United Healthcare EPO Option and Cost-Sharing Table

United Healthcare EPO

Option and Cost-Sharing Table

§  Active employees and their covered dependents

§  Retirees, disabled former employees and their covered dependents NOT eligible for Medicare

United Healthcare EPO Option and Cost-Sharing Table

United Healthcare EPO Option

Beginning effective January 1, 2002, United Healthcare EPO networks in selected locations are offered as a medical option to active employees and certain former employees of Unisys.

Unisys has contracted with United Health Group, a third-party administrator (TPA) for claims processing, precertification, utilization review, member services, grievance resolution, and a provider network under the United Healthcare EPO option available through Unisys. United:

§  Has a network of physicians, hospitals, and health-care centers that are available as part of the United Healthcare EPO option available through Unisys,

§  Follows a credentialing process before a provider is admitted to their network; and

§  Monitors the performance of their network providers.

Neither Unisys nor United Healthcare engages in the performance or delivery of medical, hospital services, or other types of health-care services. United has contractual agreements with their network providers to furnish covered services within the scope of their licenses to plan members. Neither Unisys nor United guarantee the professional services of the providers. The selection of a provider and the decision to receive or decline health-care services is solely your decision and responsibility.

This document serves as an amendment to the Self-Insured Managed-Care Option for Unisys Participants in Designated Geographic Locations Supplement to the Summary Plan Description for Medical Plans Sponsored by Unisys, dated January 2001 (Supplement). This information, together with:

§  The Supplement,

§  The Health and Welfare Summary Plan Description booklet,

§  Summary of Plan Changes booklets that describe changes to the Unisys Health and Welfare Plans

serve as the plan document and summary plan description for the United Healthcare EPO option.

United Healthcare EPO Cost-Sharing Table

The following chart outlines benefits for those enrolled in the United Healthcare EPO self-insured option as an active employee, including enrolled eligible dependents. It also applies to those not eligible for Medicare enrolled as an eligible retiree or disabled former employee, including their enrolled dependents not eligible for Medicare. All care must be received from a network provider in order for you to receive benefits. This chart is just a summary of the benefits. Some services may have limits. Specific conditions, limits and exclusions are detailed in the Supplement to the Summary Plan Description booklet (SPD).

