered under this COC, provided the drug has been
shown to effectively treat yaur illness or disturbance and the following conditions are met:
a. You were treated with the drug for 90 calendar days before a change im PIC 's formulary or a change in
your health plan,
b. Your physician designates that the prescription must be dispensed as commnunicated, and
c. Your physician certifies ill writing to PIC that the prescription drug will best treat your condition.
An exception is valid for up to one year. Your plzysiciarr 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 ~articipatirrg provider pharmacy are covered, eligible charges include
only the PIC nun ~c~rrticiputirrg pr°avider~ reimbrrrscruent value. The PIC northarticipating pravider
reimbrrrsernentvolue is the cost of the generic equivalent of the pr°escription drag and the dispensing fee, or if a
generic equivalent does not exist, the charge that PIC determixles is to be customary for such prescription drar~g.
If the nzernber• requests a brand name drug when a generic drug alternative is available, the member will be
requil-ed to pay the applicable coinsurance plus the difference in cost between the brand name and the generic
dnlg. The difference in cost between the brand name drug and the generic drug will not apply to any applicable
deductible or coinsurance costs the mernber° incurs. When the member has reached the out-of-pocket limit, the
rnenrbcr° still pays the difference in the allowed amount between the brand name and the generic drug, even
though the rrrember is no longer responsible for the prescription drug cairrsur•arrce.
Corrrporrrrded drugs will be covered provided that at least one active ingredient is a prescription ding. Payment
for a conrparinded 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 phas~nacy. The applicable benefit level will be applied.
Compounded drugs contaiiung 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.
PIC07-740-R2 44 PCHI0409 ISOO.I00.2RxF.V (1/IO)
Cornpourrded drags will be covered according to the n2ernber"'s pharmacy network benefits. If a non-
participating provider pharmacy is used to obtain the compounded prescription, the nonparticipating provider
benefit level will apply, without exception.
Off-label. uses of chugs 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
specicdty drags are not covered.
Prior Authorization. It is recommended that you or yore" provider have certain prescription dr°ugs prior
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. It is your responsibility to prior authorize
with PIC when non. par"ticipating providers are used. If yorr have questions about prior authorization, you may
call PIC at the phone number listed on the inside front cover of this COC. These pr-escriptiorr dr~trgs may
include, but are not limited to:
1. prescription dr•rrgs, that are over:
a. $150 if a compound prescription;
b. $1,500 if a retail prescription; or
c. $2,500 if a email order prescription;
2. SpGClalty dr"rlgs;
3. weight loss drugs to treat obesity; and
4. oral antifungal chugs.
Exclusions:
a. Please see the "Exclusions." section later in this COC for all exclusions.
b. Replacement of a prescription dr~rrg 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 d~°rrgs that are equivalent or similar to OTC drugs, except as provided in this COC.
e. OTC home testing products, except as provided in tlvs 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 drr,rgs and OTC dr°rrgs for smoking cessation, except as provided in this COC.
j. Prescriptions written by a dentist unless in connection with dental procedures covered under this Plcrn.
k. Drugs used far cosmetic purposes.
1. Unit dose packaging.
m. Homeopathic medicine, including dietary supplements.
n. Prescr°iption drags 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 dr°rrgs if purchased by mail order through a probnam not administered by PIC's pharmacy
vendor.
s. Prescr°iption drugs for the treatment of erectile dysfunction.
t. Prescription drugs are excluded that have a sili>ilar OTC dr"rrg (on the PIC OTC list) which has an identical
strength, id~entieal route of administration, identical active chemical ingredient(s), and identical dosage
form.
u. Off-label use of specialty drags.
v. Certain combination drags and other drugs, regardless of for-mrrlary 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 chugs. This policy is subject to change.
PIC07-740-R2 45 PCH10409 1500.100.2RxF.V (1/10)
Benefit Participating Provider Benefit Noiz-Participating Provider Be~zefit
PIC pays: PIC pays:
Note: For ~~on-partr'cipating providers,
in addition to any deda~ctibles and
coi~zserrarzce, you pay all charges that
exceed the PIC Non-Participating
Provider Reif~zburse»aent Irahre.
Reconstructive Surgery 100% of eligible chard>~s after the 75% of eligzhle charges after the
deductible. deductible.
PIC covers rncdicully necessary recor~str•uctive surgery due to siclc~aess, 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 suz°gery follotiating a nastectomy 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 "Exclusions." section later in this COC for all exclusions.
b. Services and/or drugs to treat conditions that are cosn~ctic in nature.
PIC07-740-R2 46 PCH10409 1500.100.2RxF.V (t/10)
Benefit Pa~^ticipating Provider Benefit Non-Participating Provider Benefit
PIC pays: PIC pays:
Note: For r~ara participating providers,
in addition to any deductibles and
coinsurance, you pay all charges that
exceed the PIC Non-Participating
Provider Reimbiirsenzent halve.
Skilled Nursing Facility Care
Skilled rehabilitation, 100% of eligible charges after the 75% of eligible charges after the
including room and board deductible. deductible.
Coverage for confirren2ents in non-
participating hospitals and sitzlled nur-sin
.facilities is limited to a combined
maximum of 120 calendar days per
calendar year-.
Daily s1~-zlled care as an 100% of eligible charges after the 75% of eligible charges after the
alternative to hospital deductible. deductible,
con finernents
PIC covers the eligible skilled nursing facility services for post-acute treatment and rehabilitative care of
sick~less or injury. These services must be directed or referred by a pl~ysicicr~T and pre-certified by PIC 's
medical director or designee.
