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UPS Health Program
F O R PA R T - T I M E E M P LOY E E S
S U M M A R Y P L A N D E S C R I P T I O N
Schedule 115
Central Ohio Locals 20, 40, 908, 957
Indiana Locals 89, 135
Kentucky Locals 89 (Center 4210), 957
Metro Detroit Locals 20, 164, 243, 339
Michigan Locals 7, 328, 332, 339, 406, 486, 580
North Ohio Locals 20, 377
South Illinois Locals 215, 236UPS
HEALTH
Your Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
PROGRAM
Who is Covered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Schedule
When Coverage Begins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
115
When Coverage Ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Important Information About Plan Expenses . . . . . . . . . . . . . . . . . . . . . . . . . 4
Basic Hospital Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Basic Medical Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Major Medical Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Alternatives to a Hospital Stay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Prescription Drug Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Vision Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Dental Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Life Insurance and AD&D Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Short-term Disability Income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Extension of Medical Coverage During Disability . . . . . . . . . . . . . . . . . . . . . . 25
How to File a Claim. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
If Your Claim is Denied . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Right of Recovery/Subrogation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Coordination of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Life Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Continuation of Coverage under COBRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Your Right to Obtain Individual Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
ERISA Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Plan Administration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Since this booklet was last updated, certain changes, required notifications
1
and clarifications have been made to the Plan. You’ll find any notices of
these changes, called Summary of Changes, at the end of this booklet.
Refer to this information when reviewing your coverage.UPS
HEALTH Concern for the security and well-being Your coverage from the Plan is a result
of you and your family is the cornerstone of the Company’s agreement with your
PROGRAM of our benefits philosophy. We regard our collective bargaining unit. You’ll find
benefits expenditures as an investment in specific reference to the coverage in
your health and security. The UPS Health your labor agreement.
Schedule Program (the Plan) provides health benefits
115 to help pay for the cost of your health care.
The Plan also protects you and your family WHO IS COVERED
with life insurance, accidental death and
dismemberment and short-term disability As a part-time bargaining unit employee
income coverage. UPS pays the full cost of UPS, you and your qualified dependents
of the benefits described in this booklet. are covered once you meet the Plan’s eligi-
bility requirements as described in the “When
Coverage Begins” section of this booklet.
YOUR PLAN
An “eligible dependent” is defined as:
As an employee of United Parcel Service, • Your legal spouse
you’re eligible for benefits from the Plan • An unmarried child who is:
once you’ve met the eligibility require- —A natural child, an adopted child,
ments. There may be a waiting period for a stepchild or a child for whom you
certain coverage for you or for your depen- are the legal guardian or custodian
dents. Please see “When Coverage Begins” and who depends on you for finan-
in this booklet for eligibility requirements cial support and lives with you in
you and/or your dependents must meet a parent-child relationship, and
before you receive benefits from this Plan.
—Under age 19, or up to age 25 if a
The UPS Health Program Schedule 115 full-time student and still financially
covers part-time union member employees dependent on you.
in the following work groups:
Incapacitated Children
• Central Ohio Locals 20, 40, 908, 957 A child who becomes incapacitated
• Indiana Locals 89, 135 before age 19 (or before age 25, if a full-
• Kentucky Locals 89 time student) will continue to have medical
(Center 4210), 957 coverage as long as the incapacitation
• Metro Detroit Locals 20, 164, exists and you remain eligible for the Plan.
243, 339 This continuing coverage is available as
• Michigan Locals 7, 328, 332, 339, long as the child becomes incapacitated
406, 486, 580 while covered by the Plan, is unmarried
and primarily dependent on you for support
• North Ohio Locals 20, 377
and maintenance. Dependent life insurance
• South Illinois Locals 215, 236 continues through the end of the year in
which your child turns 19 (or age 25 if
Other benefit schedules have been prepared
a full-time student).
describing this Plan as it applies to employees
in other employment groups. Please be cer-
tain you have the proper information for
your employment group.
