UnitedHealthcare Choice

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United Healthcare of Illinois, Inc. YOUR BENEFITS 233 N. Michigan / Chicago, IL 60601 / (312) 424-4460 CHC.BenSum.H.02.IL UnitedHealthcare Choice Plan PVG Choice plan gives you the freedom to see any Physician or other health care professional from our Network, including specialists, without a referral. With this plan, you will receive the highest level of benefits when you seek care from a network physician, facility or other health care professional. In addition, you do not have to worry about any claim forms or bills.
Some of the Important Benefits of Your Plan: You have access to a Network of physicians,
facilities and other health care professionals,
including specialists, without designating a
Primary Physician or obtaining a referral.
Benefits are available for office visits and
hospital care, as well as inpatient and
outpatient surgery.
Care Coordination SM services are available to help identify and prevent delays in care for
those who might need specialized help. Emergencies are covered anywhere in the
world.
Pap smears are covered.
Prenatal care is covered.
Routine check-ups are covered.
Childhood immunizations are covered.
Mammograms are covered.
Vision and hearing screenings are covered. The Managed Care Reform and Patient Rights Act of 1999 established rights for enrollees in
health care plans. These rights cover the following:
What emergency room visit will be paid for by your health care plan.
How specialists (both in and out of network) can be accessed.
How to file complaints and appeal health care plan decisions (including external independent reviews). How to obtain information about your health care plan, including general information about its financial arrangements with providers. For general assistance and information, please contact the Illinois Department of Insurance Office of
Consumer Health Insurance at 1-(877) 527-9431. (Please be aware that the Office of Consumer Health
Insurance will not be able to provide specific plan information. For this type of information you should
contact your health care plan directly.)
This summary of Benefits is intended only to highlight your Benefits and should not be relied upon to
fully determine coverage. This plan may not cover all your health care expenses. Please refer to the
Certificate of Coverage for a complete listing of services, limitations, exclusions and a description of
all the terms and conditions of coverage. If this description conflicts in any way with the Certificate
of Coverage, the Certificate of Coverage prevails. Terms that are capitalized in the Benefit
Summary are defined in the Certificate of Coverage. Choice Benefits Summary Types of Coverage Network Benefits /Copayment Amounts We pay Network Providers directly for your Covered Health
Services. If a Network Provider bills you for any Covered Health
Service, contact us. However, you are responsible for meeting the
Annual Deductible and for paying Copayments to a Network
provider at the time of service, or when you receive a bill from the
provider.

Annual Deductible: No Annual Deductible

Out-of-Pocket Maximum: $1,500 per Covered Person per calendar
year, not to exceed $3,000 for all Covered Persons in a family. The
Out-of-Pocket Maximum does include the Annual Deductible.
This Benefit Summary is intended
only to highlight your Benefits and
should not be relied upon to fully
determine coverage. This benefit
plan may not cover all of your
health care expenses. More
complete descriptions of Benefits
and the terms under which they
are provided are contained in
the Certificate of Coverage that
you will receive upon enrolling
in the Plan.
If this Benefit Summary conflicts
in any way with the Policy issued
to your employer, the Policy shall
prevail.
Terms that are capitalized in the
Benefit Summary are defined in
the Certificate of Coverage.
Benefits are payable for Covered
Health Services provided by or
under the direction of your
Network physician.
*Prior Notification is required for
certain services.
Maximum Policy Benefit: No Maximum Policy Benefit 1. Ambulance Services - Emergency only Ground Transportation: 20% of Eligible Expenses Air Transportation: 20% of Eligible Expenses 2. Dental Services - Accident only *20% of Eligible Expenses *Prior notification is required before follow-up treatment begins. 3. Durable Medical Equipment Benefits for Durable Medical
Equipment are limited to $2,500
per calendar year. 20% of Eligible Expenses YOUR BENEFITS Types of Coverage Network Benefits /Copayment Amounts 4. Emergency Health Services A serious medical condition or
symptom resulting from Injury,
Sickness or Mental Illness
which manifests itself by acute
symptoms of such severity that a
prudent layperson, who holds an
average knowledge of health
and medicine, could reasonably
expect the absence of immediate
medical care would result in:
-Placing the health of the
individual (or with respect to a
pregnant woman, the health of
the woman or her unborn child)
in serious jeopardy.
