SUMMARY PLAN DESCRIPTION

City of Orlando Choice Plan

Effective: January 1, 2025

Group Number: 706664

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CITY OF ORLANDO MEDICAL CHOICE

i TABLE OF CONTENTS

TABLE OF CONTENTS

SECTION 1 - WELCOME

SECTION 2 - INTRODUCTION

Eligibility

Cost of Coverage

How to Enroll

When Coverage Begins

Changing Your Coverage

SECTION 3 - HOW THE PLAN WORKS

Accessing Benefits

Eligible Expenses

Annual Deductible

Copayment

Out-of-Pocket Maximum

How the Plan Works - Example

SECTION 4 - PERSONAL HEALTH SUPPORT AND PRIOR AUTHORIZATION

Care Management

Prior Authorization

Special Note Regarding Medicare

SECTION 5 - PLAN HIGHLIGHTS

Payment Terms and Features

Schedule of Benefits

SECTION 6 - ADDITIONAL COVERAGE DETAILS

Ambulance Services - Emergency only

Ambulance Services - Non-Emergency

Cellular and Gene Therapy

Cleft Lip/Cleft Palate Treatment

Clinical Trials

Congenital Heart Disease (CHD) Surgeries

Dental Services - Accident Only

Dental Services - Anesthesia and Hospitalization

Diabetes Services ii TABLE OF CONTENTS

Durable Medical Equipment (DME)

Emergency Health Services - Outpatient

Enteral Nutrition

Eye Examinations

Fertility Preservation for Iatrogenic Infertility

Gender Dysphoria

Hearing Aids

Home Health Care

Hospice Care

Hospital - Inpatient Stay

Injections received in a Physician's Office

Maternity Services

Mental Health Services

Neurobiological Disorders - Autism Spectrum Disorder Services

Nutritional Counseling

Ostomy Supplies

Outpatient Surgery, Diagnostic and Therapeutic Services

Physician Fees for Surgical and Medical Services

Physician's Office Services - Sickness and Injury

Preimplantation Genetic Testing (PGT-M and PGT-SR) and Related Services

Preventive Care Services

Prosthetic Devices

Reconstructive Procedures

Rehabilitation Services - Outpatient Therapy

Skilled Nursing Facility/Inpatient Rehabilitation Facility Services

Spinal Treatment & Chiropractic Care

Substance-Related and Addictive Disorders Services

Temporomandibular Joint (TMJ) Services

Transplantation Services

Urgent Care Center Services

Urinary Catheters

Virtual Care Services

SECTION 7 - CLINICAL PROGRAMS AND RESOURCES

iii TABLE OF CONTENTS

Consumer Solutions and Self-Service Tools

Disease Management Services

Complex Medical Conditions Programs and Services

Wellness Programs

SECTION 8 - EXCLUSIONS AND LIMITATIONS: WHAT THE MEDICAL PLAN WILL NOT

COVER

Alternative Treatments

Comfort or Convenience

Dental

Drugs

Experimental or Investigational or Unproven Services

Foot Care

Gender Dysphoria

Medical Supplies and Appliances

Mental Health, Neurobiological Disorder - Autism Spectrum Disorder Services/Substance-Related and Additictive Disorders Services

Nutrition

Physical Appearance

Providers

Reproduction

Services Provided under Another Plan

Transplants

Travel

Vision and Hearing

All Other Exclusions

SECTION 9 - CLAIMS PROCEDURES

Network Benefits

Non-Network Benefits

Prescription Drug Benefit Claims

If Your Provider Does Not File Your Claim

Health Statements

Explanation of Benefits (EOB)

Claim Denials and Appeals iv TABLE OF CONTENTS

External Review Program

Limitation of Action

SECTION 10 - COORDINATION OF BENEFITS (COB)

Benefits When You Have Coverage under More than One Plan

When Does Coordination of Benefits Apply?

What Are the Rules for Determining the Order of Benefit Payments?

How Are Benefits Paid When This Plan is Secondary?

How is the Allowable Expense Determined when this Plan is Secondary?

What is Different When You Qualify for Medicare?

Medicare Crossover Program

Right to Receive and Release Needed Information?

Does This Plan Have the Right of Recovery?

SECTION 11 - SUBROGATION AND REIMBURSEMENT

Right of Recovery

SECTION 12 - WHEN COVERAGE ENDS

Coverage for a Disabled Dependent Child

Continuing Coverage Through COBRA

When COBRA Ends

Uniformed Services Employment and Reemployment Rights Act

SECTION 13 - OTHER IMPORTANT INFORMATION

Qualified Medical Child Support Orders (QMCSOs)

Your Relationship with UnitedHealthcare and City of Orlando

Relationship with Providers

Your Relationship with Providers

Interpretation of Benefits

Review and Determine Benefits in Accordance with UnitedHealthcare Reimbursement Policies