United Healthcare EPO Cost-Sharing Table /
Feature / Cost-Sharing /
Annual Deductible
/ None
Annual Out-of-Pocket Limit
/ None
Lifetime Maximum Benefit
/ None
Precertification / Network provider handles for you, except treatment for medical emergency or urgent medical need when care is received outside the United service area by a non-network provider
Network Physician Visits for Preventive Services
§  Well-child care; frequency/type based on United Healthcare EPO guidelines / You pay $10/visit to PCP or $15/visit to a specialist,
then Plan pays 100%
§  Routine visits, age 18 and older (annual) / You pay $10/visit to PCP or $15/visit to a specialist,
then Plan pays 100%
§  Well-woman exam (annual) / You pay $10/visit to network OB/GYN,
then Plan pays 100%
§  Prenatal care / You pay $15 for first office visit to network OB/GYN,
then Plan pays 100% for all prenatal care thereafter
§  Cancer screenings (physician services only); frequency/type based on United. Healthcare guidelines / You pay $10/visit to PCP or $15/visit to specialist,
then Plan pays 100%
§  Vision
§  Examination by network optometrist or ophthalmologist; no referral required; frequency based on United Healthcare guidelines / You pay $15/visit,
then Plan pays 100%
§  Eyewear / Not covered
Network Physician Visits Other Than Preventive Services
§  Treatment of illness or injury / You pay $10/visit to PCP or $15/visit to specialist,
then Plan pays 100%
§  Office surgery / You pay $10/visit to PCP or $15/visit to referral specialist,
then Plan pays 100%
§  Office lab and x-ray
§  Billed with office visit
§  No office visit when services rendered / Plan pays 100%
You pay $15/test or x-ray;
then Plan pays 100%
§  Allergy testing and treatment / You pay $10/visit to PCP or $15/visit to specialist,
then Plan pays 100%
Inpatient Network Hospital Services
§  Hospital semi-private room & board and ancillary services / You pay $250/admission,
(not applicable for re-admission within 30 days for the same condition; $750 maximum/person/year),
then Plan pays 100%
§  Lab and x-ray / Plan pays 100% after the hospital copayment
§  Surgeons' charges / Plan pays 100% after the hospital copayment
§  Physician hospital visits / Plan pays 100% after the hospital copayment
§  Anesthesia / Plan pays 100% after the hospital copayment
§  Delivery — normal or C-section / Plan pays 100% after the hospital copayment
Network Alternatives to Inpatient Care: Precertification required
§  Skilled nursing facility
(maximum of 90 days/lifetime) / Plan pays 100% after the hospital copayment
§  Home-health care / Plan pays 100%
§  Home IV therapy / Plan pays 100%
§  Inpatient hospice for palliative care of terminally ill / Plan pays 100% after the hospital copayment
Outpatient Services (treatment and services by network providers performed in a network facility other than in the physician’s office or as an inpatient in a hospital)
§  Surgery, including surgeon
and facility / You pay $100/procedure,
then Plan pays 100%
§  Independent lab and x-ray facilities / You pay $15/test or x-ray,
then Plan pays 100%
§  Hospital emergency room (medical emergency defined in the Supplement)
§  For treatment of a medical emergency / You pay $50/visit
(waived if admitted within 24 hours for the same condition),
then Plan pays 100%
§  For non-emergency care not authorized in advance by PCP / Not covered
§  Hospital observation room for up to 24 hours without admission / Same as outpatient hospital emergency room services
§  Follow-up care with PCP or referral specialist / You pay $10/visit for PCP or $15/visit for specialist,
then Plan pays 100%
§  Ambulance (ambulance and medical emergency defined in the Supplement)
§  For a medical emergency / Plan pays 100%
§  For non-emergency transportation approved by United and recommended by a network provider / Play pays 100%;
otherwise, not covered
Treatment for Mental Health Conditions by Network Providers
§  Inpatient hospital or specialized treatment facility / You pay hospital copayment,
then Plan pays 100%;
up to 30 days/year, up to 90 days/lifetime;
annual and lifetime maximums include inpatient care for detoxification and treatment of substance abuse conditions (each day in a partial-day treatment program counts as an inpatient day)
§  Physician inpatient visits / Plan pays 100%,
up to 30 days/year, up to 90 days/lifetime;
annual and lifetime maximums include inpatient care for detoxification and treatment of substance abuse conditions
§  Office/outpatient visits / You pay $15/visit,
then Plan pays 100%;
up to 30 visits/year
(individual, family, group or other visits count as one visit)
Treatment for Substance Abuse Conditions by Network Providers
§  Detoxification / You pay hospital copayment,
then Plan pays 100%
§  Inpatient hospital or specialized treatment facility / You pay hospital copayment,
then Plan pays 100%;
up to 30 days/year, up to 90 days/lifetime;
annual and lifetime maximums include inpatient care for detoxification and treatment of mental health conditions (each day in a partial-day treatment program counts as an inpatient day)
§  Physician inpatient visits / Plan pays 100%;
up to 30 days/year, up to 90 days/lifetime;
annual and lifetime maximums include inpatient care for detoxification and treatment of mental health conditions
§  Outpatient rehabilitation / You pay $15/visit for referral specialist,
then Plan pays 100%;
up to 30 visits/year;
(individual, family, group or other visits count as one visit)
Other Network Services and Supplies
§  Acupuncture
only when provided by a physician for anesthesia in connection with a covered surgery / Plan pays 100%
§  Chiropractic services
§  Only for short-term treatment when there is a reasonable expectation that a condition will improve over a short-predictable period of time
§  Does not include maintenance or palliative care / You pay $15/visit for network provider,
then Plan pays 100%;
up to 15 visits within 60 consecutive days/incidence, measured from start of treatment;
United Healthcare Medical Director can authorize additional therapy, provided the conditions noted to the left continue to apply
§  Dental services / You pay $100/procedure for surgical removal of partial or fully bony impacted wisdom tooth or tumors, then Plan pays 100%; other dental procedures are not covered
§  Diabetes self-management training and education
§  Educational tools
§  Blood glucose monitor
§  Program consistent with national standards established by the American Diabetes Association / You pay $10/visit to PCP or $15/visit to specialist,
then Plan pays 100%
§  Durable medical equipment (DME) / Plan pays 100% for precertified DME when obtained from network DME vendors
§  Infertility treatments:
limited to the diagnosis and treatment of medical conditions resulting in infertility and treatment to return the body to normal bodily function / Covered the same as treatment for other conditions
§  Nutritional supplements for the treatment of PKU / Plan pays 100%
§  Prosthetic devises; limited to items noted in the Supplement. / Plan Pays 100% for precertified covered prosthetic devices when obtained from network vendors;
Covered wigs limited to $350 per year
§  Reconstructive and restorative surgery that is not cosmetic in nature / Same as other surgery
§  Rehabilitative services: cognitive, physical, occupational, pulmonary, and speech therapy
§  Only for short-term treatment when there is a reasonable expectation that a condition will improve over a short, predictable period of time
§  Only to restore function lost through illness or injury
§  Does not include maintenance or palliative care / You pay $15/visit,
then Plan pays 100%;
up to 60 consecutive days/condition, measured from start of treatment;
United Healthcare Medical Director can authorize additional therapy,
provided the conditions noted to the left continue to apply