Skilled nursing facility services include room and board, daily skilled nursing anal 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 directar or designee determines if a private room is medically rtecessa~~J. 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 roam rate iu 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 "Exclusions." section later in this COC for all exclusions.
b. Hospitalization, transportation, supplies, or medical services, including physicians' services furnished by
the United. States Goverment 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-R2 47 PCI-110409 1500.100.2RxF.V (U10)
Specified Non-Pa~~ticipating P~~ovide~~ 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 pr-ovider benefits. Yorr are not required to receive these services from a
participating provider. For example, an office visit, (whether by a pm-ticipating provider or a norr-
participatingprovider) for the services listed below will be covered at the participating pr°ovider benefit level.
l . 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 IIIV-related conditions.
Exclusions:
a_ Please see the "Exclusions." section later in this COC for all exclusions.
PIC07-740-R2 48 PCH 10409 1500.100.2RxF. V (1 / 10)
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 beconsidered apre-existing condition.
In the case of a late enrollee, apre-existing condition is excluded from coverage until the end of 1 S 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 Enrolhnent provision, apre-existing condition is excluded from coverage
until the end of 12 months from the enr°olhnent date.
The pre-existing condition limitation is reduced by any period of time during which the rnernber had corztiazuozrs
and cre~btable coverage prior to his or her eiuollment under the GMC. This limitation does not apply to
newborns, adopted children, or children placed for adoption.
Exclusions
In addition to any other exclnsions or limitations specified in dais COC, d'dC 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 may be obtained by calling PIC Customer Service.
6. Orthognatl>ic surgery.
7. Services received before coverage under PIC begins or after yoz€r coverage under PIC ends.
8. Services or supplies not directly related to yorrr~ care.
9. Services or supplies t1n-ough a provider- ordered or rendered by pr°oviders 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° Reinzbursernerrt 1'alz~e for services or supplies
received from non participating providers, including non-participating pharmacies.
12. Services prohibited by law or regulation, or illegal under applicable laws.
P1C07-740-R2 49 PCH104Q9 1500.1002RxF,V (1/10)
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) yorr 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 irrcrrrred outside the United States if the rrzember 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
saibscr^iber or of the srrbscriber~'s spouse) or anyone who customarily lives in the sr~bscriber-'s household.
19. PIC or the member- are not liable for charges for services performed by certified surgical technicians,
surgical tecluvcians or eert~ed operating room technicians.
20. All services, except emer°ger~rev services, for nrernbers when outside the United States.
21. Services provided by massage therapists, doulas, and. personal. trainers and. others who have not completed
professional level education and licensure as determined by PIC.
22. Sexual devices, services; or supplies or pr°escription 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
maimimograms, that are not ordered by a plzysician.
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.
PIC07-740-RZ 50 PCH10409 1500.100.2RxF.V (1/10)
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 1~ospital such as transfers and admission to
hospitals performed only for convenience.
34. Chiropractic Services:
a. See all exclusions.*
b. Services primarily educational ii1 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 licensed acupuncture
practitioner or a pi~ovide~~ licensed or trained ill 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.
e. 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 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 proeedlu-es 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 eda~rcatio~ual in nature or for vocation, comfort, convenience or recreation.
PIC07-740-R2 51 PCH10409 1500.100.2RxF.V (1/10)
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
carver.
1. Over-the-counter orthotics and. appliances.
m. Orthopedic shoes and custom molded foot orthotics, except for rnem.bers 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. 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-er~zergency 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 yoi~sr 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 yatrr^ home for convenience.
g. Services provided in your home due to lack of transportation.
h. Caistodial care.
i. Services at any site other than your home.
j. Recreational therapy.
39. Hospice Care:
a. See all 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.
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 physiciar~ts' services furnished
by the United States Government or by an institution operated by the United States Government, unless
payment is requn°ed in accordance with applicable law.
d. Private room, except when r~iedically necessmy or if it is the only option available at the admitted
facility.
e. Non-emerge~zcy ambulance service from hospital to hospital, such as transfers anal admissions to
hospitals performed only for convenience.
f Services and/or drugs to treat conditions that ale cosmetic in nature.
PICO'7-740-R2 52 PCH10409 1500.100.2RxF.V (1/10)
g. Orthoptics and refractive surgery (i.e. lasik) for opthalmie 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 sick-rress when you are not diagnosed with the specific sickness by a physician or
you are not at high risk for the specific sick-rzess as confirmed by a physician.
j. Homeopathic medicine; hypnosis; chelation therapy, except chelation therapy will be covered w11en
medically necesscny far the treatment of heavy metal poisoning.
k. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture
practitioner or a provider licensed or trained in acupuncture.
1. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease.
m. Autopsies.
n. Bariatr^ic surgeries.
o. Services for items for personal convenience, such as television rental.
p. Commercial weight lass programs.
q. Nutritional counseling, except when:
1. provided during a cor2fi.nemerrt;
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 playsiciarz.
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. Zn vitro fertilization.
e. Gamete and zygote intrafaliopian transfer (GIFT and ZIFT}procedures.
f Surrogate pregnancy.
g. Sperm bai~lcing.
h. Embryo and egg storage.
i. Artificially assisted technology, such as, but not limited to, artificial insemination (AI) and intrauterine
insemination (IUL).
j. Donor sperm.
k. Oral and injectable drugs for infertility.