Information and Records

Incentives to Providers

Incentives to You

Workers' Compensation Not Affected

Future of the Plan

Summary Plan Description v TABLE OF CONTENTS

Medicare Eligibility

SECTION 14 - GLOSSARY

SECTION 15 - OUTPATIENT PRESCRIPTION DRUGS

Benefits for Prescription Drug Products

What You Must Pay

Payment Terms and Features - Outpatient Prescription Drugs

Schedule of Benefits - Outpatient Prescription Drugs

Identification Card (ID Card) - Network Pharmacy

Benefit Levels

Retail

Mail Order

Benefits for Preventive Care Medications

Designated Pharmacies

Specialty Prescription Drug Products

Variable Copayment Program

Assigning Prescription Drug Products to the Prescription Drug List (PDL)

Prescription Drug Benefit Claims

Limitation on Selection of Pharmacies

Supply Limits

Prescription Drug Products Prescribed by a Specialist Physician

Step Therapy

Coupons, Incentives and Other Communications

Price Edge Cost List

Exclusions - What the Prescription Drug Plan Will Not Cover

Glossary - Outpatient Prescription Drugs

Your Right to Request an Exception for Contraceptives

SECTION 16 - IMPORTANT ADMINISTRATIVE INFORMATION

ATTACHMENT I - HEALTH CARE REFORM NOTICES

Patient Protection and Affordable Care Act ("PPACA")

ATTACHMENT II - LEGAL NOTICES

Women's Health and Cancer Rights Act of 1998

Statement of Rights under the Newborns' and Mothers' Health Protection Act vi TABLE OF CONTENTS

ATTACHMENT III – NONDISCRIMINATION AND ACCESSIBILITY REQUIREMENTS

ATTACHMENT IV – GETTING HELP IN OTHER LANGUAGES OR FORMATS

1 SECTION 1 - WELCOME

SECTION 1 - WELCOME

Quick Reference Box

■ Member services, claim inquiries, Personal Health Support and Mental

Health/Substance-Related and Addictive Disorder Administrator: 1-800-382-5480.

■ Claims submittal address: UnitedHealthcare - Claims, P.O. Box 740800, Atlanta, GA, 30374-0800.

■ Online assistance: www.myuhc.com.

City of Orlando is pleased to provide you with this Summary Plan Description (SPD), which describes the health Benefits available to you and your covered family members. 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. It supersedes any previous printed or electronic SPD for this Plan.

IMPORTANT

The healthcare service, supply or Pharmaceutical Product is only a Covered Health Service if it is Medically Necessary. (See definitions of Medically Necessary and Covered Health Service in Section 14, Glossary.) The fact that a Physician or other provider has performed or prescribed a procedure or treatment, or the fact that it may be the only available treatment for a Sickness, Injury, Mental Illness, substance-related and addictive disorders, disease or its symptoms does not mean that the procedure or treatment is a Covered Health Service under the Plan.

This Plan, may be modified, changed, revised, amended or terminated at any time, for any reason, and without prior notice. 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. The City of Orlando has delegated to United Healthcare the discretion and authority to decide whether a treatment or supply is a Covered Health Service and how Eligible Expenses will be determined and otherwise covered under the Plan. UnitedHealthcare also administers claims. Although

2 SECTION 1 - WELCOME

UnitedHealthcare will assist you in many ways, it does not guarantee any Benefits. City of Orlando is solely responsible for paying Benefits described in this SPD.

Please read this SPD thoroughly to learn how the Choice Plan works. If you have questions contact Employee Benefits or call the number on 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 Employee Benefits.

■ 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.

■ City of Orlando 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.

3 SECTION 2 - INTRODUCTION

SECTION 2 - INTRODUCTION

What this section includes:

■ Who's eligible for coverage under the Plan.

■ The factors that impact your cost for coverage.

■ Instructions and timeframes for enrolling yourself and your eligible Dependents.

■ When coverage begins.

■ When you can make coverage changes under the Plan.

Eligibility You are eligible to enroll in the Plan if you meet one of the following categories:

■ A full-time or a part-time employee of the City of Orlando who works twenty (20) hours or more a week (excluding temporary or seasonal employees as classified by the City) as defined under City policies and procedures;

■ Retiree eligible to participate in the Plan under City policies and procedures for retiree health care;

■ COBRA Participant;

■ Eligible Long Term Disability (LTD) participant (as defined under City policies and procedures) under the City of Orlando’s LTD plan;

■ Defined benefit plan co-annuitants receiving monthly benefits as set forth in City policies and procedures; and

■ A temporary or seasonal employee identified to have worked an average of 30 or more hours per week during an initial or subsequent twelve-month look-back period.

Eligibility will be limited to the following tiers of coverage: Employee Only or Employee plus Child(ren).

Your eligible Dependents may also participate in the Plan. An eligible Dependent is considered to be:

■ Your Spouse, as defined in Section 14, Glossary.

■ Dependent children includes natural children, legally adopted children, stepchildren, foster children, disabled dependents and children you have LEGAL guardianship/custody paperwork through the court system. Coverage is provided for a newborn child of an eligible dependent from birth to 18 months of age. The parent of this child (your dependent) must continue to remain eligible and enrolled in order for their child (your grandchild) to remain covered to the maximum age of 18 months.

■ Children are covered to age 26. Eligibility for coverage continues until the end of the calendar year in which the child reaches 26 as long as they continue to meet the above eligibility requirements.