-Serious impairment to bodily
functions; or -Serious dysfunction of any bodily organ or part. $100 per visit 5. Eye Examinations Refractive eye examinations are
limited to one every calendar
year from a Routine Vision
Network Provider. $30 per visit 6. Home Health Care Benefits are limited to 60 visits
for skilled care services per
calendar year. One visit equals
four hours of skilled care
services. 20% of Eligible Expenses 7. Hospice Care Benefits are limited to 360 days
during the entire period of time
a Covered Person is covered
under the Policy. 20% of Eligible Expenses 8. Hospital - Inpatient Stay
Inpatient Stay in a Hospital.
Benefits are available for:
-Services and supplies received
during the Inpatient Stay. -Room and board in a Semi- private Room (a room with two
or more beds). $250 per Inpatient Stay Types of Coverage Network Benefits /Copayment Amounts 9. Injections Received in a Physicians Office $30 per visit 10. Maternity Services Same as 8, 11, 12 and 13 No Copayment applies to Physician office visits for prenatal care
after the first visit. 11. Outpatient Surgery, Diagnostic and Therapeutic
Services Outpatient Surgery 20% of Eligible Expenses Outpatient Diagnostic Services For lab and radiology/Xray: No Copayment For mammography testing: No Copayment Outpatient Diagnostic/Therapeutic Services
- CT Scans, Pet Scans, MRI and
Nuclear Medicine 20% of Eligible Expenses Outpatient Therapeutic Treatments 20% of Eligible Expenses 12. Physicians Office Services $30 per visit. No Copayment applies when a Physician charge is not assessed. 13. Professional Fees for Surgical and Medical Services 20% of Eligible Expenses 14. Prosthetic Devices Benefits for prosthetic devices
are limited to $2,500 per
calendar year. 20% of Eligible Expenses 15. Reconstructive Procedures Same as 8, 11, 12, 13 and 14 16. Rehabilitation Services - Outpatient Therapy
Benefits are limited to 60 visits
per calendar year for any
combination of physical
therapy, occupational therapy,
speech therapy, pulmonary
rehabilitation and cardiac
rehabilitation. 20% of Eligible Expenses 17. Skilled Nursing Facility/Inpatient
Rehabilitation Facility
Services
Benefits are limited to 60 days
per calendar year. 20% of Eligible Expenses 18. Transplantation Services *20% of Eligible Expenses YOUR BENEFITS Types of Coverage Network Benefits /Copayment Amounts 19. Urgent Care Center Services $50 per visit Additional Benefits Dental Services Anesthesia
and Hospital or Facility Charges As required for safe and effective
treatment of a dental condition but
only as specifically described in
the COC for Covered Persons who
are: age 6 or under; severely or
developmentally disabled; or who
are afflicted with one or more
medical conditions that require
hospitalization or general
anesthesia for dental care. Same as 8, 11, 12, and 13 Diabetes Self-Management and
Training Same as 8, 11, 12, and 13 Examination and Treatment for
Sexual Assault Same as 8, 11, 12, and 13 Mental Health Services
Outpatient
Must receive prior authorization
through the Mental
Health/Substance Abuse Designee.
Benefits are limited to 20 visits
per calendar year. Two sessions of
outpatient visits for Mental Health
Services may be substituted for
one day of inpatient Mental Health
Services. 50% of Eligible Expenses Mental Health Services
Inpatient and Intermediate
Must receive prior authorization
through the Mental
Health/Substance Abuse Designee.
Benefits are limited to 20 days per
calendar year. Two sessions of
intermediate care (such as partial
hospitalization) for Mental Health
Services may be substituted for
one day of inpatient Mental Health
Services. One inpatient day of
Mental Health Services may be
substituted for two outpatient
visits for Mental Health Services. 20% of Eligible Expenses Types of Coverage Network Benefits /Copayment Amounts Substance Abuse Services
Outpatient
Must receive prior authorization
through the Mental
Health/Substance Abuse Designee.
Benefits are limited to 20 visits
per calendar year. Two sessions of
outpatient visits for Substance
Abuse Services may be substituted
for one day of inpatient Substance
Services. 50% of Eligible Expenses Substance Abuse Services
Inpatient and Intermediate
Must receive prior authorization
through the Mental
Health/Substance Abuse Designee.