2UPS
Your child must have a mental or physical Qualified Medical Child Support Orders HEALTH
incapacity that renders the child unable to (QMCSO)
care for herself/himself, as determined by Medical, dental and vision coverage will PROGRAM
the claims administrator. For this purpose, comply with the terms of a Qualified
the incapacity must be verified before cov- Medical Child Support Order. A QMCSO
erage can be continued. In addition, periodic is a judgment, decree or order (including Schedule
medical documentation of the continuing approval of settlement agreement) issued 115
incapacity is required. by a court of competent jurisdiction or an
administrative process established under
When Spouses or Children Are UPSers state law which has the force and effect
If you and your spouse both work for of law or a judgment from a state court
UPS and are both covered through a UPS- directing a plan administrator to cover a
administered plan, you may not cover your child by a company’s group health plans.
spouse as a dependent in the Health Program.
Your dependent children can have health care Federal law requires that a QMCSO must
coverage as one parent’s dependent only. meet certain form and content requirements
in order to be valid. When an order is
If you and your dependent child both received, each affected participant and each
work for UPS and are both covered through child covered by the order will be notified
a UPS-administered plan, you cannot of the implementation procedure to deter-
cover your child as a dependent in the mine if the order is valid. If you have any
Health Program. questions or would like to receive a copy
of the UPS written procedure for determin-
There is no coordination of benefits avail- ing whether a QMCSO is valid, please con-
able between two UPS-administered plans. tact your Human Resources department.
WHEN COVERAGE BEGINS
Eligibility for medical, life and accidental
death and dismemberment (AD&D) cover-
age for you and your dependents begins
on the first day of the month following
one full month of employment, provided
you have attained seniority. If you have not
attained seniority at this time, coverage will
begin on your seniority attainment date.
Eligibility for vision and dental coverage
begins six months from your hire date,
provided you have attained seniority.
A definition of seniority can be found
in your collective bargaining agreement.
3UPS
HEALTH WHEN COVERAGE ENDS IMPORTANT INFORMATION
PROGRAM For You...
ABOUT PLAN EXPENSES
• Coverage ends 31 calendar days All expenses covered by this Plan must be:
after you leave UPS
Schedule • The end of the second month
• Medically necessary, as determined
by the claims administrator, Aetna
115 of a layoff period • Neither investigational nor experi-
• The day you start a personal leave that mental, as determined by the
is not covered by the Family Medical claims administrator
Leave Act • Within the standards for the reasonable
and customary amount, as determined
For Your Spouse...
by the claims administrator
The earliest of:
• Not excluded by the Plan
• The date your coverage ends
• The date you and your spouse Medically Necessary
are divorced Services and Supplies
• The date you and your spouse Only medically necessary services are
are legally separated covered by the UPS Health Program. A
service or supply is medically necessary
For Your Dependent Children... if the Plan determines that it is required
The earliest of: for the diagnosis, care or treatment of a
• The date your coverage ends disease, injury or pregnancy in accordance
• The end of the calendar year in which with generally accepted medical practice.
your dependent turns 19 This determination is at the sole discretion
of the Plan Administrator.