42. Mental and Substance-Related Disorder Services:
a. See all exciusions.'~
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 i11 this COC.
e. Services to hold or confine a member under chemical influence when no medically r7ecessary services
are required, regardless of where the services are received (e.g. detoxification centers).
f. Early behavioral interventions for children ilicluding but not limited to Lovaas therapy, applied
behavioral analysis, discrete trial trainng, 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-R2 53 PCH10409 1500.100.2RxF.V (1/10)
Home-based mental or behavioral health services, unless authorized by PIC 's medical director or
designee.
Biofeedback.
Developmental disabilities or mental conditions that, according to generally accepted professional
standards, are not amenable to favorable modification, except far initial evaluation, diagnosis or crisis
intervention.
k. Services provided by a licensed residential treatment facility, except as authorized in advance by PIC 's
medical director or designee.
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 rnearber~ has been diagnosed with a chronic medical condition by a physician.
In all cases, except corrfinerrzent, nutritional counselil~g 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 pant of a
routine preventive health exannunation.
j. Charges for duplicating and obtailning medical records from non ~~ar•ticipating providers unless
requested by PIC.
k. Genetic testing and associated services when done as a screening test to predict whether you may be a
car-ier of a specific sich~ress when yorc are not diagnosed with a specific sick~ress by a physician or you
are not at high risk for the specific siclaiess as confirmed by a physician.
L I~omeopathic medicine; hypnosis; chelation therapy, except chelation therapy will be covered when
rneclr,'eally accessary for the treatment of hcavy metal poisoning.
m. Acupuncture, except for treatment in a chronic pain prot,~ram and rendered by a licensed acupuncture
practitioner or a provider' licensed or trailned inn 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 i11 an office setting.
r. Biofeedback.
s. Routine hearing exams.
44. Organ and Bone Marrow Transplaart Ser~~ices:
a. See all exclusions.*
b. Services related to organ, tissue and bone marrow transplants and stem cell support procedures or
periphei°al stem cell support procedures for a condition that is ir7vestigative.
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-R2 54 PCH10409 1500.100.2RxF.V (1/10)
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 zztaintenance cm-e.
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. Prescriptiont Dz°ug 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. Prescz•iptiozz dz•ugs that are equivalent or similar to OTC drzzgs, 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 zzecessazy 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 comiection 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 chugs for the treatment of infertility.
o. Topical or oral acne treatments for members age 19 and aver.
p. Non-FDA approved route of adminstration (e.g., chug 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 tlu-ough a protn-am not administered by PIC 's pharmacy
vendor.
s. Prescription drzzgs for the treatment of erectile dysfunction.
t. Prescription drugs are excluded that have a similar OTC clz°ug (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 cozztbizzation drugs and other drugs, regardless of .foz•mulczzy 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-R2 55 PCH10409 1500.100.2RxF.V (1./10)
47. Reconstructive Surgery:
a. See all exclusions.*
b. Services and/or drugs to treat conditions that are cosmetic in nature.
48. S7,zlled Nizz°sing Facility Care:
a. See all exclusions.`
b. Hospitalization, transportation, supplies, or medical services, including physiciazzs' services furnished
by the Unted States Government or by an institution operated by the United States Government, unless
payment is required in accordance with applicable law.
e. Private room, except when medically necessary or if it is the only option available at the admitted
facility.
d. Respite or czzstodia7 care.
49. Specified Non-Paz-ticipatizzg Provider Services:
a. See all exclusions.*
Ending Your Coverage
Coverage of the subscziber and/or his or her dependents will terminate on the earliest of the following dates,
except that coverage may be coi~~tinued or converted in some instances as spec;itied in the "Continuation of
Coverage" and "Youz~ Right to Convert Coverage" sections:
I . 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 szzbscrihez• retires, unless PIC and the
employer have agreed to provide coverage for retirees under the GMC.
3. For the szzbscz~iber and dependents, the end of the month in which the subscriber's eligibility under the GMC
ends.
4. For the szzbscz~ibez- and dependents, the end of the month following the receipt of a written request from the
sztbscriher to cancel coverage.
5. For a child covered as a deperulezzt, the end of the month in which the child is no longer eligible as a
dependent, unless the eligible deperzdezzt is disabled.
6. For the subscz°iber and dependents, termination. will be retroactive to the last calendar day for which the
suhscz~ibez°'s contribution towards premium has been received.
7. For the subscribez- 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 as~angement (HRA} plan sponsored by the
employer, for the subscriber and dependents including those em-olled 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-R2 56 PCH10409 1500.1002RxF.V (1/10)
Extension of Benefit if Health Plan or Carrier Replaced
If you are confined on the effective date of this coverage, the prior carrier is responsible for all eligible charges
until yo1.11- final discharge from the inpatient facility or until contract maximums have been met.
An extension of benefits will be provided under this COC to a r1lem~ber who is confined in a hospital or skilled
nursing_facility on the date the member's employer terminates its GMC with PIC and replaces group medical or
health coverage with another health plan or insurance carrier. If the employer replaces PIC coverage with
another group health plan or insurance carrier, PIC will pay benefits while the rtlelnber is confined as described in
this section, until discharge, upon receipt of due proof of the following:
1. the naember• i11c1u~red eligible charges while confined,
2. the eligible charges are related to the sic11~1ess or i11ju1y which caused the member to be confined; and
3. the eligible chcuges would have resulted in a valid post-sewice claim if this benefit had been in effect at the
time expenses were incur°~°ed.
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
0011 tl"I b 2l 11011 s.
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 r11er11ber returns to work
immediately following his or her approved FMLA leave, no waiting periads 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 fast absent due to uniformed service duty.
