i Table of Contents Summary Plan Description........................................................................1 What Is the Summary Plan Description? ..................................................................................................1 Can This SPD Change?............................................................................................................................1 Other Information You Should Have .........................................................................................................1 Introduction to Your SPD...........................................................................2 What Are Defined Terms?.........................................................................................................................2 How Do You Use This Document? ...........................................................................................................2 How Do You Contact the Claims Administrator? ......................................................................................2 Your Responsibilities.................................................................................3 Enrollment and Required Contributions ....................................................................................................3 Be Aware the Plan Does Not Pay for All Health Care Services................................................................3 Decide What Services You Should Receive .............................................................................................3 Choose Your Physician.............................................................................................................................3 Obtain Prior Authorization.........................................................................................................................3 Pay Your Share.........................................................................................................................................3 Pay the Cost of Excluded Services...........................................................................................................3 Show Your ID Card ...................................................................................................................................4 File Claims with Complete and Accurate Information ...............................................................................4 Use Your Prior Health Care Coverage......................................................................................................4 Claims Administrator and Plan Sponsor Responsibilities .....................5 Determine Benefits....................................................................................................................................5 Process Payment for the Plan's Portion of the Cost of Covered Health Care Services............................5 Process Plan Payment to Network Providers ...........................................................................................5 Process Plan Payment for Covered Health Care Services Provided by Out-of-Network Providers .........5 Review and Determine Benefits in Accordance with the Claims Administrator's Reimbursement Policies ..................................................................................................................................................................5 Offer Health Education Services to You....................................................................................................6 United Healthcare Services, Inc. ...............................................................7 Schedule of Benefits ..................................................................................7 How Do You Access Benefits? .................................................................................................................7 Does Prior Authorization Apply? ...............................................................................................................7 Care Management ....................................................................................................................................8 Special Note Regarding Medicare ............................................................................................................8 What Will You Pay for Covered Health Care Services?............................................................................8 Payment Term and Description Table.......................................................................................................9 Schedule of Benefits Table .....................................................................................................................12 Allowed Amounts ....................................................................................................................................34 Designated Network Benefits and Network Benefits...............................................................................35 Out-of-Network Benefits..........................................................................................................................35 Advocacy Services..................................................................................................................................36 Provider Network.....................................................................................................................................37 Designated Providers..............................................................................................................................37 Health Care Services from Out-of-Network Providers Paid as Network Benefits ...................................38 Limitations on Selection of Providers......................................................................................................38 Section 1: Covered Health Care Services ..............................................39 When Are Benefits Available for Covered Health Care Services?..........................................................39 Ambulance Services ...............................................................................................................................39 Cellular and Gene Therapy.....................................................................................................................40 Chronic Pain Management......................................................................................................................40