Glossary
A health care facility that is attached to a Hospital and designated by the Hospital as an Alternate Facility. It may also be a separate freestanding facility that is not a Hospital. An Alternate Facility provides one or more of the following services on an outpatient basis:
- Pre-scheduled surgical services
- Emergency health services
- Pre-scheduled rehabilitative, laboratory, diagnostic, or therapeutic services
An alternate facility may also provide mental health or substance use disorder treatment on an outpatient basis.
A charge—in addition to the coinsurance—that you are required to pay for a covered Brand Name Prescription Drug Product that you (not your doctor) request when a Generic is available. Available Generic substitutions are identified on the Maximum Allowable Cost (MAC) List. The Ancillary Charge is calculated as the difference between the network pharmacy's contracted reimbursement rate for the Prescription Drug Product dispensed, and the MAC List price of the Generic substitute.
The annual deductible is the amount you pay in eligible expenses each year before the plan pays benefits.
A family deductible also applies. Once met, all individuals covered under the family plan will be considered to have met their deductible for the year. To satisfy the family deductible, one person in the family must satisfy his or her individual deductible, then remaining family members, in aggregate, must satisfy the remainder of the deductible amount.
This is the maximum amount per individual that the plan will pay for covered dental services in a calendar year.
UnitedHealthcare provides certain claim administration services for the plan.
A form of cost sharing in which you and the plan each pay a set percentage for covered services.
The charge you are required to pay for certain Covered Health Services. A copayment may be either a set dollar amount or a percentage of eligible expenses.
Procedures or services that change or improve appearance without significantly improving physiological function as determined by the Claims Administrator.
Health services provided for the purpose of preventing, diagnosing, or treating a sickness, injury, mental illness, substance abuse, or their symptoms. A Covered Health Service is a health care service or supply as described by the plan and which is not excluded. Covered Health Services must be provided:
- When the plan is in effect,
- Before your or your dependents' coverage ends, and
- Only when the patient is an eligible covered person.
Services that:
- Are non-health related services, such as assistance in feeding, dressing, bathing, transferring, and ambulating
- Are health-related services which do not seek to cure, or which are provided during periods when the medical condition of the patient is not expected to change
- Do not require continued administration by trained medical personnel in order to be delivered safely and effectively
The employee's spouse/domestic partner or an unmarried dependent child of the employee or the employee's spouse, as defined under General Health Care Facts.
Any dental practitioner who is properly licensed and qualified by law.
A facility that has entered into an agreement with the Claims Administrator or with an organization contracting on behalf of the plan to provide covered health services for the treatment of specified diseases or conditions. A Designated Facility may or may not be located within your geographic area. The fact that a facility is a Network facility does not mean it is a Designated Facility.
Medical equipment that is all of the following:
- Can withstand repeated use
- Is not disposable
- Is used to treat a sickness, injury, or their symptoms
- Is generally not useful to a person in the absence of a sickness, injury, or their symptoms
- Is appropriate for use in the home
The Eligible Expense is the amount the plan will pay for a Covered Health Service. Eligible expenses are determined solely in accordance with the claims administrator’s reimbursement policy guidelines. The claims administrator develops the reimbursement policy guidelines, in its discretion, following evaluation and validation of all provider billings in accordance with one or more of the following methodologies:
- As indicated in the most recent edition of the Current Procedural Terminology (CPT), a publication of the American Medical Association, and/or the Centers for Medicare and Medicaid Services (CMS);
- As reported by generally recognized professionals or publications;
- As used for Medicare; or
- As determined by medical staff and outside medical consultants pursuant to other appropriate source or determination that the Claims Administrator accepts.
A serious medical condition or symptom resulting from injury, sickness, or mental illness which:
- Arises suddenly, and
- In the judgment of a reasonable person, requires immediate treatment—generally within 24 hours of onset—to avoid jeopardy to life or health.
Any services, products, or supplies that UnitedHealthcare and TAMS determine are:
- Not approved by the U.S. Food and Drug Administration (FDA) for marketing,
- Not identified in the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as appropriate,
- Subject to review and approval by any institutional review board for the proposed use,
- The subject of an ongoing Phase 1, 2, or 3 clinical trial as set forth in the FDA regulations, except where noted as a covered service.
If you have a life threatening sickness or condition that is likely to cause death within one year of the request for treatment, UnitedHealthcare and TAMS may, at their discretion, consider an otherwise Experimental or Investigational Service to be covered for that condition. Before such consideration, UnitedHealthcare and TAMS must determine that the service has significant potential as an effective treatment and that the service would be provided under standards equivalent to those defined by the National Institutes of Health.
