Drivetime Automotive Group, Inc.
Choice Plus Traditional Plan
Effective: January 1, 20178
Group Number: 709715
Drivetime Automotive Group, Inc. Medical Choice Plus Traditional Plan
RIGHT HAND PAGETABLE OF CONTENTS
SECTION 1 - WELCOME 1
SECTION 2 - INTRODUCTION 3
Eligibility 3
Cost of Coverage 4
How to Enroll 4
When Coverage Begins 4
Changing Your Coverage 5
SECTION 3 - HOW THE PLAN WORKS 7
Accessing Benefits 7
Eligible Expenses 10
Annual Deductible 12
Copayment 12
Coinsurance 12
Out-of-Pocket Maximum 12
SECTION 4 - PERSONAL HEALTH SUPPORT 14
Requirements for Notifying Personal Health Support 15
Special Note Regarding Medicare 16
SECTION 5 - PLAN HIGHLIGHTS 17
Payment Terms and Features 17
Schedule of Benefits 20
SECTION 6 - ADDITIONAL COVERAGE DETAILS 31
Acupuncture Services 31
Allergy Care 32
Ambulance Services 32
Clinical Trials 32
Congenital Heart Disease (CHD) Surgeries 34
Dental Services - Accident Only 36
Diabetes Services 37
Durable Medical Equipment (DME) 37
Emergency Health Services - Outpatient 39
Hearing Aids 39
Home Health Care 40
Hospice Care 40
Hospital - Inpatient Stay 41
Lab, X-Ray and Diagnostics - Outpatient 41
Lab, X-Ray and Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine - Outpatient 42
Mental Health Services 42
Neurobiological Disorders - Autism Spectrum Disorder Services 43
Nutritional Counseling 44
Obesity Surgery 45
Ostomy Supplies 46
Pharmaceutical Products - Outpatient 46
Physician Fees for Surgical and Medical Services 47
Physician's Office Services - Sickness and Injury 47
Pregnancy - Maternity Services 48
Preventive Care Services 49
Prosthetic Devices 50
Reconstructive Procedures 50
Rehabilitation Services - Outpatient Therapy and Manipulative Treatment 51
Scopic Procedures - Outpatient Diagnostic and Therapeutic 54
Skilled Nursing Facility/Inpatient Rehabilitation Facility Services 54
Smoking Cessation 55
Substance-Related and Addictive Disorders Services 56
Surgery - Outpatient 57
Temporomandibular Joint (TMJ) Services 57
Therapeutic Treatments - Outpatient 58
Transplantation Services 59
Travel and Lodging 59
Urgent Care Center Services 61
Vision Examinations 61
Wigs 61
SECTION 7 - Clinical Programs and Resources 62
Consumer Solutions and Self-Service Tools 62
Disease and Condition Management Services 64
Wellness Programs 65
SECTION 8 - EXCLUSIONS AND LIMITATIONS: WHAT THE MEDICAL PLAN WILL NOT COVER 67
Alternative Treatments 67
Dental 68
Devices, Appliances and Prosthetics 69
Drugs 69
Experimental or Investigational or Unproven Services 70
Foot Care 71
Medical Supplies and Equipment 71
Mental Health, Neurobiological Disorders - Autism Spectrum Disorder and Substance-Related and Addictive Disorders Services 72
Nutrition 72
Personal Care, Comfort or Convenience 73
Physical Appearance 74
Procedures and Treatments 74
Providers 76
Reproduction 76
Services Provided under Another Plan 77
Transplants 77
Travel 77
Types of Care 78
Vision and Hearing 78
All Other Exclusions 79
SECTION 9 - CLAIMS PROCEDURES 81
Network Benefits 81
Non-Network Benefits 81
Prescription Drug Benefit Claims 81
If Your Provider Does Not File Your Claim 81
Health Statements 83
Explanation of Benefits (EOB) 83
Claim Denials and Appeals 84
Federal External Review Program 85
Limitation of Action 91
SECTION 10 - COORDINATION OF BENEFITS (COB) 92
Determining Which Plan is Primary 92
When This Plan is Secondary 94
When a Covered Person Qualifies for Medicare 94
Right to Receive and Release Needed Information 95
Overpayment and Underpayment of Benefits 95
SECTION 11 - SUBROGATION AND REIMBURSEMENT 97
Right of Recovery 100
SECTION 12 - WHEN COVERAGE ENDS 102
Coverage for a Disabled Child 103
Extended Coverage for Total Disability 103