4 SECTION 2 - INTRODUCTION

■ In the event that your Dependent meets the following requirements, extended coverage may be eligible for that Dependent up to the age of 30. Contact your Plan Administrator for details and to complete necessary paperwork. To be eligible for extended coverage, a Dependent must satisfy the following:

■ Children age 27 to 30 are eligible if they

- reside in the state of Florida or if they are a student enrolled outside of Florida;

- are unmarried and does not have dependent of his or her own;

- Does not have coverage as a named subscriber, insured, enrollee or covered person under any other group, blanket or franchise health insurance policy or individual health benefits plan, or is not entitled to benefits under Title XVIII of the Social Security Act.

- A child who is covered between the ages of 27 and 30 under extended coverage provisions set forth above ceases to be eligible as a Dependent on the last day of the calendar year following the child's attainment of the limiting age or when the child no longer meets the requirements.

■ Coverage for an unmarried enrolled Dependent child who is disabled will not end just because the child has reached a certain age. The Plan will extend the coverage for that child beyond the limiting age if both of the following are true regarding the enrolled Dependent child:

- Is not able to be self-supporting because of mental or physical handicap or disability.

- Depends mainly on you for support.

■ Coverage will continue as long as the enrolled Dependent is medically certified as disabled unless coverage is otherwise terminated in accordance with the terms of the Plan.

Note: Your Dependents may not enroll in the Plan unless you are also enrolled. In addition, if you and your Spouse are both covered under the Plan, you may each be enrolled as a Participant or be covered as a Dependent of the other person, but not both. In addition, if you and your Spouse are both covered under the Plan, only one parent may enroll your child as a Dependent.

A Dependent also includes a child for whom health care coverage is required through a Qualified Medical Child Support Order or other court or administrative order, as described in Section 13, Other Important Information.

Cost of Coverage You and City of Orlando share in the cost of the Plan. Your contribution amount depends on your eligibility status, the Plan you select, and the family members you choose to enroll.

How to Enroll You will need to enroll within 31 days of the date you first become eligible for medical Plan coverage. If you do not enroll within 31 days, you will be automatically enrolled in the basic level of benefits as funded by the City of Orlando. With certain exceptions described below, (“Changing Your Coverage”) your benefit elections will remain in effect for the remainder of

5 SECTION 2 - INTRODUCTION

the Plan Year and you will need to wait until the next annual Open Enrollment to make your benefit elections.

Each year during annual Open Enrollment, you have the opportunity to review and change your medical election. Any changes you make during Open Enrollment will become effective the following January 1. If you do not make any changes, you are automatically enrolled at the same level and plan you had during the last plan year.

Important If you wish to change your benefit elections following your marriage, birth, adoption of a child, placement for adoption of a child or other family status change, you must contact Employee Benefits within 31 days of the event and provide the necessary documentation.

Otherwise, you will need to wait until the next annual Open Enrollment to change your elections (see “Changing your Coverage”). However, if your dependent no longer qualifies as eligible dependent, you must notify Employee Benefits immediately.

When Coverage Begins Once Employee Benefits receives your properly completed enrollment, for employees hired on or before June 30, 2023, coverage will begin on the day following the completion of an 89-day waiting period. For employees hired on or after July 1, 2023, coverage will begin on the day following the completion of a 30-day waiting period. Coverage for your Dependents will start on the date your coverage begins, provided you have enrolled them in a timely manner.

Coverage for a Spouse or Dependent stepchild that you acquire via marriage becomes effective the date of your marriage, provided Employee Benefits receives notice and proper documentation within 31 days of your marriage. Coverage for Dependent children acquired through birth, adoption, or placement for adoption is effective the date of the family status change, provided Employee Benefits receives notice and proper documentation within 31 days of the birth, adoption, or placement.

For newborns, coverage begins at the moment of birth. For newborns placed for adoption or foster care, coverage begins from the moment of birth if there is an agreement to place or adopt the newborn and the newborn is ultimately placed in the Participant’s home. You must notify Employee Benefits within 60 days of the birth and provide the necessary documentation.

If You Are Hospitalized When Your Coverage Begins If you are an inpatient in a Hospital, Skilled Nursing Facility or Inpatient Rehabilitation Facility on the day your coverage begins, the Plan will pay Benefits for Covered Health Services that you receive on or after your first day of coverage related to that Inpatient Stay as long as you receive Covered Health Services in accordance with the terms of the Plan.

These Benefits are subject to any prior carrier's obligations under state law or contract.

You should notify UnitedHealthcare of your hospitalization within 48 hours of the day your coverage begins, or as soon as is reasonably possible. For Benefit plans that have a Network

6 SECTION 2 - INTRODUCTION

Benefit level, Network Benefits are available only if you receive Covered Health Services from Network providers.

Changing Your Coverage You may make coverage changes during the year only if you experience a change in family status. The change in coverage must be consistent with the change in status (e.g., you cover your Spouse following your marriage, your child following an adoption, etc.). The following are considered family status changes for purposes of the Plan:

■ Your marriage, divorce, legal separation or annulment.

■ The birth, legal adoption, placement for adoption, placement for foster care, legal custody, or legal guardianship of a child.

■ A change in employment which causes a loss of group health coverage or involuntary loss of health coverage (other than coverage under the Medicare or Medicaid programs) under another employer's plan.

■ Loss of coverage due to the exhaustion of another employer's COBRA benefits, provided you were paying for premiums on a timely basis.