• The end of the calendar year in which
your dependent turns 25, provided he To be medically necessary, the service
or she is a full-time student or supply must be:
• The date your dependent marries or • Care or treatment that is as likely to
otherwise fails to meet the require- produce as significant a positive out-
ments of an eligible dependent as come (and no more likely to produce
described in the “Who is Covered” a negative outcome) as any alternative
section service or supply, with respect both to
the disease or injury involved and to
See the “Continuation of Coverage During
the person’s overall health condition,
Disability” section for information on
or
extension of coverage for you and your
dependents during a disability period. • A diagnostic procedure, indicated by
the health status of the person, that is
There is also important information as likely to result in information that
about the Consolidated Omnibus Budget could affect the course of treatment as
Reconciliation Act (COBRA), the Family (and no more likely to produce a nega-
Medical Leave Act (FMLA) and conver- tive outcome than) any alternative
sion privileges in later sections of this service or supply, with respect to both
booklet. These provisions may extend the disease or injury involved and the
the date on which coverage will end. person’s overall health condition, and
4UPS
• As to diagnosis, care and treatment, • Dressings, splints and plaster casts HEALTH
no more costly (taking into account • Inpatient laboratory and X-ray
all health care expenses incurred in examinations PROGRAM
connection with the service or supply) • Physical therapy
than any alternative service or supply
that meets the above tests
• Electrocardiograms Schedule
• Oxygen and anesthesia and their
Reasonable and Customary Charges administration 115
A reasonable and customary (R&C) charge • The cost and administration of blood
is the lower of either the provider’s usual and blood-plasma
charge or the prevailing fee for a medical • Intravenous injections and solutions
service or supply in your geographic area • X-ray and radium therapy
as determined by the claims administrator. • Prescribed drugs
If you’re charged more than what is con-
sidered reasonable and customary, you’ll Outpatient Hospital Services
be responsible for paying anything over the The following outpatient hospital services
R&C amount. R&C charges are regularly are also covered in full under the basic
reviewed to keep Plan benefits up-to-date portion of your Plan:
with current rates. • Pre-surgical testing within seven days
of a scheduled inpatient admission or
a scheduled ambulatory surgery
BASIC HOSPITAL COVERAGE procedure
Room and Board • Chemotherapy infusion
You and your eligible dependents receive • Kidney dialysis performed either
full coverage for reasonable and customary in the hospital or in your home
room and board charges and for other related • Hospital charges connected with
services and supplies during a medically outpatient surgery
necessary confinement in a full-service acute • Hospital emergency room treatment
care or specialty hospital. If you choose to of a diagnosed life-threatening sudden
stay in a private room, you’re responsible and serious illness, if care is given
for the difference between the actual semi- within 72 hours after the injury occurs
private room charge and the private room rate. or after the illness begins
Inpatient Hospital Services
Your Plan pays full reasonable and customary
charges for these other inpatient hospital
services as long as they are medically nec-
essary to treat the condition requiring hos-
pitalization and are billed by the hospital:
• The use of operating, recovery and
treatment rooms and their equipment
• The use of intensive care and cardiac
care units
5UPS
HEALTH BASIC MEDICAL COVERAGE For benefits to be paid, emergency care
must be given within 72 hours of an acci-
PROGRAM Basic Surgical Coverage dental injury or the onset of a diagnosed
Basic surgical coverage pays 100 percent sudden and serious illness.
of the reasonable and customary charges
Schedule of a surgeon and assistant surgeon (when Physician Charges for Hospital Visits
Often when you or your covered depen-
115 required) including anesthesia for the pro-
dents are hospitalized, your physician will
cedure. You do not need to pay a deductible
before the Plan pays benefits. treat you in the hospital. These charges are
covered up to $20 per day.
For benefit purposes, usual, necessary and
related pre-operative and post-operative The total amount payable for all treatments
care is considered part of the surgery. Post- during one period of continuous disability
operative care must be given during the is $7,300 per individual. If you incur charges
14 days after surgery. over the amounts payable under this por-
tion of your coverage, they will qualify for
Other surgical procedures are covered coverage under the major medical portion
by the Plan, including functional repair of the Plan.
of birth abnormalities or congenital defects;
oral surgery, including the removal of See the section “What’s Not Covered by
impacted and wisdom teeth, and tubal Your Plan” for information on expenses
ligations or vasectomies. excluded from this coverage.
Diagnostic Procedures Mastectomy Coverage
Outpatient diagnostic X-rays and laboratory A participant or eligible dependent receiv-
procedures are also covered up to the R&C ing benefits for a medically necessary mas-
amount, including medically necessary tectomy will also receive coverage for:
ultrasounds and dental X-rays in connec- • Reconstruction of the breast on which
tion with an injury. Up to $300 can be paid the mastectomy has been performed,
in benefits for each person each calendar • Surgery and reconstruction of the
year. The major medical portion of the other breast to produce a symmetrical
Plan covers charges above $300. appearance, and
• Prostheses and treatment of physical
In addition, radiologists’ and pathologists’ complications of all stages of mastec-
charges for services given while you tomy, including lymphedemas.
