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This Amendment Applies to Services on and after January 1, 2003


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Medica

Option and Cost-Sharing Table

This Amendment Applies to Services on and after January 1, 2003


  • Active employees and their covered dependents

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

  • Retirees, disabled former employees and their covered dependents eligible for Medicare

Medica Choice Classic

Beginning for services received on or after January 1, 2003, benefit levels for network care will be the same – whether you refer yourself to network providers or a Primary Care Provider (PCP) at your Primary Care Clinic (PCC) directs your care. In other words, you no longer will see a distinction between Tier I and Tier II benefits. The product name is “Medica Choice Classic.” It is an open access plan. Open access means that referrals are not mandatory – though it is still recommended that you maintain an ongoing relationship with a PCC/PCP.


The following notations in the Self-Insured Managed-Care Option for Unisys Participants in Designated Geographic Locations Supplement to the Summary Plan Description for Medial plans sponsored by Unisys no longer will apply for services on and after January 1, 2003:

  • Note for Medica Self-Insured: Medica allows you to refer yourself to network providers without referral from your PCC. This is called “self-referral.” Tier II benefits apply for all covered services directly from the self-referral provider as well as all covered services ordered or coordinated by the self-referral provider. Copayments and coinsurance are higher under Tier II than when you obtain a referral from your PCC (Tier I).

  • Sentence two of Paragraph two before the Cost-Sharing Table that begin on page 30 of the Supplement

Tier II benefits apply for all covered services received directly from the self-referral provider, as well as all covered services ordered or coordinated by the self-referral provider.

  • The Cost-Sharing table shown on pages 30 to 37. This table is replaced with the following Cost-Sharing Table.


Standard office visit copayments

With this change is a standardization of copayments for office visits:



  • $10/visit to a network primary care physician – a Family Practice Physician, an Internist, a Pediatrician or a General Practice Physician

  • $15/visit to a network specialist.


Maximum out-of-pocket cost protection

Effective retroactive to services provided on or after January 1, 2002, a $750 per person annual out-of-pocket maximum applies.



  • For services received in 2002, the maximum applies to Tier I benefits – services provided by or directed by your PCC/PCP (out-of-pocket costs noted below do not count toward the annual out-of-pocket maximum)

  • For services received on or after January 1, 2003, the maximum applies to your share of all covered services.

Once you reach your annual out-of-pocket maximum, the Plan pays 100 percent of covered expenses


There is no out-of-pocket maximum protection for the expenses noted below. In other word, these expenses are not paid at 100 percent once the annual out-of-pocket maximum is met.

  • Copayments for prescription drugs or the difference between a brand-name price and the established generic unit price when a generic drug is available

  • Charges for services that are not medically necessary.

  • Expenses not covered under the Plan.

  • The $10 or $15 copayment for covered visits to a network physician or urgent care center.

Medica Cost-Sharing Table

The following chart outlines benefits for those enrolled in the Medica option as an active employee, a retiree, a disabled former employee, or an enrolled dependent of an active employee, retiree, or disabled former employee.


For retirees, disabled former employees, and their covered dependents eligible for Medicare, plan benefits are payable after copayments and Medicare payments are considered.
This chart is just a summary of the benefits. Some services may have limits. Specific conditions, limits and exclusions are detailed in the Supplement.



Medica Cost-Sharing Table

Feature

Cost-Sharing for services on or after 1/01/2003
Annual Deductible

None
Annual Out-of-Pocket Limit

$750

see exclusions noted above


Lifetime Maximum Benefit

None

Precertification

If required, network provider handles for you, except treatment for medical emergency or urgent medical need when care is received outside the Medica service area by a non-network provider

Network Physician Visits for Preventive Services

You pay $10/visit to PCC/PCP or $15/visit to a specialist,
then Plan pays 100%

  • Routine visits, age 18 and older (annual)

You pay $10/visit to PCC/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

You pay $10/visit to PCC/PCP or $15/visit to specialist,
then Plan pays 100%

  • Vision

  • Examination by network optometrist or ophthalmologist; no referral required; frequency based on Medica guidelines

You pay $15/visit,
then Plan pays 100%

    • Eyewear

Not covered;

