Sandia Total Health administered by UnitedHealthcare (Employees, PreMedicare Retirees, Survivors, & Long Term Disability (LTD) Terminees) Revised: January 1, 2021 Program Summary IMPORTANT This Program Summary applies to all employees, PreMedicare retirees, survivors, and Long Term Disability (LTD) Terminees effective January 1, 2021. For more information on other benefit programs, refer to the National Technology & Engineering Solutions of Sandia, LLC. ("NTESS") Health Benefits Plan for Employees Summary Plan Description or the NTESS Health Benefits Plan for Retirees Summary Plan Description. The Sandia Total Health Program is maintained at the discretion of NTESS and is not intended to create a contract of employment and does not change the at will employment relationship between you and NTESS. The NTESS Board of Managers (or designated representative) reserve the right to amend (in writing) any or all provisions of the Sandia Total Health Program, and to terminate (in writing) the Sandia Total Health Program at any time without prior notice, subject to applicable collective bargaining agreements. The Sandia Total Health Program’s terms cannot be modified by written or oral statements to you from human resources representatives or other NTESS personnel. Sandia National Laboratories is a multimission laboratory managed and operated by National Technology & Engineering Solutions of Sandia, LLC., a wholly owned subsidiary of Honeywell International, Inc., for the U.S. Department of Energy’s National Nuclear Security Administration under contract DE-NA0003525. SAND2021-3597 O Contents Section 1. Introduction .................................................................................................. 1 Section 2. Summary of Changes ................................................................................... 2 Section 3. Accessing Care .............................................................................................. 5 In-Network and Out-of-Network Options ....................................................................... 5 Eligible Expenses ............................................................................................................ 6 In-Network Benefits ................................................................................................ 7 Prior Authorization Requirements ................................................................................... 8 Medical Services ..................................................................................................... 9 Behavioral Health .................................................................................................. 11 Predetermination of Benefits ......................................................................................... 12 Non-Emergency or Non-Urgent Care Away from Home ............................................. 12 Provider Networks ......................................................................................................... 12 UnitedHealth Premium® Designation Program ............................................................ 13 Provider Directories....................................................................................................... 14 Provider Searches Online ...................................................................................... 15 Precertification Requirements for EAP Services .................................................. 15 Virtual Visits ................................................................................................................. 16 UnitedHealth Personal Health Support Program ........................................................... 17 Case Management Program .................................................................................. 17 Disease Management Program .............................................................................. 19 Centers of Excellence (formerly United Resource Networks (URN) Programs) .......... 20 Transplant Resource Services Program (Organ and Tissue Transplantation) ....... 23 Cancer Resource Services Program ...................................................................... 25 i Sandia Total Health Program Summary UnitedHealthcare Congenital Heart Disease Resource Services Program ......................................... 27 Healthcare Fraud Information ....................................................................................... 28 Section 4. Deductibles, Out-of-Pocket Limits and Lifetime Limits ......................... 29 Deductibles .................................................................................................................... 29 Deductibles for Admissions Spanning Two Calendar Years ................................ 31 Coinsurance ................................................................................................................... 31 Out-of-Pocket Limits ..................................................................................................... 32 Medical Expenses Incurred through UnitedHealthcare......................................... 32 Prescription Drug Expenses Incurred through Express Scripts............................. 35 Lifetime Limits .............................................................................................................. 35 Section 5. Health Reimbursement Account ............................................................... 36 Health Reimbursement Account (HRA) Amounts ........................................................ 36 Annual Allocation of HRA Contributions ............................................................ 36 Events Resulting in Loss of HRA Funds .............................................................. 37 New Hires .............................................................................................................. 38 Eligible Mid-Year Election Change Events .......................................................... 38 Open Enrollment Changes for Dual Sandians ....................................................... 38 What Healthcare Expenses are Eligible for HRA Reimbursement ............................... 39 How the HRA Works .................................................................................................... 39 Example 1 .............................................................................................................. 39 Example 2 .............................................................................................................. 40 UHC Healthcare Spending MasterCard ........................................................................ 41 Claims Processing with an HCFSA and/or HRA .......................................................... 42 Medical Expenses .................................................................................................. 43 ii Sandia Total Health Program Summary UnitedHealthcare Prescription Drugs ................................................................................................. 43 Setting up Direct Deposit ...................................................................................... 44 Turning off the Auto-Rollover Feature ......................................................................... 44 If you have an HRA .............................................................................................. 44 If you have both an HCFSA and HRA .................................................................. 44 Health Assessment and Biometric Screenings .............................................................. 45 Health Assessment Process ................................................................................... 45 Biometric Screenings Process ............................................................................... 46 Virgin Pulse Incentive Management Program .............................................................. 46 Health Action Plan ................................................................................................ 46 Tools and Resources to Become a More Informed Consumer ...................................... 47 My UHC Website .................................................................................................. 47 Express Scripts Website ........................................................................................ 47 Section 6. Covered Medical Plan Services & Limitations ........................................ 49 Program Highlights ....................................................................................................... 49 Coverage Details ........................................................................................................... 50 Acupuncture Services ............................................................................................ 50 Allergy Services .................................................................................................... 50 Ambulance Services .............................................................................................. 50 Auditory Integration Training ............................................................................... 51 Behavioral Health Services ................................................................................... 51 Special Mental Health Programs and Services ..................................................... 52 Cancer Services ....................................................................................................