(or a dependent) are hospitalized are
also covered by the basic medical portion
of the Plan.
Emergency Care Physician
Emergency care given by a physician is
covered in full up to R&C charges. The care
may be given in a clinic, doctor’s office or
the outpatient department of a hospital.
6UPS
MAJOR MEDICAL COVERAGE In calculating your out-of-pocket expenses, HEALTH
the dollar amounts included are the deductible
After you pay a yearly deductible, your and the coinsurance amount. Dollar amounts PROGRAM
major medical coverage pays 80 percent not included in determining the out-of-pocket
of most medical expenses not covered by maximum are any amounts over reasonable
the basic portion of the Plan. and customary and expenses that are not Schedule
covered by the Plan. 115
Yearly Deductible
You’re responsible for paying a major med- Lifetime Maximum Benefits
ical deductible each calendar year. There Up to $500,000 in lifetime medical benefits
are individual deductibles and a maximum can be paid for each person covered by the
family deductible. Plan. The maximum is a combined amount
that is the total benefits paid to you.
The individual deductible is the first $50
of covered major medical expenses. The Each January 1, up to $1,000 in individual
maximum family deductible is $100. This benefits paid during the preceding year or
means that if two or more family members years will automatically be restored. If
have combined covered expenses of $100, proof of your (or your dependent’s) good
no further individual deductibles are required health is approved by Aetna, the $500,000
for the balance of that year. major medical maximum can be fully restored.
Coinsurance Covered Major Medical Expenses
After the deductible has been met, The following is a general listing of cov-
the Plan pays 80 percent of the reasonable ered expenses under the major medical
and customary charges for covered major portion of your Plan:
medical expenses. You pay the remaining • Reasonable and customary charges
20 percent. of a physician, including an osteopath,
chiropractor or podiatrist for medically
Out-of-Pocket Maximum necessary treatment
There is an important provision of your • Second surgical opinions
major medical coverage that assures you
• Charges of a social worker. In order
that your yearly out-of-pocket expenses for
for expenses to be covered, the social
covered major medical charges will never
worker must be either a licensed clini-
be more than a certain dollar amount. This
cal social worker, a diplomate social
feature can be particularly valuable if you
worker or a member of the Academy
(or a dependent) have a catastrophic illness
of Credited Social Workers and licensed
or injury.
in the state where he or she practices.
After you meet the out-of-pocket maxi- • Charges of a registered graduate nurse
mum of $1,500 per individual each year, (RN), licensed vocational nurse (LVN)
100 percent of most covered charges are or licensed practical nurse (LPN)
paid for that individual for the rest of the • Some charges relating to care of mental
calendar year. or nervous disorders, chronic alcoholism
or drug addiction (See the “Mental
Health Treatment,” and “Substance
Abuse” sections.)
7UPS
HEALTH • Charges for home health care (See the Maternity
“Home Health Care” section.) Maternity expenses are covered just like any
PROGRAM • Charges for hearing exams and an other condition requiring medical attention.
initial hearing aid. To be covered,
the hearing aid must be recommended Your medical coverage for pregnancy and
Schedule by an otolaryngologist. Eyeglass-type delivery includes full hospital and surgical
benefits. Charges for hospital and diagnos-
115 hearing aids are covered up to the cost
tic services are covered as described in
of one traditional hearing aid. Replace-
ment or repair of a lost, broken or earlier sections.
stolen aid is not covered.