Discount arrangements are available through the Plan


Network Physician Visits Other Than Preventive Services

  • Treatment of illness or injury

You pay $10/visit to PCC/PCP or $15/visit to specialist,
then Plan pays 100%

  • Office surgery

You pay $10/visit to PCC/PCP or $15/visit to specialist,
then Plan pays 100%

  • Office lab and x-ray

Plan pays 100%

Plan pays 100%


  • Allergy testing and treatment

You pay $10/visit to PCC/PCP or $15/visit to specialist,
then Plan pays 100%
Network Convenient/Urgent Care Centers

  • Services after normal PCC hours

You pay $10/visit,
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

Plan pays 100% after the hospital copayment
Network Alternatives to Inpatient Care

  • Skilled nursing facility
    (maximum of 90 days/lifetime)

You pay 20%,

then Plan pays 80%;


after out-of-pocket maximum met, Plan pays 100%

  • Home-health care

You pay 20%,

then Plan pays 80%;


after out-of-pocket maximum met, Plan pays 100%;

For high-risk prenatal care, Plan pays 100%



  • Home IV therapy

You pay 20%,

then Plan pays 80%;

after out-of-pocket maximum met, Plan pays 100%


  • Inpatient hospice for palliative care of terminally ill

Plan pays 100%

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 network 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 on page 52 of 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 PCC/PCP

Not covered

You pay $100,

then Plan pays 100%



  • Follow-up care with PCC/PCP or referral specialist

You pay $10/visit for PCC/PCP or $15/visit for specialist,
then Plan pays 100%

  • Ambulance (see definitions of ambulance, page 50, and medical emergency, page 52 of the Supplement)

  • For a medical emergency

You pay 20%,

then Plan pays 80%;

after out-of-pocket maximum met, Plan pays 100%



  • For non-emergency transportation approved by Medica and recommended by a network provider

You pay 20%,

then Play pays 80%;

after out-of-pocket maximum met, Plan pays 100%
otherwise, not covered

Network Treatment for Mental Health Conditions by Network Providers: must be precertified by UBH @ 1-800-848-8327

You pay standard 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)

Network Treatment for Substance Abuse Conditions by Network Providers: must be precertified by UBH @ 1-800-848-8327

  • Detoxification

You pay standard hospital copayment,
then Plan pays 100%

  • Inpatient hospital or specialized treatment facility

You pay standard 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 visits

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

You pay $10/visit to PCC/PCP or $15/visit to a network specialist M.D.,
then Plan pays 100%;

maximum 15 visits per year



  • 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;
Medica Medical Director can authorize additional therapy, provided the conditions noted to the left continue to apply

  • Communication or interpretation services for a ventilator-dependent patient during an inpatient stay

Plan pays 100%,

up to 120 hours/lifetime



  • Dental services

Limited to:

  • surgical procedures commonly viewed as medical rather than dental in nature (same benefits as other outpatient surgery)

  • certain services or supplies for an accidental injury to sound natural teeth if the service is done or supply provided as part of the initial emergency treatment (same benefits as other emergency treatment)

Other dental procedures are not covered

  • Diabetes self-management training and education

  • Medical nutrition therapy

  • Program consistent with national standards established by the American Diabetes Association




You pay $10/visit to PCC/PCP or $15/visit to specialist,
then Plan pays 100%

  • Durable medical equipment (DME)

Plan pays 100% for initial DME;

For replacement, repair, or revision of artificial eyes, limbs, and breast prosthesis made necessary by normal wear and usage, you pay 20%,

then Plan pays 80%;

after out-of-pocket maximum met, Plan pays 100%



  • 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

  • Miscellaneous covered medical services – some examples include, but are not limited to:

  • Blood clotting factors (Factors VIII and IX)

  • Levonorgestrel (i.e. Norplant); limited to 1 implant every 3 years

  • Total parenteral nutrition




You pay 20%,

then Plan pays 80%;

after out-of-pocket maximum met, Plan pays 100%


  • Nutritional supplements for the treatment of PKU

You pay 20%,

then Plan pays 80%;

after out-of-pocket maximum met, Plan pays 100%


  • Prosthetic devises; limited to items noted on pages 68 and 69 of the Supplement.

Plan Pays 100% for 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

Plan pays 100%

  • 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 15 visits/therapy/condition; Medica Medical Director or designee can authorize additional therapy, provided the conditions noted to the left continue to apply

  • Treatment to lighten or remove the coloration of a port wine stain

You pay $10/visit to PCC/PCP or $15/visit to a specialist,
then Plan pays 100%


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