■ Your death or the death of a Covered Dependent.

■ Your Dependent child no longer qualifying as an eligible Dependent.

■ A change in your or your eligible Dependent’s position or work schedule that impacts eligibility for health coverage.

■ Contributions were no longer paid by the employer (this is true even if you or your eligible Dependent continues to receive coverage under the prior plan and to pay the amounts previously paid by the employer).

■ You or your eligible Dependent who were enrolled in an HMO no longer live or work in that HMO's service area.

■ Benefits are no longer offered by the Plan to a class of individuals that include you or your eligible Dependent.

■ Termination of your or your Dependent's Medicaid or Children's Health Insurance Program (CHIP) coverage as a result of loss of eligibility (you must contact Employee Benefits within 60 days of termination).

■ You or your Dependent become eligible for a premium assistance subsidy under Medicaid or CHIP (you must contact Employee Benefits within 60 days of the date of determination of subsidy eligibility).

■ You or your Dependent lose eligibility for coverage in the individual market, including coverage purchased through a public exchange or other public market established under the Affordable Care Act (Marketplace) (other than loss of eligibility for coverage due to failure to pay premiums on a timely basis or termination of coverage for cause, such as making a fraudulent claim or an intentional misrepresentation of a material fact)

7 SECTION 2 - INTRODUCTION

regardless of whether you or your Dependent may enroll in other individual market coverage, through or outside of a Marketplace.

■ A strike or lockout involving you or your Spouse, which causes loss of group health coverage.

■ A court or administrative order.

Unless otherwise noted above, if you wish to change your elections, you must contact Employee Benefits within 31 days of the change in family status provide the necessary documentation. Otherwise, you will need to wait until the next annual Open Enrollment.

However, if your dependent no longer qualifies as an eligible dependent, you must notify Employee Benefits immediately.

While some of these changes in status are similar to qualifying events under COBRA, you, or your eligible Dependent, do not need to elect COBRA continuation coverage to take advantage of the special enrollment rights listed above. These will also be available to you or your eligible Dependent if COBRA is elected.

Note: Any child under age 26 who is placed with you for adoption will be eligible for coverage on the date the child is placed with you, even if the legal adoption is not yet final. If you do not legally adopt the child, all medical Plan coverage for the child will end when the placement ends. No provision will be made for continuing coverage (such as COBRA coverage) for the child.

Change in Family Status - Example Jane is married and has two children who qualify as Dependents. At annual Open Enrollment, she elects not to participate in City of Orlando's medical plan, because her husband, Tom, has family coverage under his employer's medical plan. In June, Tom loses his job as part of a downsizing. As a result, Tom loses his eligibility for medical coverage. Due to this family status change, Jane can elect family medical coverage under City of Orlando's medical plan outside of annual Open Enrollment.

8 SECTION 3 - HOW THE PLAN WORKS

SECTION 3 - HOW THE PLAN WORKS

What this section includes:

■ Accessing Benefits.

■ Eligible Expenses.

■ Annual Deductible.

■ Copayment.

■ Out-of-Pocket Maximum.

Accessing Benefits As a participant in this Plan, you have the freedom to choose the Network Physician or health care professional you prefer each time you need to receive Covered Health Services.

You are eligible for Benefits under this Plan when you receive Covered Health Services from Physicians and other health care professionals who have contracted with UnitedHealthcare to provide those services. You must see a Network Physician in order to obtain Benefits.

Except as specifically described within the SPD, Benefits are not available for services provided by a non-Network provider. This Plan does not provide a non-Network level of Benefits.

Benefits apply to Covered Health Services that are provided by a Network Physician or other Network provider.

Emergency Health Services provided by a non-Network provider will be reimbursed as set forth under Eligible Expenses as described at the end of this section.

Covered Health Services provided at certain Network facilities by a non-Network Physician, when not Emergency Health Services, will be reimbursed as set forth under Eligible Expenses as described at the end of this section. For these Covered Health Services, "certain Network facility" is limited to a hospital (as defined in 1861(e) of the Social Security Act), a hospital outpatient department, a critical access hospital (as defined in 1861(mm)(1) of the Social Security Act), an ambulatory surgical center as described in section 1833(i)(1)(A) of the Social Security Act, and any other facility specified by the Secretary.

Air Ambulance transport provided by a non-Network provider will be reimbursed as set forth under Eligible Expenses as described at the end of this section.

Ground Ambulance transport provided by a non-Network provider will be reimbursed as set forth under Eligible Expenses as described at the end of this section.

Depending on the geographic area and the service you receive, you may have access through UnitedHealthcare's Shared Savings Program to non-Network providers who have agreed to discounts negotiated from their charges on certain claims for Covered Health Services. Refer to the definition of Shared Savings Program in Section 14, Glossary, of the SPD for details about how the Shared Savings Program applies.

9 SECTION 3 - HOW THE PLAN WORKS

You must show your identification card (ID card) every time you request health care services from a Network provider. If you do not show your ID card, Network providers have no way of knowing that you are enrolled under the Plan. As a result, they may bill you for the entire cost of the services you receive.