EIigibility. 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, Arny National Guard, Air
National Guard or the conmlissioned corps of the Public Health Service. Duty includes absence for active duty,
active duty for training, initial active duty for training, il~active duty training and for the purpose of an
examination to determine fitness for duty.
Covered depcrrdents who have coverage under PIC innnediately prior to the date of the subscrib~l•'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 orpre-existing condition linutations will apply.
Contribution Payment. If continuation of coverage is elected under USERRA, the stlbscribcl° 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
PIC07-740-R2 57 PCH10409 1500.100.2RxF.V (1/10)
absences exceeding 31 calendar days, the cost may be up to 102% of the cost of coverage under PIC. This
includes the szsbscriher's share and any portion previously paid by the employer.
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 sasbscr•ibe~~ fails to apply for or return to employment as required by USERRI~, after
completion of a period of service;
3. the early termination of USERRA continuation coverage due to the subscr•ihe~~'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." Subsc~~iher'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 returns 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 returns 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-R2 58 PCH10409 1500.100.2RxF.V (1/10)
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 yoctir right to continue coverage under this CDC 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 saibscl•ibef•
and/or covered naenzber 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 szrbscriber's and/or covered nzernber'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, yoit 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
tirneiy 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 depe~~cie~Zts 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
emmployer.
PIC shall not be required to establish, maintain or eonh-ibute to a HRA on behalf of an eligible r~ier~~ber or the
employer.
PIC07-740-R2 59 PCH10409 1500.100.2RxF.V (1/10)
The subscriber, his or her covered spouse and covered deperzderzt 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 deperzderzts in your 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 deperzderzt 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:
I. In certain cases, the szsbscriber znay 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 rzzernbers; and
4. Continuation coverage with PIC ends when the GMC terminates or as explained in detail on the following
Continuation Chart. The szsbscriber, his or her covered spouse and covered deperzderzt children may,
however, be entitled to continuation coverage under another group health plan. offered by the employer. Yozc
should contact t17e 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, yozs should contact the employer.
Qualifying Events
1. Loss of coverage under the GMC by the szsbscriber due to one of these events:
a. Voluntary or involuntary termination of employment of the szsbscriber for reasons other than "gross
misconduct."
b. Reduction in the hours of employment of the szrbscriher-.
c. Layoff of the subscriber.
d. Leave of absence of die subscriber.
e. Early retirement of the szrbscr°iber.
f. Totezl disability of the szsbscriber while employed by the employer.
2. Loss of coverage under the GMC by the covered spouse and/or covered deperulesrt 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 i11 the hours of employment of the szebscr°iber•.
c. Layoff of the szsbscriber.
d. Leave of absence of the subscr°iber°.
e. Early retirement of the subscriber.
£ 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 szsbscriber.
PIC07-740-R2 60 PCH10409 1500.100.2RxF.V (1/10)
3. Loss of coverage under the GMC by the covered deperzde~~t 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 depende~zt 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 membe~~s. You do not need to notify the employer of these
qualifying events. However, for other qualifying events including divorce or legal separation of the szrbsc~~iber
and loss of dependent child status, continuation is available only if you provide timely, written notice to the
employer. You 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 general continuation notices as required by law; determine if the met~zbe~~ is eligible to
continue coverage according to applicable laws;
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 subsci•ibet•, covered spouse and/or covered deperade~at children.;
4. Infann the r~zer~tber~ of the pt°erF~aiun~x contribution required to continue coverage and flow to pay the p~~emium
contribution; and
l~iotify the »~~en~zber• when he or she is no longer entitled to continuation coverage or when his or her
continuation coverage is ending before expu-ation of the maximum (18-, 29-, 36-month) continuation period.
What you must do:
1. Yaer 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 depertde~~t 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 yoccr• 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. (You may obtain a copy of the
approved form from the employer.) Tlus notice must be submitted to the employer in writing and must
include the following:
a. the name of the employer;
PIC07-740-R2 61 PCH10409 1500.100.2RxF.V (1/10)
b. the name and address of the szzbscriber or former subscriber;
c. the names and addresses of all applicable deperrderzts;
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 subscr°iber, fornler 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 yozc 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, yozc must notify the employer of your- election in writing within 60 calendar days after
the date the nrenzber's coverage ends, or the date the employer notifies the nrerr2ber 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. (You may obtain a copy of the
approved form from the employer.) Tlus election must be submitted in writing to the employer; and
5. Yozr must pay continuation prerrxiuru contributions:
a. The prerrzizruz 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 toted disability of the subscriber- while employed). For a rTZember 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 continuation election form will set forth your continuation
prerraiurrr contribution rate(s).
b. The first prerr2iuru contribution must be paid by check within 4~ 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 begiiuling of each month for which coverage is cantinued.
c. The nzenrher° must pay subsequent prerniurrz contributions by check on or before the required due date,
plus the 30-calendar day grace period required by law, and if authorized by PICs such longer period.
allowed by the employer or required by law.
What you must do to apply for continuation extension:
A. Social Security Disability:
1. If you are currently eiuolled 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 lus or her termination of employment for reasons other than gross misconduct. To request an
extension of contvluation, yozn 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
e. the date on which yozti would lose coverage under the GMC as a result of the subscriber's
PIC07-740-R2 62 PCH10409 1500.100.2RxF.V (1/10)
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`x' month of your initial continuation coverage using the
employer's approved disability notice form. (Yozz 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 szzbscribez;
c. the names and addresses of all applicable depezzdents 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 merzaber;
f. the date the r~zernber 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 individual can
be a szrbscriber•, former szzbscz-iber, or his or her depezzdezzt(s); or a representative acting on behalf of
the employee or deperzdezzt(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 submitrting, in wl°iting, all required information
and supporting documentation.
