Summary Plan Description City of Milwaukee Active Choice Plan Effective: January 1, 2012 Group Number: 712481 CITY OF MILWAUKEE MEDICAL ACTIVE CHOICE PLAN TABLE OF CONTENTS SECTION 1 - WELCOME ................................................................................................................. 1 SECTION 2 - INTRODUCTION ......................................................................................................... 3 Eligibility ....................................................................................................................................... 3 Cost of Coverage ......................................................................................................................... 3 How to Enroll .............................................................................................................................. 4 When Coverage Begins ............................................................................................................... 4 Changing Your Coverage ............................................................................................................ 5 SECTION 3 - HOW THE PLAN WORKS .......................................................................................... 7 Network and Non-Network Benefits ....................................................................................... 7 Eligible Expenses ......................................................................................................................... 8 Annual Deductible ....................................................................................................................... 8 Coinsurance .................................................................................................................................. 8 Out-of-Pocket Maximum ........................................................................................................... 9 SECTION 4 - PERSONAL HEALTH SUPPORT ............................................................................ 11 Requirements for Notifying Personal Health Support ......................................................... 12 Special Note Regarding Medicare ............................................................................................ 12 SECTION 5 - PLAN HIGHLIGHTS ................................................................................................. 13 SECTION 6 - ADDITIONAL COVERAGE DETAILS ...................................................................... 19 Ambulance Services ................................................................................................................... 19 Autism Spectrum Disorder Services ....................................................................................... 20 Breast Reduction Surgery .......................................................................................................... 22 Cancer Resource Services (CRS) ............................................................................................. 22 Clinical Trials .............................................................................................................................. 23 Congenital Heart Disease (CHD) Surgeries ........................................................................... 24 Dental/Anesthesia – Hospital or Ambulatory Surgery Services ......................................... 25 Dental Services - Accident Only .............................................................................................. 25 Diabetes Services ....................................................................................................................... 27 Durable Medical Equipment (DME) ...................................................................................... 27 Emergency Health Services - Outpatient ............................................................................... 28 I TABLE OF CONTENTS CITY OF MILWAUKEE MEDICAL ACTIVE CHOICE PLAN Hearing Aids and Testing ......................................................................................................... 29 Home Health Care ..................................................................................................................... 29 Hospice Care .............................................................................................................................. 30 Hospital - Inpatient Stay ........................................................................................................... 30 Kidney Resource Services (KRS) ............................................................................................. 30 Lab, X-Ray and Diagnostics - Outpatient .............................................................................. 31 Lab, X-Ray and Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine - Outpatient................................................................................................................................. 32 Mental Health Services .............................................................................................................. 32 Nutritional Counseling .............................................................................................................. 34 Oral Surgery ................................................................................................................................ 34 Ostomy Supplies ........................................................................................................................ 35 Pharmaceutical Products - Outpatient .................................................................................... 35 Physician Fees for Surgical and Medical Services ................................................................. 35 Physician's Office Services - Sickness and Injury .................................................................. 36 Pregnancy - Maternity Services ................................................................................................ 36 Preventive Care Services ........................................................................................................... 36 Prosthetic Devices ..................................................................................................................... 37 Reconstructive Procedures ....................................................................................................... 38 Rehabilitation Services - Outpatient Therapy and Manipulative Treatment ..................... 38 Scopic Procedures - Outpatient Diagnostic and Therapeutic ............................................. 39 Skilled Nursing Facility/Inpatient Rehabilitation Facility Services .................................... 40 Substance Use Disorder Services ............................................................................................ 41 Surgery - Outpatient .................................................................................................................. 43 Temporomandibular Joint (TMJ) Services ............................................................................. 43 Therapeutic Treatments - Outpatient ..................................................................................... 43 Transplantation Services ........................................................................................................... 44 Travel and Lodging .................................................................................................................... 45 Urgent Care Center Services .................................................................................................... 46 Vision Examinations ................................................................................................................. 46 SECTION 7 - RESOURCES TO HELP YOU STAY HEALTHY ...................................................... 47 Consumer Solutions and Self-Service Tools .......................................................................... 47 Disease and Condition Management Services ....................................................................... 51 II TABLE OF CONTENTS CITY OF MILWAUKEE MEDICAL ACTIVE CHOICE PLAN Wellness Programs ..................................................................................................................... 53 SECTION 8 - EXCLUSIONS: WHAT THE MEDICAL PLAN WILL NOT COVER .......................... 55 Alternative Treatments .............................................................................................................. 55 Dental .......................................................................................................................................... 55 Devices, Appliances and Prosthetics ...................................................................................... 56 Drugs ........................................................................................................................................... 57 Experimental or Investigational or Unproven Services ....................................................... 57 Foot Care .................................................................................................................................... 58 Medical Supplies and Equipment ............................................................................................ 59 Mental Health/Autism Spectrum Disorder/Substance Use Disorder .............................. 59 Nutrition .....................................................................................................................................