Network Providers UnitedHealthcare or its affiliates arrange for health care providers to participate in a Network. At your request, UnitedHealthcare will send you a directory of network providers free of charge. Keep in mind, a provider's Network status may change. To verify a provider's status or request a provider directory, you can call UnitedHealthcare at the number on your ID card or log onto www.myuhc.com.

Network providers are independent practitioners and are not employees of City of Orlando or UnitedHealthcare. It is your responsibility to select your provider.

UnitedHealthcare's credentialing process confirms public information about the providers' licenses and other credentials, but does not assure the quality of the services provided.

Before obtaining services, you should always verify the Network status of a provider. A provider's status may change. You can verify the provider's status by calling UnitedHealthcare. A directory of providers is available online at www.myuhc.com or by calling the number on your ID card to request a copy. If you receive a Covered Health Service from a non-Network provider and were informed incorrectly prior to receipt of the Covered Health Service that the provider was a Network provider, either through a database, provider directory, or in a response to your request for such information (via telephone, electronic, web-based or internet-based means), you may be eligible for Network Benefits.

It is possible that you might not be able to obtain services from a particular Network provider. The network of providers is subject to change. Or you might find that a particular Network provider may not be accepting new patients. If a provider leaves the Network or is otherwise not available to you, you must choose another Network provider to get Benefits.

However, if you are currently receiving treatment for Covered Health Services from a provider whose network status changes from Network to non-Network during such treatment due to expiration or nonrenewal of the provider's contract, you may be eligible to request continued care from your current provider at the Network Benefit level for specified conditions and timeframes. This provision does not apply to provider contract terminations for failure to meet applicable quality standards or for fraud. If you would like help to find out if you are eligible for continuity of care Benefits, please call the telephone number on your ID card.

If you are currently undergoing a course of treatment utilizing a non-Network Physician or health care facility, you may be eligible to receive transition of care Benefits. This transition period is available for specific medical services and for limited periods of time. If you have questions regarding this transition of care reimbursement policy or would like help determining whether you are eligible for transition of care Benefits, please contact the number on your ID card.

Do not assume that a Network provider's agreement includes all Covered Health Services.

Some Network providers contract with UnitedHealthcare to provide only certain Covered Health Services, but not all Covered Health Services. Some Network providers choose to be

10 SECTION 3 - HOW THE PLAN WORKS

a Network provider for only some of UnitedHealthcare's products. Refer to your provider directory or contact UnitedHealthcare for assistance.

Health Services from Non-Network Providers If specific Covered Health Services are not available from a Network provider, you may be eligible for Benefits when Covered Health Services are received from a non-Network provider. In this situation, your Network Physician will notify the Claims Administrator, and if the Claims Administrator confirms that care is not available from a Network provider, the Claims Administrator will work with you and your Network Physician to coordinate care through a non-Network provider.

When you receive Covered Health Services through a Network Physician, the Plan will pay Network Benefits for those Covered Health Services, even if one or more of those Covered Health Services is received from a non-Network provider.

This plan participates in the Shared Savings Program. Refer to the definition of Shared Savings Program in Section 14, Glossary, of the SPD for details about how the Shared Savings Program applies.

Looking for a Network Provider?

In addition to other helpful information, www.myuhc.com, UnitedHealthcare's consumer website, contains a directory of health care professionals and facilities in UnitedHealthcare's Network. While Network status may change from time to time, www.myuhc.com has the most current source of Network information. Use www.myuhc.com to search for Physicians available in your Plan.

Possible Limitations on Provider Use If UnitedHealthcare determines that you are using health care services in a harmful or abusive manner, you may be required to select a Network Physician to provide and coordinate all of your future Covered Health Services.

In the event that you do not use the selected Network Physician, Benefits will not be paid.

Designated Providers If you have a medical condition that UnitedHealthcare believes needs special services, UnitedHealthcare may direct you to a Designated Provider chosen by UnitedHealthcare. If you require certain complex Covered Health Services for which expertise is limited, UnitedHealthcare may direct you to a Network facility or provider that is outside your local geographic area. If you are required to travel to obtain such Covered Health Services from a Designated Provider, UnitedHealthcare may reimburse certain travel expenses at UnitedHealthcare's discretion.

In both cases, Benefits will only be paid if your Covered Health Services for that condition are provided by or arranged by the Designated Provider or other provider chosen by UnitedHealthcare.

You or your Network Physician must notify UnitedHealthcare of special service needs (such as transplants or cancer treatment) that might warrant referral to a Designated Provider. If you do not notify UnitedHealthcare in advance, and if you receive services from a non-

11 SECTION 3 - HOW THE PLAN WORKS

Network facility (regardless of whether it is a Designated Provider) or other non-Network provider, Benefits will not be paid.

Eligible Expenses City of Orlando has delegated to the Claims Administrator the discretion and authority to decide whether a treatment or supply is a Covered Health Service and how the Eligible Expenses will be determined and otherwise covered under the Plan.

Eligible Expenses are the amount the Claims Administrator determines that the Plan will pay for Benefits.

■ For Network Benefits for Covered Health Services provided by a Network provider, except for your cost sharing obligations, you are not responsible for any difference between Eligible Expenses and the amount the provider bills.