Benefits are limited to 20 days per
calendar year. Two sessions of
intermediate care (such as partial
hospitalization) for Substance
Abuse Services may be substituted
for one day of inpatient Substance
Abuse Services. One inpatient day
of Substance Abuse Services may
be substituted for two outpatient
visits for Substance Abuse
Services. 20% of Eligible Expenses Spinal Manipulation
Benefits include diagnosis and
related services and are limited to
one visit and treatment per day.
Benefits are limited to 24 visits
per calendar year. 20% of Eligible Expenses YOUR BENEFITS
Continuity of Treatment: You may be eligible for transition of care services. If you are a new enrollee,
have a condition that requires an ongoing course of treatment, and your provider is not a Network provider,
you must request transitional services within 30 days of enrollment. If you are a current member, have a
condition that requires an ongoing course of treatment, and your provider terminates his relationship with
us, you must request transitional services within 30 days of notification of the provider's termination.

Appeals Process: If you have a concern or question regarding the provision of Covered Health Services or
Benefits under the Policy, you should contact the Member Services Department at the telephone number or
address shown on your identification card. If the issue is not resolved through information discussions, you
may file a written complaint. You must present a written complaint to the Member Services representative at United Healthcare of
Illinois, Inc. We will acknowledge the receipt of your appeal within 3 days in writing and request all the
information required to evaluate your case. A formal decision will be made within 15 days after the receipt
of all required information.
If we make a final decision to deny Benefits, you may choose to request an independent external review.
Within 30 days after you receive written notice of our decision, you must send a written request to us,
including documentation to support your request. We will respond to the request within 30 days and
provide for the joint selection of an external independent reviewer. The independent external reviewer will
make a decision within 5 days after the receipt of all necessary information. Please contact us using the number on your identification card for more information regarding the
appeal process and external independent review.
If you have a complaint concerning products, services, operations or protocols, you should contact the
Member Services Department at the telephone number or address on your identification card.
If you are dissatisfied with the decision, you may take the grievance to the State of Illinois
Department of Insurance, Consumer Division at: 320 West Washington Street; Springfield, IL
62767-0001 OR 100 West Randolph Street; Suite 15-100; Chicago, IL 60601-3251.
You may also contact the Department electronically at http://www.state.il.us/ins.

Provider Disclosure: In accordance with the Managed Care Reform and Patient Rights Act of 1999
("Act"), a health care provider must provide you with the following information, where applicable, if you
request it:
Information related to the provider's educational background, training, experience, specialty, and board
certification.
Names of licensed facilities on the provider panel where the provider presently has privileges for the
treatment, illness, or procedure that is the subject of the request.
Information regarding the provider's participation in continuing education programs and compliance with
any licensure, certification, or registration requirements. Exclusions United Healthcare of Illinois, Inc. Except as may be specifically provided in Section 1 of
the Certificate of Coverage (COC) or through a Rider to
the Policy, the following are not covered:
A. Alternative Treatments
Acupressure; hypnotism; rolfing; massage therapy;
aromatherapy; acupuncture; and other forms of
alternative treatment.
B. Comfort or Convenience
Personal comfort or convenience items or services such
as television; telephone; barber or beauty service; guest
service; supplies, equipment and similar incidental
services and supplies for personal comfort including air
conditioners, air purifiers and filters, batteries and
battery chargers, dehumidifiers and humidifiers;
devices or computers to assist in communication and
speech.
C. Dental
Except as specifically described as covered in Section 1
of the COC under the headings Dental Services
Accidental Only and Dental Services Anesthesia and
Hospital or Facility Charges, dental care is excluded.
There is no coverage for services provided for the
prevention, diagnosis, and treatment of the teeth,
jawbones or gums (including extraction, restoration,
and replacement of teeth, medical or surgical treatments
of dental conditions, and services to improve dental
clinical outcomes). Dental implants and dental braces
are excluded. Dental x-rays, supplies and appliances
and all associated expenses arising out of such dental
services (including hospitalizations and anesthesia) are
excluded, except as might otherwise be required for
transplant preparation, initiation of
immunosuppressives, or the direct treatment of acute
traumatic Injury, cancer, or cleft palate. Treatment for
congenitally missing, malpositioned, or super numerary
teeth is excluded, even if part of a Congenital Anomaly.
D. Drugs
Prescription drug products for outpatient use that are
filled by a prescription order or refill. Self-injectable
medications. Non-injectable medications given in a
Physicians office except as required in an Emergency.
