April 12, 2024 • UMR CARE: Clinical Advocacy Relationships to Empower: UMR’s specialty injectables program name was updated to UMR Medical Specialty Drug Program. Language was updated to be applied more broadly and also account for customers who modify the program in the following section(s): ➢ Services Requiring Prior Authorization • UMR CARE: Clinical Advocacy Relationships to Empower: ➢ Language has been added to the following areas to provide flexibility in accommodating certain providers that may not be required to obtain prior authorization on certain services: o Prior Authorization / Notification Requirements. o Definitions. o Penalties for Not Obtaining Prior Authorization. o Retrospective Review. ➢ Prior Authorization / Notification Requirements: Language has been enhanced to better define the roles and responsibilities of the member and provider. ➢ Special Notes: Language has been clarified to provide a more accurate description pertaining to prior authorization notification in emergency circumstances. ➢ Definitions: A Managed Care UnitedHealthcare Network Provisions definition has been added. ➢ Services Requiring Prior Authorization: Access via the website for prior authorizations before receiving services has been added. ➢ Ongoing Condition CARE: Language has been revised to remove the specific reference to high- risk since members do not need to know which risks receive outreach. • Coordination of Benefits: ➢ The types of plans that the plan will coordinate benefits with has been revised to align with the national standard Coordination of Benefit rules. ➢ The bullet regarding married dependent children has been clarified. In order to reduce plan-to- plan conflicts for Coordination of Benefits rules, this change has been made to confirm the plan’s alignment with the national standard Coordination of Benefits rules, which were revised to apply the longer/shorter rule in those situations where a child is covered simultaneously as a dependent until age 26 under both a parent’s plan and a spouse’s plan. • Right of Subrogation, Reimbursement, and Offset: ➢ References to “You” or “Your” have been clarified. ➢ Language has been revised to use the broader term “recoveries” versus “settlement funds.” ➢ “Alleged/Allegedly” language has been added to reduce the burden of proof. ➢ Language has been added for cases of occupational illness or injury. • General Exclusions: ➢ Language has been clarified as exclusions relate to the No Surprises Act. ➢ Self-Administered Services: Language has been revised to clarify that the exclusion generally includes self-infused medications, with certain exceptions. ➢ Workers’ Compensation language has been revised to reflect current industry standard language that appropriately accommodates the varying regulatory requirements for entities to have applicable coverages in place. • Claims and Appeal Procedures: ➢ Types of Claims and Definitions: Pre-Service claim language has been revised to clarify that either the Covered Person or the provider is to obtain approval. ➢ How Health Benefits Are Calculated: Language has been added to refer to the Protection from Balance Billing section. ➢ Reimbursement: Language changes have been made for consistency and alignment for out-of- network reimbursement program methodologies. • Glossary of Terms: ➢ Ambulance Transportation language has been clarified for coverage of emergency ambulance transportation to an appropriate hospital for consistency with No Surprises Act coverage of emergencies. ➢ Medical Specialty Medications (including gene therapy and CAR-T therapy) has been changed to align with internal processes and to account for drugs that may not be injectables / infusions.