- For Covered Health Services that are Ancillary Services received at certain Network facilities on a non-Emergency basis from non-Network Physicians, you are not responsible, and the non-Network provider may not bill you, for amounts in excess of your Copayment, Coinsurance or deductible which is based on the Recognized Amount as defined in this SPD.

- For Covered Health Services that are non-Ancillary Services received at certain Network facilities on a non-Emergency basis from non-Network Physicians who have not satisfied the notice and consent criteria or for unforeseen or urgent medical needs that arise at the time a non-Ancillary Service is provided for which notice and consent has been satisfied as described below, you are not responsible, and the Non-Network provider may not bill you, for amounts in excess of your Copayment, Coinsurance or deductible which is based on the Recognized Amount as defined in the SPD.

- For Covered Health Services that are Emergency Health Services provided by a non-Network provider, you are not responsible, and the non-Network provider may not bill you, for amounts in excess of your applicable Copayment, Coinsurance or deductible which is based on the Recognized Amount as defined in this SPD.

- For Covered Health Services that are Air Ambulance services provided by a Non- Network provider, you are not responsible, and the Non-Network provider may not bill you, for amounts in excess of your applicable Copayment, Coinsurance or deductible which is based on the rates that would apply if the service was provided by a Network provider which is based on the Recognized Amount as defined in the

SPD.

Eligible Expenses are determined in accordance with the Claims Administrator's reimbursement policy guidelines or as required by law, as described in the SPD.

For Network Benefits, Eligible Expenses are based on the following:

■ When Covered Health Services are received from a Network provider, Eligible Expenses are our contracted fee(s) with that provider.

■ When Covered Health Services are received from a non-Network provider as arranged by the Claims Administrator, including when there is no Network provider who is

12 SECTION 3 - HOW THE PLAN WORKS

reasonably accessible or available to provide Covered Health Services, Eligible Expenses are an amount negotiated by the Claims Administrator or an amount permitted by law.

Please contact the Claims Administrator if you are billed for amounts in excess of your applicable Coinsurance, Copayment or any deductible. The Plan will not pay excessive charges or amounts you are not legally obligated to pay.

When Covered Health Services are received from a non-Network provider as described below, Eligible Expenses are determined as follows:

■ For non-Emergency Covered Health Services received at certain Network facilities from non-Network Physicians when such services are either Ancillary Services, or non-Ancillary Services that have not satisfied the notice and consent criteria of section 2799B-2(d) of the Public Health Service Act with respect to a visit as defined by the Secretary, the Eligible Expense is based on one of the following in the order listed below as applicable:

- The reimbursement rate as determined by a state All Payer Model Agreement.

- The reimbursement rate as determined by state law.

- The initial payment made by the Claims Administrator, or the amount subsequently agreed to by the non-Network provider and the Claims Administrator.

- The amount determined by Independent Dispute Resolution (IDR).

For the purpose of this provision, "certain Network facilities" are limited to a hospital (as defined in 1861(e) of the Social Security Act), a hospital outpatient department, a critical access hospital (as defined in 1861(mm)(1) of the Social Security Act), an ambulatory surgical center as described in section 1833(i)(1)(A) of the Social Security Act, and any other facility specified by the Secretary.

IMPORTANT NOTICE: For Ancillary Services, non-Ancillary Services provided without notice and consent, and non-Ancillary Services for unforeseen or urgent medical needs that arise at the time a service is provided for which notice and consent has been satisfied, you are not responsible, and a non-Network Physician may not bill you, for amounts in excess of your applicable Copayment, Coinsurance or deductible which is based on the Recognized Amount as defined in the SPD.

■ For Emergency Health Services provided by a non-Network provider, the Eligible Expense is based on one of the following in the order listed below as applicable:

- The reimbursement rate as determined by a state All Payer Model Agreement.

- The reimbursement rate as determined by state law.

- The initial payment made by the Claims Administrator, or the amount subsequently

IMPORTANT NOTICE: You are not responsible, and a non-Network provider may not bill you, for amounts in excess of your applicable Copayment, Coinsurance or deductible which is based on the Recognized Amount as defined in the SPD.

13 SECTION 3 - HOW THE PLAN WORKS

■ For Air Ambulance transportation provided by a non-Network provider, the Eligible Expense is based on one of the following in the order listed below as applicable:

- The reimbursement rate as determined by a state All Payer Model Agreement.

- The reimbursement rate as determined by state law.

- The initial payment made by the Claims Administrator, or the amount subsequently

IMPORTANT NOTICE: You are not responsible, and a non-Network provider may not bill you, for amounts in excess of your Copayment, Coinsurance or deductible which is based on the rates that would apply if the service was provided by a Network provider which is based on the Recognized Amount as defined in the SPD.

■ For Emergency ground ambulance transportation provided by a non-Network provider, the Eligible Expense, which includes mileage, is a rate agreed upon by the non-Network provider or, unless a different amount is required by applicable law, determined based upon the median amount negotiated with Network providers for the same or similar service.

IMPORTANT NOTICE: Non-Network providers may bill you for any difference between the provider’s billed charges and the Eligible Expense described here.

Don't Forget Your ID Card Remember to show your UnitedHealthcare ID card every time you receive health care services from a Network provider. If you do not show your ID card, a Network provider has no way of knowing that you are enrolled under the Plan.

