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Medical SummaryValero 1,000 Deductible Retiree Choice PlusCopay/ 500 Deductible Retiree Choice Plus 500 Deductible Retiree Out-of-Area PPOEffective: January 1, 2021Group Number: 907816
VALERO MEDICAL COVERAGESTABLE OF CONTENTSWELCOME . 5INTRODUCTION. 5HOW THE COVERAGE WORKS . 5PERSONAL HEALTH SUPPORT and PRIOR AUTHORIZATION . 6Care Management . 6Prior Authorization. 7Covered Health Services which Require Prior Authorization . 8ADDITIONAL COVERAGE DETAILS . 10Acupuncture Services . 10Ambulance Services . 10Cellular and Gene Therapy . 11Clinical Trials - Routine Patient Care Costs . 11Congenital Heart Disease (CHD) Surgeries . 13Dental Services - Accident Only. 15Diabetes Services . 16Durable Medical Equipment (DME) . 16Emergency Health Services - Outpatient . 18Enteral Nutrition. 19Gender Dysphoria . 20Hearing Aid Exams and Hearing Aids . 20Home Health Care . 21Hospice Care . 21Hospital - Inpatient Stay . 22Infertility Services . 22Lab, X-Ray and Diagnostics - Outpatient . 25Lab, X-Ray and Major Diagnostics - CT, PET Scans, MRI, MRA and Nuclear Medicine- Outpatient. 26Mental Health Services . 26Neurobiological Disorders - Autism Spectrum Disorder Services. 27Nutritional Counseling . 29iTABLE OF CONTENTS
VALERO MEDICAL COVERAGESObesity Surgery . 30Ostomy Supplies . 30Pharmaceutical Products - Outpatient . 31Physician Fees for Surgical and Medical Services . 32Physician's Office Services - Sickness and Injury . 32Pregnancy - Maternity Services . 32Preventive Care Services . 33Private Duty Nursing - Outpatient. 34Prosthetic Devices . 34Reconstructive Procedures . 35Rehabilitation Services - Outpatient Therapy and Manipulative Treatment . 36Scopic Procedures - Outpatient Diagnostic and Therapeutic . 39Skilled Nursing Facility/Inpatient Rehabilitation Facility Services . 39Substance-Related and Addictive Disorders Services. 40Surgery - Outpatient . 42Therapeutic Treatments - Outpatient . 43Transplantation Services . 44Urinary Catheters . 45Urgent Care Center Services . 45Virtual Visits . 45CLINICAL PROGRAMS AND RESOURCES . 45Consumer Solutions and Self-Service Tools . 46Disease Management Services . 49Complex Medical Conditions Programs and Services . 49Travel and Lodging Assistance Program . 52EXCLUSIONS AND LIMITATIONS: WHAT THE MEDICAL BENEFIT WILL NOT COVER . 55Alternative Treatments. 56Dental . 56Devices, Appliances and Prosthetics . 57Drugs . 58Experimental or Investigational or Unproven Services . 59Foot Care . 59iiTABLE OF CONTENTS
VALERO MEDICAL COVERAGESGender Dysphoria . 60Medical Supplies and Equipment . 60Mental Health, Neurobiological Disorders - Autism Spectrum Disorder Services andSubstance-Related and Addictive Disorders Services. 61Nutrition . 62Personal Care, Comfort or Convenience . 62Physical Appearance . 63Procedures and Treatments . 63Providers . 65Reproduction . 65Services Provided under Another Plan . 66Transplants. 67Travel . 67Types of Care . 67Vision and Hearing . 68All Other Exclusions . 68CLAIMS PROCEDURES . 71Network Benefits . 71Non-Network Benefits . 71If Your Provider Does Not File Your Claim. 71Health Statements . 73Explanation of Benefits (EOB) . 73Claim Denials and Appeals . 73Federal External Review Program . 75Limitation of Action . 82COORDINATION OF BENEFITS (COB) . 83Determining Which Coverage is Primary. 83When This Coverage is Secondary . 84Right to Receive and Release Needed Information . 85Overpayment and Underpayment of Benefits. 85SUBROGATION AND REIMBURSEMENT . 87Right of Recovery . 90iiiTABLE OF CONTENTS
VALERO MEDICAL COVERAGESWHEN COVERAGE ENDS . 92OTHER IMPORTANT INFORMATION . 92Qualified Medical Child Support Orders (QMSCOs) . 92Your Relationship with UnitedHealthcare and Valero. 92Relationship with Providers . 92Your Relationship with Providers . 93Interpretation of Benefits . 93Review and Determine Benefits in Accordance with UnitedHealthcare ReimbursementPolicies . 94Information and Records. 95Incentives to Providers . 96Incentives to You . 96Rebates and Other Payments . 96Future of the Plan . 97Plan Document . 97GLOSSARY . 98IMPORTANT ADMINISTRATIVE INFORMATION: ERISA . 114HEALTH CARE REFORM NOTICES . 114LEGAL NOTICES . 114ATTACHMENT I – NONDISCRIMINATION AND ACCESSIBILITY REQUIREMENTS . 115ATTACHMENT II – GETTING HELP IN OTHER LANGUAGES OR FORMATS . 117ivTABLE OF CONTENTS