Over-the-counter drugs and treatments. Where a drug
prescribed for the treatment of a type of cancer has not
been approved by the Food and Drug Administration
for this particular purpose, the Plan will include
Coverage for such drug, provided that it meet the
specific criteria stated in Section 2 of the COC.

E. Experimental, Investigational or Unproven
Services
Experimental, Investigational or Unproven Services are
excluded. The fact that an Experimental, Investigational
or Unproven Service, treatment, device or
pharmacological regimen is the only available treatment
for a particular condition will not result in Benefits if
the procedure is considered to be Experimental,
Investigational or Unproven in the treatment of that
particular condition.
F. Foot Care
Routine foot care (including the cutting or removal of
corns and calluses), except when needed for prevention
of complications due to diabetes. Nail trimming,
cutting, or debriding. Hygienic and preventive
maintenance foot care (for example cleaning and
soaking the feet, applying skin creams in order to
maintain skin tone, or other services that are performed
when there is not a localized Illness, Injury or symptom
involving the foot). Treatment of flat feet or
subluxation of the foot. Shoe orthotics.
G. Medical Supplies and Appliances
Devices used specifically as safety items or to affect
performance in sports-related activities. Prescribed or
non-prescribed medical supplies and disposable
supplies (examples include elastic stockings, ace
bandages, gauze and dressings and ostomy supplies).
Orthotic appliances that straighten or re-shape a body
part (including cranial banding and some types of
braces). Tubings and masks are not covered except
when used with Durable Medical Equipment as
described in Section 1 of the COC.
H. Mental Health/Substance Abuse
Services performed in connection with conditions not
classified in the current edition of the Diagnostic and
Statistical Manual of the American Psychiatric
Association. Services that extend beyond the period
necessary for short-term evaluation, diagnosis,
treatment, or crisis intervention. Mental Health
treatment of insomnia and other sleep disorders,
neurological disorders, and other disorders with a
known physical basis.
Treatment for Mental Illnesses that will not
substantially improve beyond the current level of
functioning, or for conditions not subject to favorable
modification or management according to generally
accepted standards of psychiatric care as determined by
the Mental Health/Substance Abuse Designee. This
includes, but is not limited to, conduct and impulse
control disorders, personality disorders and paraphilias. Exclusions United Healthcare of Illinois, Inc. Services utilizing methadone treatment as maintenance,
L.A.A.M. (1-Alpha-Acetyl-Methadol), Cyclazocine, or
their equivalents. Treatment provided in connection
with or to comply with involuntary commitments,
police detentions and other similar arrangements, unless
authorized by the Mental Health/Substance Abuse
Designee. Residential treatment services.
I. Nutrition
Megavitamin and nutrition based therapy; nutritional
counseling for either individuals or groups, except
when prescribed for treatment of diabetes. Enteral
feedings and other nutritional and electrolyte
supplements, including infant formula and donor breast
milk.
J. Physical Appearance
Cosmetic Procedures (examples include
pharmacological regimens, scar or tattoo removal or
revision procedures such as salabrasion, chemosurgery
and other such skin abrasion procedures; and skin
abrasion procedures performed as a treatment for acne).
Replacement of an existing breast implant if the earlier
breast implant was a Cosmetic Procedure (Note:
replacement of an existing breast implant is considered
reconstructive if the initial breast implant followed
mastectomy. See Reconstructive Procedures in Section
1 of the COC). Physical conditioning programs such as
athletic training, body-building, exercise, fitness,
flexibility, and diversion or general motivation. Weight
loss programs whether or not they are under medical
supervision. Weight loss programs for medical reasons
are also excluded. Wigs, regardless of the reason for the
hair loss.
K. Providers
Services performed by a provider with your same legal
residence or who is a family member by birth or
marriage, including spouse, brother, sister, parent or
child. This includes any service the provider may
perform on himself or herself. Services provided at a
free-standing or Hospital-based diagnostic facility
without an order written by a Physician or other
provider as further described in Section 2 of the COC
(this exclusion does not apply to mammography
testing). L. Reproduction
Health services and associated expenses for infertility
treatments. Surrogate parenting. The reversal of
voluntary sterilization. Costs for preservation of an
embryo.
