Page 83 - QCS.19 SPD - HSA

When a rate is not published by CMS for the service, we use a gap methodology established by OptumInsight
and/or a third party vendor that uses a relative value scale. The relative value scale is usually based on the
difficulty, time, work, risk and resources of the service. If the relative value scale currently in use becomes no
longer available, we will use a comparable scale(s). We and OptumInsight are related companies through
common ownership by UnitedHealth Group.
For Pharmaceutical Products, we use gap methodologies that are similar to the pricing methodology used by
CMS, and produce fees based on published acquisition costs or average wholesale price for the pharmaceuticals.
These methodologies are currently created by RJ Health Systems, Thomson Reuters (published in its Red Book),
or UnitedHealthcare based on an internally developed pharmaceutical pricing resource.
When a rate is not published by CMS for the service and a gap methodology does not apply to the service, the
Allowed Amount is based on 50% of the provider's billed charge
For Emergency ambulance transportation provided by an out-of-Network provider, the Allowed Amount is a rate
agreed upon by the out-of-Network provider or determined based upon 365% of the published rates allowed by
the Centers for Medicare and Medicaid Services (CMS) for the same or similar service.
IMPORTANT NOTICE: Out-of-Network providers may bill you for any difference between the provider's billed
charges and the Allowed Amount described here.

Alternate Facility - a health care facility that is not a Hospital and that provides one or more of the following
services on an outpatient basis, as permitted by law:

· Surgical services;
· Emergency Health Care Services; or

· Rehabilitative, laboratory, diagnostic or therapeutic services.
Amendment - any attached written description of added or changed provisions to the Plan. It is effective only
when distributed by the Plan Sponsor or the Plan Administrator. Amendments are subject to all conditions,
limitations and exclusions of the Plan, except for those that the amendment is specifically amending.
Ancillary Charge - a charge, in addition to the Deductible, Co-payment and/or Co-insurance, that you must pay
when a covered Prescription Drug Product is dispensed at your or the provider's request, when a Chemically
Equivalent Prescription Drug Product is available.
For Prescription Drug Products from Network Pharmacies, the Ancillary Charge is the difference between:

· The Prescription Drug Charge or Maximum Allowable Cost (MAC) List price for Network Pharmacies for
the Prescription Drug Product.
· The Prescription Drug Charge or Maximum Allowable Cost (MAC) List price of the Chemically Equivalent
Prescription Drug Product.
Annual Deductible - The amount you must pay for Covered Health Care Services per calendar year before the
Plan will begin paying Benefits in that calendar year. The Deductible is shown in the first table in Section 4,
Schedule of Benefits.
Autism Spectrum Disorder – a condition, marked by enduring problems communicating and interacting with
others, along with restricted and repetitive behavior, interests or activities.

Benefits - Plan payments for Covered Health Care Services subject to the terms, conditions, limitations,
exclusions and eligibility requirements of the Plan and any Addendums and/or Amendments.

Brand-name - a Prescription Drug Product:
· which is manufactured and marketed under a trademark or name by a specific drug manufacturer; or

· that we identify as a Brand-name product, based on available data resources including, but not limited to,
First DataBank, that classify drugs as either brand or generic based on a number of factors.

You should know that all products identified as a "brand name" by the manufacturer, pharmacy, or your Physician
may not be classified as Brand-name by us.
Calendar Year - January 1 through December 31.

Cellular Therapy - administration of living whole cells into a patient for the treatment of disease.

Page 78 Section 15 - Glossary
HSA - 2017