VALERO MEDICAL COVERAGESWELCOMEValero is pleased to provide you with health benefits available to you and your coveredfamily members under and subject to the terms of the Valero Energy Corporation RetireeBenefits Plan, which health benefits are administered by UnitedHealthcare (ClaimsAdministrator). UnitedHealthcare is a private healthcare Claims Administrator whose goal isto give you the tools you need to make a wise healthcare decision.INTRODUCTIONThis summary provides more detailed information about the benefits available under theUnitedHealthcare medical coverages offered under the Valero Energy Corporation RetireeBenefits Plan for Non-Medicare participants. This document should be read in connectionwith the overall Retiree Health and Welfare Benefits Handbook provided to retirees. Allbenefits are governed by formal plan documents.For detailed information about eligibility, enrollment, effective dates, changing planelections, refer to the section of your handbook titled Plan Administration.HOW THE COVERAGE WORKSFor detailed information about how the coverages work, refer to the Highlights.5WELCOME, INTRODUCTION AND HOW THE COVERAGE WORKS
VALERO MEDICAL COVERAGESPERSONAL HEALTH SUPPORT AND PRIOR AUTHORIZATIONCare ManagementWhen you seek prior authorization as required, the Claims Administrator will work with youto implement the care management process and to provide you with information aboutadditional services that are available to you, such as disease management programs, healtheducation, and patient advocacy.UnitedHealthcare provides a program called Personal Health Support designed to encouragepersonalized, efficient care for you and your covered Dependents.Personal Health Support Nurses center their efforts on prevention, education, and closingany gaps in your care. The goal of the program is to ensure you receive the most appropriateand cost-effective services available.If you are living with a chronic condition or dealing with complex health care needs,UnitedHealthcare may assign to you a primary nurse, referred to as a Personal HealthSupport Nurse to guide you through your treatment. This assigned nurse will answerquestions, explain options, identify your needs, and may refer you to specialized careprograms. The Personal Health Support Nurse will provide you with their telephone numberso you can call them with questions about your conditions, or your overall health and wellbeing.Personal Health Support Nurses will provide a variety of different services to help you andyour covered family members receive appropriate medical care. Program components aresubject to change without notice. When the Claims Administrator is called as required, theywill work with you to implement the Personal Health Support process and to provide youwith information about additional services that are available to you, such as diseasemanagement programs, health education, and patient advocacy. As of the publication of thisMedical Summary, the Personal Health Support program includes: Admission counseling – Personal Health Support Nurses are available to help youprepare for a successful surgical admission and recovery. Call the number on your IDcard for support. Inpatient care management - If you are hospitalized, a Personal Health Support Nursewill work with your Physician to make sure you are getting the care you need and thatyour Physician's treatment plan is being carried out effectively. Readmission Management - This program serves as a bridge between the Hospital andyour home if you are at high risk of being readmitted. After leaving the Hospital, if youhave a certain chronic or complex condition, you may receive a phone call from aPersonal Health Support Nurse to confirm that medications, needed equipment, orfollow-up services are in place. The Personal Health Support Nurse will also shareimportant health care information, reiterate and reinforce discharge instructions, andsupport a safe transition home.6CLINICAL PROGRAMS AND RESOURCES
VALERO MEDICAL COVERAGES Risk Management - Designed for participants with certain chronic or complexconditions, this program addresses such health care needs as access to medicalspecialists, medication information, and coordination of equipment and supplies.Participants may receive a phone call from a Personal Health Support Nurse to discussand share important health care information related to the participant's specific chronicor complex condition. Cancer Management – You have the opportunity to engage with a nurse that specializesin cancer, education and guidance throughout your care path. Kidney Management – You have the opportunity to engage with a nurse that specializesin kidney disease, education and guidance with CDK stage 4/5 or ESRD throughoutyour care path.If you do not receive a call from a Personal Health Support Nurse but feel you could benefitfrom any of these programs, please call the number on your ID card.Prior AuthorizationUnitedHealthcare requires prior authorization for certain Covered Health Services.Network Primary Physicians and other Network providers are responsible for obtainingprior authorization before they provide these services to you.It is recommended that you confirm with the Claims Administrator that all Covered HealthServices listed below have been prior authorized as