Annual Deductible The Annual Deductible is the amount of Eligible Expenses, or the Recognized Amount when applicable, you must pay each calendar year for Covered Health Services before you are eligible to begin receiving Benefits. The amounts you pay toward your Annual Deductible accumulate over the course of the calendar year.

This Plan includes an Annual Deductible that applies to certain Covered Health Services.

Refer to Section 5, Plan Highlights, for details about the specific Covered Health Services to which the Annual Deductible applies.

Amounts paid toward the Annual Deductible for Covered Health Services that are subject to a visit or day limit will also be calculated against that maximum benefit limit. As a result, the limited benefit will be reduced by the number of days or visits you used toward meeting the Annual Deductible.

Copayment A Copayment (Copay) is the amount you pay each time you receive certain Covered Health Services. The Copay is calculated as a flat dollar amount and is paid at the time of service or when billed by the provider. When Copayments apply, the amount is listed in Section 5, Plan Highlights, next to the description for each Covered Health Service.

14 SECTION 3 - HOW THE PLAN WORKS

Please note that for Covered Health Services, you are responsible for paying the lesser of:

■ The applicable Copayment.

■ The Eligible Expense.

Details about the way in which Eligible Expenses are determined appear in this section under the heading Eligible Expenses.

Copays count toward the Out-of-Pocket Maximum. If the Eligible Expense is less than the Copay, you are only responsible for paying the Eligible Expense and not the Copay.

Out-of-Pocket Maximum The annual Out-of-Pocket Maximum is the most you pay each calendar year for Covered Health Services. If your eligible out-of-pocket expenses in a calendar year exceed the annual maximum, the Plan pays 100% of Eligible Expenses for Covered Health Services through the end of the calendar year.

The Out-of-Pocket Maximum applies to all Covered Health Services under the Plan, as indicated in the table below, including Covered Health Services provided in Section 15, Outpatient Prescription Drugs. The Out-of-Pocket Maximum for Network Benefits includes the amount you pay for outpatient prescription drug products provided in Section 15, Outpatient Prescription Drugs.

The following table identifies what does and does not apply toward your Out-of-Pocket Maximum:

Plan Features Applies to the Out-of-Pocket Maximum?

Copays for Covered Health Services available in the Section 5, Plan Highlights table and Copays for Covered Health Services available in Section 15, Outpatient Prescription Drugs

Yes

Payments toward the Annual Deductible Yes

Charges for non-Covered Health Services No

Charges that exceed Eligible Expenses, or the Recognized Amount when applicable No

15 SECTION 3 - HOW THE PLAN WORKS

How the Plan Works - Example The following example illustrates how the Annual Deductible and Copays work in practice.

Let's say Gary has individual coverage under the Plan, and he needs to see a Physician. The following flow chart shows what happens when he visits a Network Physician.

Network Benefits

1. Gary goes to see a Network Physician, and presents his ID card.

2. He receives treatment from the Physician. The Eligible Expense for the Network office visit equals $125.

3. On his way out, Gary pays $125 if he had not yet reached his Annual Deductible of $250. If he had already met his Annual Deductible, he would only pay a $15 Copay. Since Network Physician office visits are covered at 100% after the Copay, Gary has met his financial obligations for this office visit.

4. If Gary had not yet met his Annual Deductible the Plan would not make a payment. If Gary had met his annual deductible, the Plan pays $110 ($125 Eligible Expense minus $15 Copay).

5. As another example, if on his first visit the Eligible Expense for the Network office visit is $400, then Gary would pay his $250 Annual Deductible plus a $15 Copay. The Plan would pay $135 (for a total of $400 paid to the provider). Gary’s future visits would be Copay only.

16 SECTION 4 - PERSONAL HEALTH SUPPORT AND PRIOR AUTHORIZATION

SECTION 4 - PERSONAL HEALTH SUPPORT AND PRIOR AUTHORIZATION

What this section includes:

■ An overview of the Personal Health Support program.

■ Covered Health Services which Require Prior Authorization.

Care Management When you seek prior authorization as required, the Claims Administrator will work with you to implement the care management process and to provide you with information about additional services that are available to you, such as disease management programs, health education, and patient advocacy.

UnitedHealthcare provides a program called Personal Health Support designed to encourage personalized, efficient care for you and your covered Dependents.

Personal Health Support Nurses center their efforts on prevention, education, and closing any gaps in your care. The goal of the program is to ensure you receive the most appropriate and cost-effective services available.

If you are living with a chronic condition or dealing with complex health care needs, UnitedHealthcare may assign to you a primary nurse, referred to as a Personal Health Support Nurse, to guide you through your treatment. This assigned nurse will answer questions, explain options, identify your needs, and may refer you to specialized care programs. The Personal Health Support Nurse will provide you with their telephone number so you can call them with questions about your conditions, or your overall health and well-being.

Personal Health Support Nurses will provide a variety of different services to help you and your covered family members receive appropriate medical care. Program components are subject to change without notice. When the Claims Administrator is called as required, they will work with you to implement the Personal Health Support process and to provide you with information about additional services that are available to you, such as disease management programs, health education, and patient advocacy. As of the publication of this SPD, the Personal Health Support program includes:

■ Admission counseling - Personal Health Support Nurses are available to help you prepare for a successful surgical admission and recovery. Call the number on your ID card for support.