Continuing Coverage Through COBRA 104
When COBRA Ends 108
Uniformed Services Employment and Reemployment Rights Act 108
SECTION 13 - OTHER IMPORTANT INFORMATION 110
Qualified Medical Child Support Orders (QMCSOs) 110
Your Relationship with UnitedHealthcare and Drivetime Automotive Group, Inc. 110
Relationship with Providers 111
Your Relationship with Providers 112
Interpretation of Benefits 112
Information and Records 112
Incentives to Providers 113
Incentives to You 114
Rebates and Other Payments 114
Workers' Compensation Not Affected 114
Future of the Plan 114
Plan Document 115
Review and Determine Benefits in Accordance with UnitedHealthcare Reimbursement Policies 115
SECTION 14 - GLOSSARY 116
SECTION 15 - OUTPATIENT PRESCRIPTION DRUGS 130
Schedule of Benefits 130
Identification Card (ID Card) - Network Pharmacy 132
Benefit Levels 133
Retail 134
Mail Order 134
Benefits for Preventive Care Medications 135
Designated Pharmacies 135
Assigning Prescription Drug Products to the PDL 136
Prescription Drug Benefit Claims 137
Limitation on Selection of Pharmacies 137
Supply Limits 137
Special Programs 137
Prescription Drug Products Prescribed by a Specialist Physician 137
Step Therapy 137
Rebates and Other Discounts 138
Coupons, Incentives and Other Communications 138
Exclusions - What the Prescription Drug Plan Will Not Cover 138
Glossary - Outpatient Prescription Drugs 141
SECTION 16 - IMPORTANT ADMINISTRATIVE INFORMATION: ERISA 144
ATTACHMENT I - HEALTH CARE REFORM NOTICES 147
Patient Protection and Affordable Care Act ("PPACA") 147
ATTACHMENT II - LEGAL NOTICES 148
Women's Health and Cancer Rights Act of 1998 148
Statement of Rights under the Newborns' and Mothers' Health Protection Act 148
ATTACHMENT III – NONDISCRIMINATION AND ACCESSIBILITY REQUIREMENTS 149
ATTACHMENT IV – GETTING HELP IN OTHER LANGUAGES OR FORMATS 151
ADDENDUM - PARENTSTEPS® 158
Introduction 158
What is ParentSteps®? 158
Registering for ParentSteps® 158
Selecting a Contracted Provider 159
Visiting Your Selected Health Care Professional 159
Obtaining a Discount 159
Speaking with a Nurse 159
Additional ParentSteps® Information 159
SECTION 1 - WELCOME 1
SECTION 2 - INTRODUCTION 3
Eligibility 3
Cost of Coverage 4
How to Enroll 4
When Coverage Begins 4
Changing Your Coverage 5
SECTION 3 - HOW THE PLAN WORKS 7
Accessing Benefits 7
Eligible Expenses 10
Annual Deductible 12
Copayment 12
Coinsurance 12
Out-of-Pocket Maximum 12
SECTION 4 - PERSONAL HEALTH SUPPORT 14
Requirements for Notifying Personal Health Support 15
Special Note Regarding Medicare 16
SECTION 5 - PLAN HIGHLIGHTS 17
Payment Terms and Features 17
Schedule of Benefits 20
SECTION 6 - ADDITIONAL COVERAGE DETAILS 29
Acupuncture Services 29
Allergy Care 30
Ambulance Services 30
Clinical Trials 30
Congenital Heart Disease (CHD) Surgeries 32
Dental Services - Accident Only 34
Diabetes Services 35
Durable Medical Equipment (DME) 35
Emergency Health Services - Outpatient 37
Hearing Aids 38
Home Health Care 38
Hospice Care 39
Hospital - Inpatient Stay 39
Lab, X-Ray and Diagnostics - Outpatient 40
Lab, X-Ray and Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine - Outpatient 40
Mental Health Services 40
Neurobiological Disorders - Autism Spectrum Disorder Services 42
Nutritional Counseling 43
Obesity Surgery 44
Ostomy Supplies 44
Pharmaceutical Products - Outpatient 44
Physician Fees for Surgical and Medical Services 45
Physician's Office Services - Sickness and Injury 45
Pregnancy - Maternity Services 46
Preventive Care Services 47
Prosthetic Devices 48
Reconstructive Procedures 48
Rehabilitation Services - Outpatient Therapy and Manipulative Treatment 49
Scopic Procedures - Outpatient Diagnostic and Therapeutic 52