required. Before receiving these servicesfrom a Network provider, you may want to contact the Claims Administrator to verify thatthe Hospital, Physician and other providers are Network providers and that they haveobtained the required prior authorization. Network facilities and Network providers cannotbill you for services they fail to prior authorize as required. You can contact the ClaimsAdministrator by calling the number on your ID card.When you choose to receive certain Covered Health Services from non-Network providers,you are responsible for obtaining prior authorization before you receive these services. Notethat your obligation to obtain prior authorization is also applicable when a non-Networkprovider intends to admit you to a Network facility or refers you to other Networkproviders.To obtain prior authorization, call the number on your ID card. This call starts theutilization review process. Once you have obtained the authorization, please review itcarefully so that you understand what services have been authorized and what providers areauthorized to deliver the services that are subject to the authorization.The utilization review process is a set of formal techniques designed to monitor the use of,or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health careservices, procedures or settings. Such techniques may include ambulatory review, prospectivereview, second opinion, certification, concurrent review, case management, dischargeplanning, retrospective review or similar programs.7CLINICAL PROGRAMS AND RESOURCES
VALERO MEDICAL COVERAGESCovered Health Services which Require Prior AuthorizationNetwork providers are responsible for obtaining prior authorization from the ClaimsAdministrator or contacting Personal Health Support before they provide certain services toyou.When you choose to receive certain Covered Health Services from non-Network providers,you are responsible for obtaining prior authorization from the Claims Administrator beforeyou receive these services. In many cases, your Non-Network Benefits will be reduced if theClaims Administrator has not provided prior authorization.If you choose to receive a service that has been determined not to be a Medically NecessaryCovered Health Service, you will be responsible for paying all charges and no Benefits willbe paid.The services that require prior authorization from the Claims Administrator are: Ambulance - non-emergent air. Clinical Trials. Congenital heart disease surgery. Durable Medical Equipment for items that will cost more than 1,000 to purchase orrent, including diabetes equipment for the management and treatment of diabetes. Home health care for nutritional foods. Hospice care - inpatient. Hospital Inpatient Stay - all scheduled admissions and maternity stays exceeding 48hours for normal vaginal delivery or 96 hours for a cesarean section delivery. Infertility services – you must enroll in the Fertility Solutions program to receive servicesfrom a Designated Provider, a Network Physician that is not a Designated Provider or aNon-Network provider. Lab, X-Ray and Diagnostics - Outpatient – Genetic Testing and sleep studies. Mental Health Services - inpatient services (including services at a Residential Treatmentfacility). Partial Hospitalization/Day Treatment, Intensive Outpatient Treatmentprograms; outpatient electro-convulsive treatment, psychological testing; transcranialmagnetic stimulation. Neurobiological Disorders - Autism Spectrum Disorder Services -inpatient services(including services at a Residential Treatment Facility). Partial Hospitalization/DayTreatment; Intensive Outpatient Treatment programs; psychological testing; IntensiveBehavioral Therapy, including Applied Behavior Analysis (ABA).8CLINICAL PROGRAMS AND RESOURCES
VALERO MEDICAL COVERAGES Obesity surgery – you must enroll in the Bariatric Resource Services (BRS) program assoon as the possibility of obesity surgery arises. If you fail to enroll in the program, youwill be responsible for paying all charges and no Benefits will be paid. Prosthetic Devices for items that will cost more than 1,000 to purchase or rent. Private Duty Nursing. Reconstructive Procedures, including breast reconstruction surgery followingmastectomy and breast reduction surgery. Skilled Nursing Facility/Inpatient Rehabilitation Facility Services. Substance-Related and Addictive Disorders - inpatient services (including services at aResidential Treatment Facility). Partial Hospitalization/Day Treatment; IntensiveOutpatient Treatment Programs; psychological testing. Surgery – Outpatient sleep apnea surgeries. Temporomandibular joint services. Therapeutics - dialysis, IV infusion, intensity modulated radiation therapy and MRguided focused ultrasound. Transplants.Notification is required within 48 hours of admission or on the same day of admission ifreasonably possible after you are admitted to a non-Network Hospital as a result of anEmergency.For prior authorization timeframes and any reductions in Benefits that apply if you do notobtain prior authorization from the Claims Administrator, see the Additional Coverage Detailssection.Contacting UnitedHealthcare or Personal Health Support is easy.Simply call the number on your ID card.9CLINICAL PROGRAMS AND RESOURCES