Basic surgical coverage pays the cost of
• Outpatient physical therapy and occu- Lamaze or other birthing classes. It also
pational therapy subject to review and pays full surgical benefits for delivery in
approval by the claims administrator a licensed birthing center, including anes-
• Charges for speech therapy, depending thesia and pre- and post-operative care.
on the diagnosis and subject to review Obstetrical procedures that are fully cov-
and approval by the claims administra- ered include normal delivery or delivery
tor (See “Speech Therapy” section.) by cesarean section, services in connection
• Charges for vision therapy, depending on with a miscarriage or abortion, and surgery
the diagnosis and subject to review and related to an extrauterine or ectopic preg-
approval by the claims administrator nancy. The services of a registered midwife
• Charges for medically necessary are also covered.
ambulance services to the nearest
facility for appropriate treatment The Plan assumes you (or your dependent)
of the condition will have only one primary obstetrician
• Charges for diagnostic X-rays and lab- during a single pregnancy. Typically, an
oratory exams that are over the $300 obstetrician establishes a fee for the entire
paid for by basic medical coverage period of care. If you change doctors and
the second doctor’s charges are in addition
• Charges for radioactive therapy
to the first doctor’s fee, only one R&C
• Charges for outpatient or home amount will be covered by the Plan.
chemotherapy
• Charges for the rental (or purchase, The procedure for filing claims is described
if medically necessary) of durable in the section “Filing a Claim.” As you
medical or surgical equipment read that section, keep in mind you may
• Charges for allergy syringes submit your bills for maternity care on
and serums an ongoing basis. You do not need to wait
until the pregnancy is completed. However,
full maternity benefit payment will not be
made until completion of the pregnancy.
8UPS
Newborns’ and Mothers’ Health Outpatient Treatment HEALTH
Protection Act Outpatient mental health treatment is covered
Group health plans and health insurance as long as the treatment is recommended PROGRAM
issuers generally may not, under federal by a doctor, is considered medically neces-
law, restrict benefits for any hospital length sary and appropriate for the condition, and
of stay in connection with childbirth for the meets the other requirements noted above. Schedule
mother or newborn child to less than 48 Benefits are payable at 80 percent after the
yearly deductible is met.
115
hours following a vaginal delivery, or less
than 96 hours following a cesarean section.
When Benefits Are Not Payable
However, federal law generally does not No benefits are payable for charges of
prohibit the mother’s or newborn’s attend- a residential treatment facility or for educa-
ing provider, after consulting with the mother, tional services.
from discharging the mother or her new-
born earlier than 48 hours (or 96 hours, as Before you begin treatment that requires any
applicable). In any case, plans and issuers services not specifically identified as covered
may not, under federal law, require that a services for mental or nervous disorders, you
provider obtain authorization from the plan should contact the claims administrator to
or the issuer for prescribing a length of stay see if benefits are payable.
not in excess of 48 hours (or 96 hours).
Substance Abuse
Substance abuse can create difficult problems
Mental Health Treatment not only for the person who abuses the
Mental health treatment is covered as long substance, but also for all family members.
as a doctor recommends treatment and the If you would like a referral for yourself
Plan administrator determines it to be med- or your spouse or a dependent dealing with
ically necessary. a substance abuse problem, please see your
district Human Resources department, which
The treatment must be given by a psychia- will refer you to your Employee Assistance
trist or by a licensed or certified psycholo- Program (EAP) coordinator. Discussions
gist. Care given by a social worker will be between you and the EAP coordinator will
covered as long as he or she meets the cri- be confidential within the limits of legal
teria listed in the “Covered Major Medical and professional constraints.
Expenses” section. Major medical benefits
for mental health treatment apply toward the Major medical benefits for these services
$500,000 lifetime benefit maximum. apply toward the $500,000 benefit maximum.
Psychological counseling by a psychiatrist,
Inpatient Treatment licensed or certified psychologist, or a
Inpatient mental health treatment is social worker is covered. The social worker
covered the same as any other condition must meet the criteria specified in the
requiring hospitalization. The treatment “Covered Major Medical Expenses” section.
must be recommended by a doctor and be
considered medically necessary and appro-
priate for the condition. Major medical
coverage is available for partial confinement
in an approved day/night-care facility.
9UPS
HEALTH Inpatient Treatment services for all children between the ages
Inpatient treatment for substance abuse of three and 21, including help in identify-
PROGRAM is covered the same as any other condition ing and diagnosing speech and language
requiring hospitalization. Major medical disorders as well as rehabilitative and
coverage is available for partial confine- preventative treatment. As a result, treat-
Schedule ment in an approved day/night-care facility. ment of these kinds of speech problems
115 Outpatient Treatment
is not covered.
