Summary Plan Description Columbia University in the City of New York United Healthcare In-Network Option for Members of TWU 241 Maintenance at Lamont Doherty Earth Observatory and 1199 SEIU United Healthcare Workers East SSA Area Effective: January 1, 2019 Group Number: 712790 COLUMBIA UNIVERSITY MEDICAL CHOICE IN-NETWORK PLAN 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 Accessing Benefits ....................................................................................................................... 8 Eligible Expenses ....................................................................................................................... 10 Annual Deductible ..................................................................................................................... 11 Copayment .................................................................................................................................. 11 Coinsurance ................................................................................................................................ 11 Out-of-Pocket Maximum ......................................................................................................... 11 SECTION 4 - PERSONAL HEALTH SUPPORT and PRIOR AUTHORIZATION .......................... 12 Care Management ...................................................................................................................... 12 Prior Authorization.................................................................................................................... 13 Special Note Regarding Medicare ............................................................................................ 14 SECTION 5 - PLAN HIGHLIGHTS ................................................................................................. 15 Payment Terms and Features ................................................................................................... 15 Schedule of Benefits .................................................................................................................. 16 SECTION 6 - ADDITIONAL COVERAGE DETAILS ...................................................................... 25 Acupuncture Services ................................................................................................................ 25 Ambulance Services - Emergency Only ................................................................................. 25 Ambulance Services - Non-Emergency .................................................................................. 26 Cancer Resource Services (CRS) ............................................................................................. 26 Cellular and Gene Therapy ....................................................................................................... 27 Clinical Trials .............................................................................................................................. 27 I TABLE OF CONTENTS COLUMBIA UNIVERSITY MEDICAL CHOICE IN-NETWORK PLAN Congenital Heart Disease (CHD) Surgeries ........................................................................... 29 Dental Services - Accident Only .............................................................................................. 30 Diabetes Services ....................................................................................................................... 32 Durable Medical Equipment (DME) ...................................................................................... 32 Emergency Health Services - Outpatient ............................................................................... 34 Gender Dysphoria ..................................................................................................................... 34 Hearing Aids and Hearing Aid Exam ..................................................................................... 36 Home Health Care ..................................................................................................................... 36 Hospice Care .............................................................................................................................. 37 Hospital - Inpatient Stay ........................................................................................................... 37 Infertility Services ...................................................................................................................... 37 Injections in a Physician's Office ............................................................................................. 39 Lab, X-Ray and Diagnostics - Outpatient .............................................................................. 40 Lab, X-Ray and Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine - Outpatient................................................................................................................................. 40 Mental Health Services .............................................................................................................. 41 Neonatal Resource Services (NRS) ......................................................................................... 41 Neurobiological Disorders - Autism Spectrum Disorder Services ..................................... 42 Obesity Surgery .......................................................................................................................... 43 Orthognathic Surgery ................................................................................................................ 44 Ostomy Supplies ........................................................................................................................ 44 Physician Fees for Surgical and Medical Services ................................................................. 45 Physician's Office Services - Sickness and Injury .................................................................. 45 Pregnancy - Maternity Services ................................................................................................ 45 Preventive Care Services ........................................................................................................... 46 Private Duty Nursing - Outpatient.......................................................................................... 47 Prosthetic Devices ..................................................................................................................... 47 Reconstructive Procedures ....................................................................................................... 48 Rehabilitation Services - Outpatient Therapy and Manipulative Treatment ..................... 48 Scopic Procedures - Outpatient Diagnostic and Therapeutic ............................................. 50 Skilled Nursing Facility/Inpatient Rehabilitation Facility Services .................................... 51 Substance-Related and Addictive Disorders Services........................................................... 52 Surgery - Outpatient .................................................................................................................. 53 II TABLE OF CONTENTS COLUMBIA UNIVERSITY MEDICAL CHOICE IN-NETWORK PLAN Temporomandibular Joint Dysfunction (TMJ) ..................................................................... 53 Therapeutic Treatments - Outpatient ..................................................................................... 54 Transplantation Services ........................................................................................................... 55 Travel and Lodging .................................................................................................................... 56 Urgent Care Center Services .................................................................................................... 57 Virtual Visits ............................................................................................................................... 57 Vision Care.................................................................................................................................. 58 Wigs ............................................................................................................................................. 58 SECTION 7 - CLINICAL PROGRAMS AND RESOURCES ..........................................................