See Preferred Drug List.
An examination of blood or other tissue for chromosomal and DNA abnormalities and alterations, or other expressions of gene abnormalities that may indicate an increased risk for developing a specific disease or disorder.
An institution, operated as required by law, that:
- Is primarily engaged in providing inpatient health services for the acute care and treatment of injured or sick individuals
- Provides care through medical, mental health, substance use disorder, diagnostic, and surgical facilities, by or under the supervision of a staff of physicians
- Has 24-hour nursing services
A Hospital (or a special unit of a Hospital that is designated as an Inpatient Rehabilitation Facility) that provides inpatient rehabilitation health services as authorized by law for:
- Physical therapy
- Occupational therapy
- Speech therapy
An uninterrupted confinement, following formal admission to a Hospital, Skilled Nursing Facility, or Inpatient Rehabilitation Facility.
A list of Prescription Drug Products that are commonly prescribed by physicians for long-term use. This list is designated by the Claims Administrator and is subject to periodic review and modification. Contact the Claims Administrator to obtain a copy of the list of Maintenance Medications. Maintenance medications are used on an ongoing basis to treat a variety of illnesses such as:
- Anemia
- Arthritis
- Diabetes
- Emphysema
- Epilepsy
- Heart disorders
- High blood pressure
- Thyroid or adrenal conditions
- Ulcers
A list of Prescription Drug Products that will be covered at a Generic product price level. The list is established by the Claims Administrator and is subject to periodic review and modification.
Your Member ID number is a unique health care identifier. It is a nine-digit number; if there are less than nine digits, it will include preceding zeros in order to make up the difference. Your Member ID number is not your Social Security Number. TAMS and the health plans use your Member ID number to administer claims and eligibility for the following plans: medical, dental, prescription drug, employee assistance program, and mental health/substance abuse.
A Network provider contractually agrees to provide Covered Health Services to Covered Persons. He or she may agree to provide only certain Covered Health Services, but not all Covered Health Services. For services that the provider has no agreement, those charges will be eligible for Non-Network payments. Keep in mind that the participation status of providers will change from time to time.
Benefits for Covered Health Services that are provided by a Network Physician or other Network provider.
A pharmacy that has:
- Entered into an agreement with the Claims Administrator to provide Prescription Drug Products to Covered Persons
- Agreed to accept specified reimbursement rates for dispensing Prescription Drug Products
- Been designated by the Claims Administrator as a Network Pharmacy
A Prescription Drug Product or new dosage of a previously approved Prescription Drug Product that is approved by the FDA, but not yet on UnitedHealthcare's Preferred Drug List. A prescription drug product or new dosage is no longer considered new on the earlier of:
- The date it is approved by the Claims Administrator's Preferred Drug List Management Committee, or
- December 31st of the following calendar year
Benefits for Covered Health Services that are provided by a Non-Network Physician or other Non-Network provider.
The medical plans protect you from costly medical expenses by limiting the amount of covered medical expenses you pay in any one calendar year. When you reach this Out-of-Pocket limit, the plan pays 100% of Eligible Expenses for the remainder of that calendar year.
In the Choice Plus CDHP Premier, there is no Out-of-Pocket Maximum when you use network providers. That's because the plan pays 100% for covered network expenses after you meet the deductible. In other words, the deductible is the most you will have to pay if you always use network providers!
In the Choice Plus CDHP Basic and Select plans, if you use both Network and Non-Network benefits, two separate Out-of-Pocket maximums apply.
Certain types of expenses do not apply to the Out-of-Pocket limit and will never be covered at 100%, even when the Out-of-Pocket Maximum is reached. Please refer to each plan's Out-of-Pocket Maximum descriptions for details about services that apply and do not apply to the Out-of-Pocket Maximum.
The Out-of-Pocket Maximum is not prorated for new employees; if you join the plan after January 1, you must meet the full Out-of-Pocket Maximum in that calendar year.
Any Doctor of Medicine (M.D.), or Doctor of Osteopathy (D.O.) who is properly licensed and qualified by law. In addition, any podiatrist, dentist, psychologist, chiropractor, optometrist, Christian Science Practitioner, or other provider who acts within the scope of his or her license will be considered on the same basis as a physician.
Services related to pregnancy include all of the following:
- Prenatal care
- Postnatal care
- Childbirth
- Any complications associated with pregnancy
The rate the Claims Administrator has agreed to pay Network Pharmacies for a Prescription Drug Product dispensed at a Network Pharmacy. It includes dispensing fees and sales tax.