Skilled Nursing Facility/Inpatient Rehabilitation Facility Services 52
Smoking Cessation 53
Substance-Related and Addictive Disorders Services 54
Surgery - Outpatient 55
Temporomandibular Joint (TMJ) Services 56
Therapeutic Treatments - Outpatient 56
Transplantation Services 57
Travel and Lodging 58
Urgent Care Center Services 59
Vision Examinations 59
Wigs 59
SECTION 7 - RESOURCES TO HELP YOU STAY HEALTHY 60
Consumer Solutions and Self-Service Tools 60
Disease and Condition Management Services 63
Wellness Programs 64
SECTION 8 - EXCLUSIONS AND LIMITATIONS: WHAT THE MEDICAL PLAN WILL NOT COVER 66
Alternative Treatments 66
Dental 67
Devices, Appliances and Prosthetics 68
Drugs 68
Experimental or Investigational or Unproven Services 69
Foot Care 70
Medical Supplies and Equipment 70
Mental Health, Neurobiological Disorders - Autism Spectrum Disorder and Substance-Related and Addictive Disorders Services 71
Nutrition 72
Personal Care, Comfort or Convenience 72
Physical Appearance 73
Procedures and Treatments 74
Providers 75
Reproduction 75
Services Provided under Another Plan 76
Transplants 76
Travel 76
Types of Care 77
Vision and Hearing 77
All Other Exclusions 78
SECTION 9 - CLAIMS PROCEDURES 80
Network Benefits 80
Non-Network Benefits 80
Prescription Drug Benefit Claims 80
If Your Provider Does Not File Your Claim 80
Health Statements 82
Explanation of Benefits (EOB) 82
Claim Denials and Appeals 83
Federal External Review Program 84
Limitation of Action 90
SECTION 10 - COORDINATION OF BENEFITS (COB) 91
Determining Which Plan is Primary 91
When This Plan is Secondary 93
When a Covered Person Qualifies for Medicare 93
Right to Receive and Release Needed Information 94
Overpayment and Underpayment of Benefits 94
SECTION 11 - SUBROGATION AND REIMBURSEMENT 96
Right of Recovery 99
SECTION 12 - WHEN COVERAGE ENDS 100
Coverage for a Disabled Child 101
Extended Coverage for Total Disability 101
Continuing Coverage Through COBRA 102
When COBRA Ends 106
Uniformed Services Employment and Reemployment Rights Act 106
SECTION 13 - OTHER IMPORTANT INFORMATION 108
Qualified Medical Child Support Orders (QMCSOs) 108
Your Relationship with UnitedHealthcare and Drivetime Automotive Group, Inc. 108
Relationship with Providers 109
Your Relationship with Providers 110
Interpretation of Benefits 110
Information and Records 110
Incentives to Providers 111
Incentives to You 112
Rebates and Other Payments 112
Workers' Compensation Not Affected 112
Future of the Plan 112
Plan Document 113
SECTION 14 - GLOSSARY 114
SECTION 15 - OUTPATIENT PRESCRIPTION DRUGS 127
Schedule of Benefits 127
Identification Card (ID Card) - Network Pharmacy 129
Benefit Levels 130
Retail 131
Mail Order 131
Benefits for Preventive Care Medications 132
Designated Pharmacies 132
Assigning Prescription Drug Products to the PDL 133
Prescription Drug Benefit Claims 134
Limitation on Selection of Pharmacies 134
Supply Limits 134
Special Programs 134
Prescription Drug Products Prescribed by a Specialist Physician 134
Step Therapy 134
Rebates and Other Discounts 135
Coupons, Incentives and Other Communications 135
Exclusions - What the Prescription Drug Plan Will Not Cover 135
Glossary - Outpatient Prescription Drugs 138
SECTION 16 - IMPORTANT ADMINISTRATIVE INFORMATION: ERISA 141
ATTACHMENT I - HEALTH CARE REFORM NOTICES 144
Patient Protection and Affordable Care Act ("PPACA") 144
ATTACHMENT II - LEGAL NOTICES 145
Women's Health and Cancer Rights Act of 1998 145
Statement of Rights under the Newborns' and Mothers' Health Protection Act 145
ATTACHMENT III – Nondiscrimination and Accessibility Requirements 146
ATTACHMENT IV – GETTING HELP IN OTHER LANGUAGES OR FORMATS 148
ADDENDUM - UNITEDHEALTH ALLIES 155
Introduction 155