M. Services Provided under Another Plan
Health services for which other coverage is required by
federal, state or local law to be purchased or provided
through other arrangements, including but not limited to
coverage required by workers compensation, no-fault
automobile insurance, or similar legislation. If coverage
under workers compensation or similar legislation is
optional because you could elect it, or could have it
elected for you, Benefits will not be paid for any Injury,
Mental Illness or Sickness that would have been
covered under workers compensation or similar
legislation had that coverage been elected.
Health services for treatment of military service-related
disabilities, when you are legally entitled to other
coverage and facilities are reasonably available to you.
Health services while on active military duty.
N. Transplants
Health services connected with the removal of an organ
or tissue from you for purposes of a transplant to
another person. (Donor costs for removal are payable
for a transplant through the organ recipient's Benefits
under the Policy). Health services for transplants
involving mechanical or animal organs.
Transplant services that are not performed at a
Designated Facility.
O. Travel
Health services provided in a foreign country, unless
required as Emergency Health Services.
Travel or transportation expenses, even though
prescribed by a Physician. Some travel expenses related
to covered transplantation services may be reimbursed
at our discretion.
P. Vision and Hearing
Purchase cost of eye glasses, contact lenses, or hearing
aids. Fitting charge for hearing aids, eye glasses or
contact lenses. Eye exercise therapy. Surgery that is
intended to allow you to see better without glasses or
other vision correction including radial keratotomy,
laser, and other refractive eye surgery. Exclusions United Healthcare of Illinois, Inc. This summary of Benefits is intended only to highlight your Benefits and should not be relied upon to fully
determine coverage. This plan may not cover all your health care expenses. Please refer to the Certificate of
Coverage for a complete listing of services, limitations, exclusions and a description of all the terms and
conditions of coverage. If this description conflicts in any way with the Certificate of Coverage, the
Certificate of Coverage prevails. Terms that are capitalized in the Benefit Summary are defined in the
Certificate of Coverage.
02H_BS_Chc ILTAMPVG02 PVG 230-4466 _1204 Q. Other Exclusions
Health services and supplies that do not meet the
definition of a Covered Health Service - see definition
in Section 10 of the COC.
Physical, psychiatric or psychological examinations,
testing, vaccinations, immunizations or treatments
otherwise covered under the Policy, when such services
are: (1) required solely for purposes of career,
education, sports or camp, travel, employment,
insurance, marriage or adoption; (2) relating to judicial
or administrative proceedings or orders; (3) conducted
for purposes of medical research; or (4) to obtain or
maintain a license of any type.
Health services received as a result of war or any act of
war, whether declared or undeclared or caused during
service in the armed forces of any country.
Health services received after the date your coverage
under the Policy ends, including health services for
medical conditions arising prior to the date your
coverage under the Policy ends.
Health services for which you have no legal
responsibility to pay, or for which a charge would not
ordinarily be made in the absence of coverage under the
Policy.
Charges in excess of Eligible Expenses or in excess of
any specified limitation.
Services for the evaluation and treatment of
temporomandibular joint syndrome (TMJ), whether the
services are considered to be medical or dental in
nature.
Upper and lower jaw bone surgery except as required
for direct treatment of acute traumatic Injury or cancer.
Orthognathic surgery, jaw alignment, and treatment for the temporomandibular joint, except as a treatment of
obstructive sleep apnea.
Surgical treatment and non-surgical treatment of
obesity (including morbid obesity).
Growth hormone therapy; sex transformation
operations; treatment of benign gynecomastia
(abnormal breast enlargement in males); medical and
surgical treatment of excessive sweating
(hyperhidrosis); medical and surgical treatment for
snoring, except when provided as part of treatment for
documented obstructive sleep apnea. Oral appliances
for snoring.
Custodial care; domiciliary care; private duty nursing;
respite care; rest cures.
Psychosurgery. Speech therapy except as required for
treatment of a speech impediment or speech
dysfunction that results from Injury, stroke or
Congenital Anomaly.
R. Preexisting Conditions
Benefits for the treatment of a Preexisting Condition are
excluded until the date you have had Continuous
Creditable Coverage for 12 months. This exclusion only
applies to Covered Persons who enroll at a time other
than the Initial Enrollment Period, Open Enrollment
Period, or any special enrollment period described in
Section 4 of your COC.
This exclusion does not apply to newborn children or
newly adopted children. This exception for newborn
and adopted children no longer applies after the end of
the first 63-day period during which the child has not
had Continuous Creditable Coverage.

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