As long as the treatment is recommended To be eligible for benefits, treatment
by a doctor and meets the other require- of a speech problem must be prescribed,
ments noted above, benefits are payable controlled and directed by a doctor and
at 80 percent of covered expenses. approved by the claims administrator.
When Benefits Are Not Payable Besides the exclusions noted in the section
No benefits are payable for care given “What’s Not Covered by Your Medical
in a halfway house or residential treat- Benefits” and situations covered by Public
ment facility. Law 94-142, there are other conditions and
services not covered by the medical portion
Speech Therapy of the Plan. These include:
Benefits are paid only for speech therapy • Certain speech problems in children
needed to restore speech lost as a result of that are classified as developmental
an illness or injury. For example, children delays that may correct themselves
who have not fully developed their speech without treatment
skills are not eligible for these restorative
• Services rendered for the treatment
services. However, someone who loses
of delays in speech development, unless
speech capacity as a result of an accident
resulting from injury or illness
could receive benefits under this provision.
• Speech problems caused by learning
Speech problems can be unique, varying disabilities or articulation disorders
in severity from individual to individual, (if there is an underlying psychological
and frequently, diagnoses can be subjec- reason for the condition, that underly-
tive. To help determine if the condition ing condition may be covered as a
is covered by the Plan, submit information mental or nervous disorder)
to the claims administrator for advance • Services or supplies that a school
review. This way, you’ll know what bene- system is required by law to provide
fits can be paid before treatment begins. • Services of a speech therapist who
lives in your home
Certain speech problems, such as stuttering
• Special education, including lessons in
in children, may be covered by Public Law
sign language, to teach a covered person
92-142, The Education for All Handicapped
whose ability to speak has been lost or
Children Act of 1975. This law provides
impaired to function without that ability
public schools with language and speech
10UPS
ALTERNATIVES TO The following expenses are not covered HEALTH
by home health care:
A HOSPITAL STAY • Services or supplies not included PROGRAM
Rather than a stay as a hospital inpatient, in the home health care plan outlined
by your physician
an alternative course of medical care may
• Services of a person who ordinarily
Schedule
be more appropriate, cost effective and
comfortable. Expenses are covered for the lives in your home or who is a member 115
following alternatives to a hospital stay. of your or your spouse’s family
• Custodial care
Home Health Care • Transportation
Charges made by a home health agency
for a covered family member in the home Outpatient Private Duty Nursing
in accordance with a home health care plan Benefits may be paid for medically skilled
are covered by this benefit. For these expenses private duty nursing at home if your doctor
to be eligible, the home health care plan prescribes it. Benefits cover the home ser-
must be outlined by your physician. vices of registered nurses, licensed practical
nurses and licensed vocational nurses up to
After the deductible, benefits are paid a maximum of 560 hours per calendar year
at 80 percent of reasonable and customary (70 eight-hour shifts). The 560 hours are
charges. counted as they are used. For example,
a two-hour visit will be counted as two
Covered home health care expenses include: hours, rather than an eight hour shift.
• Part-time or intermittent home health
aide services, consisting primarily of To be covered, outpatient private duty
caring for the patient in conjunction nursing services must:
with skilled nursing care • Be medically necessary for treatment
• Physical, occupational or speech therapy of a disease or injury
• Drugs and most medical supplies • Require the medical training and
prescribed by a physician technical skills of a registered nurse,
• Laboratory services licensed practical nurse or licensed
vocational nurse, and
Home health care benefits are calculated • Be ordered by the attending physician
on a per-visit basis. Each visit by a nurse, as necessary treatment
therapist or aide is considered one visit;
four hours is the maximum length of one The charges of a private duty nurse in a
visit. Up to 120 home health care visits per hospital are not covered because the hospital
Plan year are covered. For the first 40 vis- provides a staff of registered nurses for care
its, the patient does not need to have been given during hospitalization. These charges
confined in a hospital in order to be eligi- are part of the room and board charges.
ble for benefits. For an additional 80 visits,
prior hospital confinement is required, and Skilled nursing care is not the same as
the home health care must begin within custodial care. Custodial care is not cov-
seven days following discharge. ered even if given by an RN, LPN or LVN.