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
4. You must pay continuation premium contributions:
a. The prerzziuzn 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 zzzezzaber
receiving an additional 11 months of coverage after the initial 18 months due to a continuation
exiension for Social Security disability, the premizurz 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 continr~ation pz°eznium 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 zzzezz~zbez^ 's monthly pa}nnents are due and payable by check at
the beginning of each month for which coverage is continued.
c. The znenaber 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 PIC, such longer
period allowed by the employer.
B. Second Oualifvin~ Events for Covered Dependents Only:
If you are cui~ently 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 deperzdezzz cluld loses eligibility, then
yozr 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/her termination of
employment for reasons other than gross nusconduct 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:
PIC07-740-R2 63 PCH10409 1500.100.2RxF.V (1110}
a. d1e date of the second qualifying event (death, divorce, legal separation, loss of deperrderrt 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 ~lependeut 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. (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 fallowing:
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 cun-ently 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, ~1d telephone number of the individual submitting the notice. This individual can
be a subscriber, former sub,ccr°zber, or his or her dependent(s}; or a representative acting on behalf of
the employee or dependent(s).
If yore do not supply all notice requu-ements in writing as previously described, then you must follow the
employer's requirements and specified time period for submtting, in writing, all required information
and supporting documentation.
3. To elect an extension of continuation coverage, you must notify the employer of the second qualifying
event in writing withal the 60 calendar day timeframe, by following the notification procedure as
previously explained in Item # l and #2, a~~~d submitting the employer's approved form; and
4. You must pay continuation premirm~r 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 merrr~ber
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 your
continuation prenriutn contribution rates.
b. The first pr°emirnn contribution must be paid by check withil7 45 calendar days after electing to
continue the coverage or such longer period as required by law. Thereafter, the rnenrber~ s monthly
payments are due and payable by check at the beginning of each. month for which coverage is
continued.
c. The nrenrber must pay subsequent pr•enrirrrn 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.
PIC07-740-R2 64 PCH10409 1500.100.2RxF.V (1/10)
Additional Notices You Must Provide: Other Coverages, Medicare Enrollment and Cessation of
Disability
You must also provide written notice of (1) yoasr other group coverage that begins after continuation is elected
under the GMC; (2) your Medicare eru-ollment (Part A, Part B or both parts) that begins after continuation is
elected under the GMC; and (3) the ~~~ember, 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:
L If providing notification of other coverage that began after continuation was elected, the name of the mer~~ber
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 m.en~ber 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 rnei~aber, 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-R2 65 PCH10409 1500.100.2RxF.V (1/10)
CONTINUATION CHART
If coverage under this GMC is lost Who is eligible to Coverage may be continued until...
because this ha ens... continue...
The subscriber's leave of absence, early Subscriber-, The earliest of the following occurs:
retu-ement, 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 procedw~es 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:
srrbscriber•. 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 iu Covered spouse The earliest of the following occurs:
A~Iedicare :rrithin 18 months before tl.e and covered 1. 36 months after enrolhnent 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 die employer's notice procedures me=nrber n1 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:
dependant 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 tinder the
GMC.
P1C07-740-R2 66 PCH10409 1500.100.2RxF.V (1/10)
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 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 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 subsc•rzber-,
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 terniination 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 contuiuation coverage
Notice of such disability must be is elected under the GMC, of the
provided by the rnen~ber to the employer applicable rnernber 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
contuiuation extensions due to Social GMC.
Security disability.
Special Enrollment Periods
If you are a subscriber^, covered spouse or covered dependcrrt 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
em-ollment), the Special Enrollment Period provisions of this COC as referenced. in the section which
describes eligibility and. enrollment will apply to yott during the continuation period required by federal law
as such provisions would apply to an active eligible employee. Eligible depertderrts that are newbonz
children or newly adopted children (as described in the eligibility and enrollment section} that are acquil-ed
by a subscriber during such subscriber's continuation period required by federal law, and are enrolled
tluough special enrollment, are entitled to continue coverage for the maximum continuation period required
by law.
If the continuation period required by federal law bas been exhausted, and you are enrolled for additional
continuation coverage pursuant to state law or the eligibility provisions of this COC, yotr may be entitled to
the special enrollment rights upon acquisition of a new dependent through mat-t-iage, birth, adoption,
placement for adoption, or legal guardianship, as referenced in the section entitled Special Enrollment
Period for New Dependents Only.
PIC07-740-R2 67 PCH10409 1500.100.2RxF.V (1/10)
Special Rule for Pre-Existing Conditions
A sub.ccrihe~~, his or her covered spouse or covered depende~at 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 n2ernber^, 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 subsc~°r,'bers who termuiate 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 dial 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 you qualify or may qualify for trade adjustment assistance under the Trade Act, contact the employer for
additional information. Yois must contact the employer promptly after qualifying for trade adjustment
assistance or yozs will lose your- special continuation rights.
All notices, elections, and information required to be furnished or submitted by a urember, 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 Mimlesota 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 Mimlesota
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 Iris or her
employer, within the deadline required by law, of intent to continue coverage. An eligible retired employee
who does not elect to continue coverage does not 1,ave a right to re-enter or re-e1;ro11 for coverage at a later
date.
