Summary Plan Descript ion New York University UnitedHealthcare High Deductible Health Plan with HSA Effective: January 1, 2021 Group Number: 175396 This page has been intentionally left blank. 015 NEW YORK UNIVERSITY MEDICAL UNITEDHEALTHCARE HIGH DEDUCTIBLE HEALTH PLAN WITH HSA TABLE OF CONTENTS SECTION 1 - WELCOME ..................................................................................................................1 SECTION 2 - INTRODUCTION..........................................................................................................4 Eligibility.........................................................................................................................................4 Cost of Coverage...........................................................................................................................4 How to Enroll................................................................................................................................5 When Coverage Begins ................................................................................................................5 Changing Your Coverage.............................................................................................................6 SECTION 3 - HOW THE PLAN WORKS...........................................................................................8 Network and Non-Network Benefits ........................................................................................8 Eligible Expenses........................................................................................................................11 Annual Deductible......................................................................................................................12 Coinsurance..................................................................................................................................13 Out-of-Pocket Maximum ..........................................................................................................13 SECTION 4 - PERSONAL HEALTH SUPPORT and PRIOR AUTHORIZATION...........................14 Care Management .......................................................................................................................14 Prior Authorization.....................................................................................................................15 Special Note Regarding Medicare.............................................................................................16 SECTION 5 - PLAN HIGHLIGHTS ..................................................................................................17 SECTION 6 - ADDITIONAL COVERAGE DETAILS .......................................................................28 Acupuncture Services.................................................................................................................28 Ambulance Services - Emergency only ...................................................................................28 Ambulance Services - Non-Emergency...................................................................................28 Cellular and Gene Therapy........................................................................................................29 Clinical Trials ...............................................................................................................................29 Congenital Heart Disease (CHD) Surgeries............................................................................31 Dental Services - Accident Only...............................................................................................32 Diabetes Services.........................................................................................................................32 Durable Medical Equipment (DME).......................................................................................33 Emergency Health Services - Outpatient................................................................................35 Enteral Nutrition.........................................................................................................................35 Eye Examinations .......................................................................................................................36 I TABLE OF CONTENTS NEW YORK UNIVERSITY MEDICAL UNITEDHEALTHCARE HIGH DEDUCTIBLE HEALTH PLAN WITH HSA Gender Dysphoria ......................................................................................................................36 Hearing Aids ................................................................................................................................38 Home Health Care......................................................................................................................39 Hospice Care................................................................................................................................39 Hospital - Inpatient Stay ............................................................................................................40 Infertility Services and Fertility Solutions (FS) Program ......................................................40 Injections received in a Physician's Office..............................................................................42 Maternity Services .......................................................................................................................43 Mental Health Services...............................................................................................................44 Neurobiological Disorders - Autism Spectrum Disorders ...................................................46 Nutritional Counseling...............................................................................................................48 Obesity Surgery ...........................................................................................................................49 Ostomy Supplies .........................................................................................................................49 Outpatient Surgery, Diagnostic and Therapeutic Services ...................................................50 Physician's Office Services - Sickness and Injury ..................................................................52 Preventive Care Services............................................................................................................52 Private Duty Nursing..................................................................................................................53 Professional Fees for Surgical and Medical Services .............................................................53 Prosthetic Devices ......................................................................................................................53 Reconstructive Procedures ........................................................................................................54 Rehabilitation Services - Outpatient Therapy.........................................................................55 Skilled Nursing Facility/Inpatient Rehabilitation Facility Services.....................................56 Spinal Treatment.........................................................................................................................57 Substance Use Disorder Services .............................................................................................57 Temporomandibular Joint (TMJ) Services..............................................................................58 Transplantation Services ............................................................................................................59 Urgent Care Center Services .....................................................................................................60 Urinary Catheters ........................................................................................................................60 Virtual Visits ................................................................................................................................60 Wigs...............................................................................................................................................61 Wisdom Teeth .............................................................................................................................61 SECTION 7 - CLINICAL PROGRAMS AND RESOURCES............................................................62 Consumer Solutions and Self-Service Tools...........................................................................62 II TABLE OF CONTENTS NEW YORK UNIVERSITY MEDICAL UNITEDHEALTHCARE HIGH DEDUCTIBLE HEALTH PLAN WITH HSA Disease Management Services...................................................................................................64 Complex Medical Conditions Programs and Services ..........................................................65 Women's Health/Reproductive................................................................................................69 SECTION 8 - EXCLUSIONS: WHAT THE MEDICAL PLAN WILL NOT COVER ..........................71 Alternative Treatments...............................................................................................................71 Comfort or Convenience...........................................................................................................71