What is UnitedHealth Allies? 155
Selecting a Discounted Product or Service 155
Visiting Your Selected Health Care Professional 155
Additional UnitedHealth Allies Information 156
ADDENDUM - PARENTSTEPS® 157
Introduction 157
What is ParentSteps®? 157
Registering for ParentSteps® 157
Selecting a Contracted Provider 158
Visiting Your Selected Health Care Professional 158
Obtaining a Discount 158
Speaking with a Nurse 158
Additional ParentSteps® Information 158
vi Table of Contents
Drivetime Automotive Group, Inc. Medical Choice Plus Traditional Plan
SECTION 1 - WELCOME
Quick Reference Box
■ Member services, claim inquiries, Personal Health Support and Mental Health/Substance-Related and Addictive Disorders Administrator: 1-800-842-5658.
■ Claims submittal address: UnitedHealthcare - Claims, P.O. Box 30555, Salt Lake City, UT 84130-0555.
■ Online assistance: www.myuhc.com.
Drivetime Automotive Group, Inc. is pleased to provide you with this Summary Plan Description (SPD), which describes the health Benefits available to you and your covered family members under the Drivetime Automotive Group, Inc. Welfare Benefit Plan. It includes summaries of:
■ Who is eligible.
■ Services that are covered, called Covered Health Services.
■ Services that are not covered, called Exclusions and Limitations.
■ How Benefits are paid.
■ Your rights and responsibilities under the Plan.
This SPD is designed to meet your information needs and the disclosure requirements of the Employee Retirement Income Security Act of 1974 (ERISA). It supersedes any previous printed or electronic SPD for this Plan.
Drivetime Automotive Group, Inc. intends to continue this Plan, but reserves the right, in its sole discretion, to modify, change, revise, amend or terminate the Plan at any time, for any reason, and without prior notice subject to any collective bargaining agreements between the Employer and various unions, if applicable. This SPD is not to be construed as a contract of or for employment. If there should be an inconsistency between the contents of this summary and the contents of the Plan, your rights shall be determined under the Plan and not under this summary.
UnitedHealthcare is a private healthcare claims administrator. UnitedHealthcare's goal is to give you the tools you need to make wise healthcare decisions. UnitedHealthcare also helps your employer to administer claims. Although UnitedHealthcare will assist you in many ways, it does not guarantee any Benefits. Drivetime Automotive Group, Inc. is solely responsible for paying Benefits described in this SPD.
Please read this SPD thoroughly to learn how the Drivetime Automotive Group, Inc. Welfare Benefit Plan works. If you have questions contact your Benefits Representative or call the number on the back of your ID card.
How To Use This SPD
■ Read the entire SPD, and share it with your family. Then keep it in a safe place for future reference.
■ Many of the sections of this SPD are related to other sections. You may not have all the information you need by reading just one section.
■ You can find copies of your SPD and any future amendments or request printed copies by contacting your Benefits Representative.
■ Capitalized words in the SPD have special meanings and are defined in Section 14, Glossary.
■ If eligible for coverage, the words "you" and "your" refer to Covered Persons as defined in Section 14, Glossary.
■ Drivetime Automotive Group, Inc. is also referred to as Company.
■ If there is a conflict between this SPD and any benefit summaries (other than Summaries of Material Modifications) provided to you, this SPD will control.
2 Section 1 - Welcome
Drivetime Automotive Group, Inc. Medical Choice Plus Traditional Plan