PIC07-740-R2 68 PCH10409 1500.100.2RxF.V (I/IO)
Yous~ 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 ar waiting periods on the later of the following dates:
L 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. Yoac 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. Yoz~ ar e eligible for Medicare;
3. Coverage terminated due to the n2c~nrber's failure to pay, when due, any required contribution toward
prer~aitma;
4. Coverage terminated due to fraud;
5. You are or could be covered under a continuation of coverage provision under the GMC or under a group
health plan of a "successor employer" (within the meaning of COBRA continuation of coverage) to the
employer.
If yoat 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 da:
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
yoa~r coverage under the GMC ends.
PIC07-740-R2 69 PCH10409 ISOO.I00.2RYF.V (I/10)
Subrogation and Reimbursement
P1C'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 yoii~° 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 sie~~aess or if7jury
from another source of compensation for your sickness or injury.
3. PIC's right to ~°ecover 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.
S. Nothing in this section shall limit PIC's right to recovery from another source which may otherwise exist at
law.
Notice Requirement
Y~it 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-R2 70 PCH10409 1500.100.2RxF.V (I/10)
Coordination of Benefits
As a member, yaar 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 depe~ulent. 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 men~zber claiming benefits under PIC must provide any facts needed to pay the
claim. If tale information caimot 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, coinsurance 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
Coorduation 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 tln-ough 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 co?2rt decree. In the absence of a court
decree, it is the parent with whom the child resides mare 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 soup, 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. a laborananagement trustee plan or a union welfare plan;
e. an employer or multi-employer plan or employee benefit plan;
£ Medicare or other govenm~ental 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-R2 71 PCH10409 1500.100.2RxF.V (1/10)
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 c}aim had been duly made.
Pa•imary 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 deternined 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 deternination 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'oe excess to any other parts of the plan provided by the employer.
A plan may consider the benefis paid or provided by another p}an in determining its benefits only wliein 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, sarbscriber, or retiree, is the primary plan; and the plan that covers the person as a c~eperrderrt 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. primacy to the plan covering the person as a nondependent (e.g., a retn-ed employee); then the order is
reversed, so the plan covering that person as a nondependent is secondary and the other plan is prunary.
PIC07-740-R2 72 PCH10409 1500.100.2RxF.V (1/10)
3. 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 i£
• 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 pal°ent; 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 i°etired employee
(or as that employee's dependent). If the other plan does not have this rile, 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, menZber, subscriber, or retiree (or as a depe~~derat of an
employee, ~~zem~ber subscriber, or reti2-ee) 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
far 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 deternuluig 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 benefit s under PIC
PIC07-740-R2 73 PCH10409 1500.100.2RxF.V (1/10)
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
tern "pa}nnent made" includes providing benefits in the form of services. In this case "pa}nnent made" means the
reasonable cash value of the benefits provided in the forni 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 t11e 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 provzder• has accepted assiglunent of Medicare, PIC determines allowable expenses based upon the amount
allowed by Medicare. PIC `s allowable expenses are the lesser of the PIC Nor7-Partr'cipatir~g Provr~der
Reinzhe~rse»7~e~1t T~alzse 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 mernher who is eligible for Medicare has not em-olled with
Medicare, then PIC will pay as the primary plan.
Renal Failw•e. If yotti begin to have services related to renal failure, tive request that you sign up for Medicare.
P1C07-740-R2 74 PCH10409 1500.1002RxF.V (1/1.0)
How to Submit a Bill if You Receive One far 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-ser-vice claims relating to services will be handled for yozr by your
participating provider. You may be asked by your pravider to sign a form allowing your provider to submit
claims on yozzr behalf. If you receive an invoice or bill from. your pravider• 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 clairrrs within 15 months after the date
services were incur°red, 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 Note-PartiCipa~itZg Providers
Claim Submission. Yau 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 pr°ovider name and charges. PIC must receive post-ser~~ice 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 clairrzs is 180 calendar days. Past-ser~~ic•e claims received after the deadline will be denied.
Payment of Post-Ser°t~ice Claz~ns. Post-serh~ice claims for benefits will be paid promptly upon receipt of written
proaf of loss. Benefits which are payable periodically during a period of continuing lass will be paid on a
periodic basis. All or any portion of any benefits provided by PIC lnay be paid directly to the provider rendering
the services. Payment will be made accarding to PIC coverage guidelines.
Initial Benefit Determinations of Post-Seswice Claims
Post-service clczirrrs are claims that are filed far payment of benefits by PIC after medical care has been received
and submitted in accordance with PIC'spost-service claim filing procedures.
If your attending provider submits apost-service claim an yozrr 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-sen~ice clczirn is denied, PIC will conununicate such denial within 30 calendar days after receipt of a
past-service claim. If PIC does not have all information it needs to make an initial benefit determination, it may
request the necessary information fiom you or a Hurd party. Yozz 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 yozr or a third party fail to provide the
necessary infor~i~nation, 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 incur°red.
P1C07-740-R2 7~ PCH10409 1500.100.2RxF.V (1/10)
Complaint and Appeal Procedures
How to Submit a Complaint
Yorr 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.
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 yotr that it received your° written complaint within 14 calendar days, unless yotrf° 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 I4 additional calendar days to notify you of its decision. Tn
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 clairrr}, yoau• 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 clair~r) your complaint must be subnutted to PIC within 180 calendar days
following denial. of the hutial determnation. A decision on your post-sef•1°ice clairrr complainnt will be made
witlun 30 calendar days from receipt of your complaint. This tilnze period maybe extended if you agree.