VALERO MEDICAL COVERAGESADDITIONAL COVERAGE DETAILSThis section supplements the Highlights.While the table provides you with Benefit limitations along with Copayment, Coinsuranceand Annual Deductible information for each Covered Health Service, this section includesdescriptions of the Benefits. These descriptions include any additional limitations that mayapply, as well as Covered Health Services for which you must obtain prior authorizationfrom the Claims Administrator as required. The Covered Health Services in this sectionappear in the same order as they do in the table for easy reference. Services that are notcovered are described in the Exclusions and Limitations section.Note: If you live in an area that is outside of the provider Network area your level ofBenefits will be the same if you visit a Network provider or non-Network provider.Therefore, the reference to Non-Network below does not apply to you. Based on theguidelines below you must obtain prior authorization from the Claims Administrator beforereceiving both Network and Non-Network services. If you fail to obtain prior authorizationas required, Benefits will be subject to a 200 reduction.Acupuncture ServicesThe coverage pays for acupuncture services for all diagnoses provided that the service isperformed in an office setting by a provider who is one of the following, either practicingwithin the scope of his/her license (if state license is available) or who is certified by anational accrediting body: Doctor of Medicine. Doctor of Osteopathy. Chiropractor. Acupuncturist.Did you know You generally pay less out-of-pocket when you use a Network provider?Ambulance ServicesThe benefit covers Emergency ambulance services and transportation provided by a licensedambulance service to the nearest Hospital that offers Emergency Health Services. See theGlossary for the definition of Emergency.Ambulance service by air is covered in an Emergency if ground transportation is impossible,or would put your life or health in serious jeopardy. If special circumstances exist,UnitedHealthcare may pay Benefits for Emergency air transportation to a Hospital that isnot the closest facility to provide Emergency Health Services.10CLINICAL PROGRAMS AND RESOURCES
VALERO MEDICAL COVERAGESThe benefit also covers non-Emergency transportation provided by a licensed professionalambulance (either ground or air ambulance, as UnitedHealthcare determines appropriate)between facilities when the transport is:From a non-Network Hospital to a NetworkHospital. To a Hospital that provides a higher level of care that was not available at the originalHospital. To a more cost-effective acute care facility. From an acute facility to a sub-acute setting.Prior Authorization RequirementIn most cases, the Claims Administrator will initiate and direct non-Emergencyambulance transportation. For Non-Network Benefits, if you are requesting nonEmergency ambulance services, including any affiliated non-Emergency groundambulance transport in conjunction with non-Emergency air ambulance transport, youmust obtain prior authorization as soon as possible prior to transport. If you fail to obtainprior authorization as required, Benefits will be subject to a 200 reduction.Cellular and Gene TherapyCellular Therapy and Gene Therapy received on an inpatient or outpatient basis at aHospital or on an outpatient basis at an Alternate Facility or in a Physician's office.Benefits for CAR-T therapy for malignancies are provided as described under TransplantationServices.Note: Non-Network Benefits are not available.Clinical Trials - Routine Patient Care CostsBenefits are available for routine patient care costs incurred during participation in aqualifying Clinical Trial for the treatment of cancer or other life-threatening disease orcondition. For purposes of this benefit, a life-threatening disease or condition is one fromwhich the likelihood of death is probable unless the course of the disease or condition isinterrupted.Benefits include the reasonable and necessary items and services used to prevent, diagnoseand treat complications arising from participation in a qualifying Clinical Trial.Benefits are available only when the Covered Person is clinically eligible for participation inthe qualifying Clinical Trial as defined
Valero 1,000 Deductible Retiree Choice Plus Copay/ 500 Deductible Retiree Choice Plus 500 Deductible Retiree Ou