■ Inpatient care management - If you are hospitalized, a nurse will work with your Physician to make sure you are getting the care you need and that your Physician's treatment plan is being carried out effectively.

■ Readmission Management - This program serves as a bridge between the Hospital and your home if you are at high risk of being readmitted. After leaving the Hospital, if you have a certain chronic or complex condition, you may receive a phone call from a Personal Health Support Nurse to confirm that medications, needed equipment, or follow-up services are in place. The Personal Health Support Nurse will also share

17 SECTION 4 - PERSONAL HEALTH SUPPORT AND PRIOR AUTHORIZATION

important health care information, reiterate and reinforce discharge instructions, and support a safe transition home.

■ Risk Management - Designed for participants with certain chronic or complex conditions, this program addresses such health care needs as access to medical specialists, medication information, and coordination of equipment and supplies.

Participants may receive a phone call from a Personal Health Support Nurse to discuss and share important health care information related to the participant's specific chronic or complex condition.

■ Cancer Management - You have the opportunity to engage with a nurse that specializes in cancer, education and guidance throughout your care path.

■ Kidney Management - You have the opportunity to engage with a nurse that specializes in kidney disease, education and guidance with CKD stage 4/5 or ESRD throughout your care path.

If you do not receive a call from a Personal Health Support Nurse but feel you could benefit from any of these programs, please call the number on your ID card.

Prior Authorization UnitedHealthcare requires prior authorization for certain Covered Health Services.

Physicians and other health care professionals who participate in a Network are responsible for obtaining prior authorization.

It is recommended that you confirm with the Claims Administrator that all Covered Health Services listed below have been prior authorized as required. Before receiving these services from a Network provider, you may want to contact the Claims Administrator to verify that the Hospital, Physician and other providers are Network providers and that they have obtained the required prior authorization. Network facilities and Network providers cannot bill you for services they fail to prior authorize as required. You can contact the Claims Administrator by calling the number on your ID card.

To obtain prior authorization, call the number on your ID card. This call starts the utilization review process. Once you have obtained the authorization, please review it carefully so that you understand what services have been authorized and what providers are authorized to deliver the services that are subject to the authorization.

The utilization review process is a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures or settings. Such techniques may include ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, retrospective review or similar programs.

Contacting UnitedHealthcare or Personal Health Support is easy.

Simply call the number on your ID card.

Services for which you are required to obtain prior authorization are identified in Section 6, Additional Coverage Details within each Covered Health Service Benefit

18 SECTION 4 - PERSONAL HEALTH SUPPORT AND PRIOR AUTHORIZATION

description. Please note that prior authorization timelines apply. Refer to the applicable Benefit description to determine how far in advance you must obtain prior authorization and any applicable reductions in Benefits.

Please note that prior authorization is required even if you have a referral from your Primary Physician to seek care from another Network Physician.

Special Note Regarding Medicare If you are enrolled in Medicare on a primary basis (Medicare pays before the Plan pays Benefits) the prior authorization requirements do not apply to you. Since Medicare is the primary payer, the Plan will pay as secondary payer as described in Section 10, Coordination of Benefits (COB). You are not required to obtain authorization before receiving Covered Health Services.

19 SECTION 5 - PLAN HIGHLIGHTS

SECTION 5 - PLAN HIGHLIGHTS

What this section includes:

■ Payment Terms and Features.

■ Schedule of Benefits.

Payment Terms and Features The table below provides an overview of Copays that apply when you receive certain Covered Health Services, and outlines the Plan’s Annual Deductible and Out-of-Pocket Maximum.

Plan Features Network Amount

Copays

In addition to these Copays, you may be responsible for meeting the Annual Deductible for the Covered Health Service described in the chart on the following pages.

■ Emergency Health Services. $200

■ Urgent Care Center Services. $35

■ Hospital - Inpatient Stay. $600

■ Hospital - Outpatient Surgery. $350

■ Non-Hospital Ambulatory Surgical Center – Outpatient Surgery

$50

■ Physician's Office Services - Primary Physician.

$25

■ Physician's Office Services - Specialist. $50

■ Hospital - CT scans, PET Scans, MRI and Nuclear Medicine.

$250

■ Non-Hospital Imaging Center - CT scans, PET Scans, MRI and Nuclear Medicine.

$50

■ Hospital – Diagnostic Minor Radiology, X-ray, Lab-work

$100

20 SECTION 5 - PLAN HIGHLIGHTS

Plan Features Network Amount

Copays do not apply toward the Annual Deductible. Copays apply toward the Out-of-Pocket Maximum.

Annual Deductible

■ Individual $500

■ Family (not to exceed the applicable Individual amount for all Covered Persons in a family).

$1,000

Coupons: The Plan Sponsor may not permit certain coupons or offers from pharmaceutical manufacturers or an affiliate to apply to your Annual Deductible.

The Annual Deductible applies toward the Out-of-Pocket Maximum for all Covered Health Services.

Annual Out-of-Pocket Maximum

■ Individual. $6,350

■ Family (not to exceed the applicable Individual amount per Covered Person).

$12,700

Coupons: The Plan Sponsor may not permit…