Haw to 1€2equest an Appeal
if after the first Ievei of pre-certification or complaint review, your request was domed, 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
uifornnation from you or your- provider within the tilnne periods set forth below for deciding an appeal, yoz~r
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 yoia, your attending
Izealth care p~°ofecsiorral and your 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, your atterzdir~tg health care professional and your attending provider within one business day
of the determination, or sooner if your medical condition requires. If the appeal concenns non-acute services,
a decision on your appeal will be made and communicated in wi7tiing to you, your attending 1~~ecrlth care
prgfessiorral and your attending pr°ovider witlun 30 calendar days. This time period may be 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 ilutial determination. When you appeal the initial determination for medical reasons, PIC will
arrange for review of the clinical material by a physician i11 the same or similar specialty who did not make
the initial determination.
PIC07-740-R2 76 PCHI0409 1500.100.2RxF.V (1/10)
Post-Ser°vice Clat~ms. If you~~ complaint is not resolved to your° satisfaction or if you received services after
yoat~~ request far 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
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
yoi~r° 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 yoT~~~° request. Yoi~t will receive a written copy of the
decision, including the key findings an which the decision is based.
The above time periods may be extended if you agree.
Upan request and. free of charge, you have the a-fight to reasanable 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 maybe submitted for an external 1°eview. See the subsection entitled "Now to File an Extenlal
Review."'
How to File a Complaint with the Commissioner of Commerce
Your or someone acting on yoa.tir behalf may file a request far review with the Commissioner of Commerce at any
time. You may reach the Mindesota 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 Miimesota to review
health plan complaints. Yoati may request an external review at any time including, if you or someone acting on
yoarr behalf has exhausted the PIC internal complaint and appeal processes, yoa~t or yo¢rt° representative may file a
request for external review to the Canunissioner of Commerce at the following adch-ess:
iVlinnesata Departrtrent of Cammerce
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. A1] disputes
and complaints may be submitted for an external review, except cases of fraudulent marketing and agent
misrepresentation. External review decisions are bidding on PIC, but not binding od the n~eln~bei°.
PIC07-740-R2 77 PCH10409 1500.100.2RxF.V (1/10)
No Guarantee of Employment or Overall Benefits
The adoption and maintenance of this COC does not guarantee or represent that coverage will continue indefinite
with respect to any class of employees and shall not be deemed to be a contract of employment between the employ
and any szzbscribez•. Nothing contained herein shall give any subscn~ber the right to be retained in the employ of t]
employer or to interfere with the right of the employer to discharge any subscriber, at any tune, nor shall it give tl
employer the right to require any szzbscriber to remain in its employ or to interfere with the subscriber's right
terminate his or her employment at any time not inconsistent with any applicable employment contract. Nothing
this COC shall be construed to extend benefits for the lifetime of any znem~ber or to extend benefits beyond the da
upon which they would otherwise end in accordance with the provisions of the GMC or any benefit description.
Definitions
Attendizzg Health Caz-e The health care professional providing care within the scope of the professional's
Professional practice and with primary responsibility for the care provided to a member.
Attending health care professiozal shall uiclude only physicians; chiropractors;
dentists; mental health professionals; podiatrists; and advanced practice nurses.
Bcxriatric Szzrgery 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.
Calezzdar Year The 12-month period begimring 3anuary 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.
C:oiz~isurance A fixed percentage of eligible charges that is paid by you and a separate fixed
percentage that is paid by PIC to the pr°ovider for covered sez•vices and supplies.
Coinsurance will be based on (1) the discounted charge negotiated between PIC and
participating providers; or (2) the PIC Non-Participating Provider Reimbuz•seznerrt
~czlue for rton ~az-ticipatizzgpz•ovic~lez~s~.
Cvrzzbizaatiozz Drug A prescription drug ili which two or more chemical entities are combined into one
commercially available dosage form.
Compozzzzded 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.
Confinezzzezzt An uninterrupted stay of 24 hours or more in a hospital, sIti-illed missing facilit~~,
rehabilitation facility or licensed residential treatment facility.
Cozztizzuous Coverage The maintenance of contimzozzs and uninterrupted creditable coverage by an eligible
employee or de~~~ezzdent. An eligible employee or dependent is considered to have
maintained continuous coverage if the individual enrolls in PIC and the break in
cz°editable coverage is less than 63 calendar days. See waitiz~~g period.
Cosmetic Services, medications and procedures that improve physical appearance but do not
coi~-ect or vnprove a physiological function, or are not medically necessazy.
PIC07-740-R2 78 PCH10409 1500.100.2RxF.V (1/10)
Cover°ed 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 (HTPAA).
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
Ser~~ices for the treatment of mental and substance related conditions.
Deductible The amount of eligible charges that each member must incur in a ccdendar 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 endodonties, oral surgery,
orthodontics, pedodontics, periodontics and prosthodontics.
Dependent The subscriber's eligible dependent as described in the "Eligibility" section.
Designated A participating provider or inoup 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.
Designated Transplant Any licensed hospital, health care provider, group or association of health care
NetworkPravider providers that has entered into a contract with or tluough PIC to provide organ or
bone marrow transplant or stem cell support and all related services and aftercare for
a member.
Educatr'orral 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-R2 79 PCH10409 1500.1002RxF.V (1/10)
Effective Date The date a rnernher becomes eligible for health care services and completes all
enrollment requirements, subject to any required waiting period.
Eligahle 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.
Errrergency Errrergerrcy 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 rnernber'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-Sen~ice Method of payment for provider services based on each visit or service rendered.
Fee Schedule The amount that the participating prohider 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.
Ftrll-tame 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 Therapy Therapy provided to develop initial functional levels of movement, strength, daily
activity or speech.
