C REDITABLE C OVERAGE

Coverage provided through a group health plan and other specified coverage that meets or exceeds the actuarial value of standard Part D coverage. Entities that offer drug coverage are required to notify eligible individuals of whether their coverage qualifies as creditable.

C

C

Services that do not require special skills or training, such as:

• Providing assistance in activities of daily living (including, but not limited to, feeding, dressing, bathing, ostomy care, incontinence care, checking of routine vital signs, transferring and ambulating)

• Do not seek to cure, or which are provided during periods when the medi- cal condition of the patient who requires the service is not changing

• Do not require continued administration by trained medical personnel in order to be delivered safely and effectively

D

The amount an individual pays out-of-pocket before a health plan will begin to pay for approved healthcare services.

D

M

E

Equipment that can stand repeated use and is primarily used to serve a medical purpose at home or in the community. Examples include hospital beds, wheel- chairs, and oxygen equipment.

E

D

The defined date a covered person becomes eligible for benefits under an exist- ing contract or plan.

E

E

Charges for covered health services that are provided while the Plan is in effect. For network providers, eligible expenses are based on contracted rates with that

For certain covered health services, you are required to pay a portion of eligible expenses in the form of a copay and/or coinsurance.

E

I

S

Medical, surgical, diagnostic, psychiatric, substance abuse or other healthcare services, technologies, supplies, treatments, procedures, drug therapies, medi- cations or devices that, at the time UnitedHealthcare and the Employer make a determination regarding coverage in a particular case, are determined to be any of the following:

• Not approved by the U.S. Food and Drug Administration (FDA) to be law- fully marketed for the proposed use and not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispens- ing Information as appropriate for the proposed use

• Subject to review and approval by any institutional review board for the proposed use (Devices which are FDA approved under the Humanitarian

Use Device exemption are not considered to be Experimental or Investiga-

tional)

• The subject of an ongoing Clinical Trial that meets the definition of a Phase 1, 2 or 3 Clinical Trial set forth in the FDA regulations, regardless of whether the trial is subject to FDA oversight.

Exceptions:

• If you have a life threatening Sickness or condition (one that is likely to cause death within one year of the request for treatment), UnitedHealthcare and the Employer may, at their discretion, consider an otherwise Experimental or Investigational Service to be a Covered Health Service for that Sickness or condition. Prior to such consideration, Unit- edHealthcare and the Employer must determine that, although unproven, the service has significant potential as an effective treatment for that Sickness or condition, and that the service would be provided under standards equivalent to those defined by the National Institutes of Health.

F

A list of prescription medications that are covered by the prescription drug plan. In the case of the coverage provided through Express Scripts Medicare, it tells which commonly used Part D prescription drugs are covered by the plan. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. Medicare has

approved the Express Scripts Medicare Drug List. The Drug List also tells you if there are any rules that restrict coverage for covered drugs. The plan does not cover all prescription drugs. In some cases, the law does not allow any Medi- care plan to cover certain types of drugs. See your Evidence of Coverage for more information about the plan’s formulary.

G

D

A prescription drug that is approved by the Food and Drug Administration (FDA) as having the same active ingredient(s) as the brand-name drug. Generally, a generic drug works the same as a brand-name drug and usually costs less.

H

D

A pharmacy that fills prescriptions through the mail, often in greater quantities and at lesser cost than retail pharmacies. Many home delivery pharmacies are

affiliated with health plans.

H

H

C

Skilled services provided to individuals in their homes, including physical thera- py, occupational therapy, speech therapy, nursing care, and home health aide assistance with activities of daily living.

L

C

The highest amount of money that can be charged for a covered service by doc- tors and other providers who don’t accept assignment. Medicare’s limit is 15% over the approved amount. It does not apply to supplies or equipment.

M

N

Services or supplies that are proper, needed, and used for diagnosis or treat- ment of a medical condition and meet the standards of good medical practice.