A PDL is a list of commonly prescribed generic and brand name medications. UnitedHealthcare physicians, pharmacists, and business leaders place medications into tiers depending on their value, effectiveness, and cost as of the time the PDL is updated.
- Tier 1 is your lowest cost
- Tier 2 is your midrange cost
- Tier 3 is your highest cost
The PDL contains both brand and generic prescription medications approved by the U.S. Food and Drug Administration.
The PDL is reviewed periodically and may change. View the PDL here.
A medication, product, or device that has been approved by the FDA and that can lawfully be dispensed by a doctor's prescription. A Prescription Drug Product includes a medication that, due to its characteristics, can be self-administered or administered by a non-skilled caregiver. This definition includes:
- Inhalers (with spacers)
- Insulin
- The following diabetic supplies:
- Insulin syringes with needles
- Blood testing strips - glucose
- Urine testing strips - glucose
- Ketone testing strips and tablets
- Lancets and lancet devices
- Insulin pump supplies, including infusion sets, reservoirs, glass cartridges, and insertion sets
- Glucose monitors
The directive to dispense a Prescription Drug Product issued by a licensed health care provider whose scope of practice permits issuing such a directive.
Preventive medications are typically prescribed for individuals who have been diagnosed with a chronic disease such as diabetes, heart disease, and cancer. These preventive medications are paid at the applicable coinsurance and are excluded from the deductible requirements of your pharmacy benefit. To determine the tier and coinsurance levels for the preventive medications, view the List of Preventive Medications. Please note that this list is subject to change by UnitedHealthcare.
Coverage is not guaranteed for all of TAMS' benefits plans. For some plans, the insurance company requires that you show ("prove") that you or your dependents are in good health before it will approve coverage. Proof of good health (also referred to as evidence of insurability) is a record of a person's past and current health events. When required, you must complete an evidence of insurability form and take any requested medical exams and lab tests. Plans that may require proof of good health are voluntary critical illness, supplemental life, dependent life, and long term care coverage.
A room with two or more beds. The cost for a private room will be covered only when:
- An inpatient stay in a semi-private room is a Covered Health Service,
- A private room is necessary in terms of generally accepted medical practice, or
- A semi-private Room is not available.
Physical illness, disease or pregnancy. The term sickness as used in this SPD does not include mental illness or substance abuse, regardless of the cause or origin of the mental illness or substance abuse.
A Hospital or nursing facility that is licensed and operated as required by law.
Detection or correction (by manual or mechanical means) of subluxations in the body to remove nerve interference or its effects. The interference must be related to distortion, misalignment, or subluxation of (or in) the vertebral column.
An employee's inability to perform all of the substantial and material duties of his or her regular employment or occupation; and a dependent's inability to perform the normal activities of a person of like age and sex. For a description of employee and dependent, see General Health Care Facts.
Health services that are not consistent with favorable conclusions of prevailing medical research and which are based on clinical trials that do not meet the following standards:
- Well-conducted, randomized controlled trials (two or more treatments are compared to each other, and the patient does not know which treatment is received)
- Well-conducted cohort studies (patients who receive study treatment are compared to a group of patients who receive standard therapy; the comparison group must be nearly identical to the study group)
If you have a life-threatening condition (one that is likely to cause death within one year of the request for treatment), the Claims Administrator may, in its discretion, determine that an Unproven Service meets the definition of a Covered Health Service for that condition. In that case, the Claims Administrator must determine that the procedure or treatment is promising, but unproven, and that the service uses a specific research protocol that meets equivalent standards as those defined by the National Institutes of Health.
An urgent medical condition is one that requires prompt medical attention, but is not life-threatening or likely to cause serious impairment. Some examples of urgent medical conditions include persistent vomiting, high fever, cuts that may require stitches, fractures, and bad sprains. You may obtain urgent medical treatment from your physician or from an Urgent Care Center.
A facility, other than a Hospital, that provides Covered Health Services to prevent serious deterioration of your health due to an unforeseen sickness, injury, or the onset of acute or severe symptoms. Urgent care centers can be an alternative way to obtain care when your medical needs can't wait for a normal appointment with your Physician.
Delta Dental's benefits are based on usual, customary, and reasonable (UCR) guidelines, which is their allowed amount for a dental service or supply. DPO/PPO and DeltaPremier dentists have agreed not to charge Delta members more than the UCR amount. Non-Delta dentists do not agree to UCR rates, so their fees may exceed the amounts allowed by Delta. Charges above the UCR amount are not covered, so you will be responsible for any charges above the UCR amount when you use non-Delta dentists.