Homebound When vorr are unable to leave home without considerable effort due to a medical
condition. Lack of transportation does not constitute horrrehourrd 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 ctrstodiul care, and is not a nursing home or
similar facility.
Ir~tcurr•ed Services and supplies rendered to yorr. Such expenses shall be considered to have
been incur°red at the time or date the service or supply was actually purchased or
provided.
Injury Bodily damage other than siclLfiress including all related conditions and recurrent
symptoms.
PIC07-740-R2 80 PCH10409 1500.100.2RxF.V (1/10)
Irzi>estigative 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 govermnent 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 is
the subject of ongoing Phase I, lI, 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 opinia~~s 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 chug,
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 i~2vestigntive,
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 jounlals, reports of
clincal trial connlittees, or technology assessment bodies, and professional.
consensus options of local and national health care providers.
PIC07-740-R2 81 PCH10409 1500.100.2RxF.V (1/10}
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.
Licensed Residential A facility that provides 24-hour-a-day care, supervision, food, lodging, rehabilitation,
Ti~ecrtment Facility or treatment and is licensed by the Minnesota Cormnissioner of Human Services and
the Minnesota Department of Health.
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, pr°eventive health car°e services, and medical treatment consistent
Medical Necessity with the diagnosis of a prescribed course of treatment for nzenzber'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 m~ernber'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 provic'lers; or
2. the provider to which the participating provider has referred the member.
With non participating provider benefits, there is rnernl?er financial responsibility of a
deductible, coirzsuranc•e, and any amount in excess of the PIC Non-Participating
Proi-~ider Reimbursement T~alrre.
Out-of-Pocket Limit The maximum amount of money yarti must pay in coinsrrrcnzce and deductible before
PIC pays yozn° eligil~rle charges at 100%. If yoar reach benefit or overall maximums,
yozr are responsible for amounts that exceed the out-of-pocltiet limit.
Over-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, pr°ovider or facility that is directly contracted to
participate i11 the PIC provider network.
Par~ticipatirrg 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-R2 82 PCH10409 1500.100.2RxF.V (1/10)
Physical Disubility A condition caused by a physical izrjzrry or congenital defect to one or more parts of
the rrzerrzber's body that is expected to be ongoing for a continuous period of at least
two years from the date the initial proof is supplied to PIC and as a result the n~errzber
is incapable to self-sustaining employment and is dependent on the subscriber for a
majority of financial support and maintenance. An illness will not be considered a
physical disability.
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-Participating The amount that will be paid by PIC to a r~ora-participating provider for a service is a
Provider percentage of the lesser of the:
Reimburserr~en~t l~'alue 1. nor 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 rrorz participating provider°.
If the amount billed by the rrorr participating provr'der is greater than the PIC non-
participating provider reirrrbursenzerrt value, you must pay the difference. This
amount is in addition to any deductible or coinsur°arrce amount you may be
responsible for according to the terms of this COC.
Post-Sen~ice Clair~rz A request for payment of benefits that is made by a naer~ber or his or her authorized
representative after services are rendered and in accordance with the procedures
described in this COC.
Prenriurrz The payment PIC requires to be paid by an individual or employer on behalf of or for
rnernber°s for the provision of the covered health care services listed u~ this COC.
Pr°cscr°iption I~r-zrg A drug approved by the Federal Drug Administration for use only as prescribed by a
pll y,ST Cl a11.
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 rnernber or lris or her authorized. representative in
accordance with the procedures described in this COC.
Preventive Hea~ltlr 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.
Reconstructive Surgery to restore or correct:
1. a defective body part when such defect is incidental to or follows surgery
resulting from injury, sick~rress, 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 plrysiciarr; or
3. a physical defect that dn•ectly adversely affects the physical health of a body part,
and the restoration or correction is determined by PIC to be medically necessary.
PIC07-740-R2 83 PCH10409 1500.100.2RxF.V (I/10)
Reconstructive Su~ge~y Coverage for ~7Zembers receiving covered services under PIC in connection with a
Following a mastectomy and who elects breast reconstruction in eomiection with such
Mastectonry mastectomy will include:
1. reconstruction of the breast on which the mastectomy I1as 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 coir~sin°ai~ce 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
~zarr-si»gfacility care; home heahh 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 Allowal~~ce A percentage of the reimbursement to a participating provider tlult is held back by
PIC. The amount withheld generally will be less than 20% of the ,fee schedT.rle
amount.
Sen~ice 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.
Slrilled Care Nursing or rehabilitation services requiring the skills of technical or professional
medical personnel to provide care or assess yoitir changing condition. Long teen
dependence on respiratory support equipment does not in and of itself define a need
for sl~~lled 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 ca3-e.
Specialist Pr°ovide~s other than those practicing i11 the areas of family practice, general practice,
internal medicine, OB/GYN or pediatrics.
Specialty Drugs Injectable and non-injectable pr-escriptio~~ 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 ad~lninistration requirements.
PIC07-740-R2 84 PCH10409 1500100.2RxF.V (1/10)
Stcu~dirrg refer°ral A process by which a merrrber 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 corztributior~ is paid; and
2. whose employment is the basis for membership, according to the G~11C; and
3. who is enrolled under the GMC.
Total Disability Disability (i.e., due to injury, sick~ress, or pregnancy) that requires regular care and
attendance of a physician, and in the opinion of the plrysiciar~ 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.
Trarrsplczrzt Ser~~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.
t~aiting 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 corrtinazous and creditable coverage.
`z'oua`Yorr~~
Refers to rrrernbar•.
PIC07-740-R2 85 PCH10409 1500.100.2RxF.V (1/10)