Custodial care includes such things as meal
11UPS
HEALTH preparation, bathing the patient, acting as The following services and supplies
a companion and other services that may are allowable when furnished to a person
PROGRAM be necessary for the normal activities of receiving outpatient hospice care coordinated
daily living, but that do not require the med- by the hospice program administrator:
ical training and technical skills of a nurse. • Part-time intermittent nursing care
Schedule Daily nursing notes will be reviewed to by an RN or LPN for up to eight hours
115 determine the portion of the nursing care in any one day
that qualifies for benefits. • Medical social services under the
direction of a physician, including:
It’s also important to understand that while
skilled nursing care may be necessary ini- —Assessment of the person’s social,
tially, alternate caregivers may be encouraged emotional and medical needs and/
to learn the skills necessary for ongoing or the home and family situation
medical care. Once alternate caregivers —Identification of community
have demonstrated their proficiency in resources needed to meet her
a particular procedure, skilled nursing or his assessed needs
coverage for that procedure may cease. —Assistance with obtaining the
resources needed to meet her
No benefits will be paid for services given or his assessed needs
by a nurse who lives with you. • Psychological and dietary counseling
• Consultation or case management
Call the toll-free number on your medical
services by a physician or nurse
identification card before you make any
arrangements for outpatient private • Physical therapy
duty nursing. • Part-time or intermittent home health
aid services for up to eight hours in
Hospice Care any one day. These consist mainly
Hospice care provides terminally ill patients of caring for the person.
and their families with an alternative to hos-
pital care while assuring them of a special- Benefits are not provided for the following
ized program tailored to each individual. hospice care services and supplies:
Terminally ill patients require specialized • Any charge for daily room and board
care, both medical and psychological, that in a private room in excess of the insti-
may not be readily available from the regu- tution’s semiprivate room rate
lar hospital staff. • Charges made for the following services:
—Bereavement counseling
For purposes of this program, a terminally
ill patient has a medical prognosis of six —Funeral arrangements
months or less to live. —Pastoral counseling
—Financial or legal counseling,
Charges for room and board made by including estate planning or
a hospice facility, hospital, convalescent the drafting of a will
facility or a physician are allowable when —Homemaker or caregiver services
furnished on a full-time inpatient basis for that are not solely related to care
pain control and other acute and chronic of the person (sitter or companion
symptom management. services for the patient or other mem-
bers of the family, transportation,
housecleaning and maintenance
of the house)
—Respite care
12UPS
Individual Case Management • Services or supplies that are not med- HEALTH
While none of us likes to think about a ically necessary, as determined by the
complicated, long-term illness or serious claims administrator, even if prescribed, PROGRAM
accident, sometimes it can happen. recommended or approved by the
attending physician or dentist
The Individual Case Management (ICM) • Care, treatment, services or supplies Schedule
program can offer you and your dependents
help with:
provided by an individual who usually 115
resides in the same household with
• Understanding treatment plans you, or who is related by blood,
and alternatives marriage or legal adoption to you
• Monitoring claims payments, and or your dependent
• Evaluating alternative treatment • Services or supplies the claims admin-
facilities and options istrator determines to be unnecessary
for the diagnosis, care or treatment
Here are some medical conditions that may of the condition involved
be appropriate for ICM: • Care, treatment or services or supplies
• Quadriplegia, paraplegia not prescribed, recommended and
• AIDS and certain associated symptoms approved by the attending physician
• Brain injury, including traumatic • Hospital care for diagnostic purposes
brain injury unless the covered person’s condition
• Newborn respiratory distress, or type of test requires hospitalization
newborn apnea • Services or supplies not provided
• Spinal cord injury in accordance with medical or profes-
sional standards of practice
• Any complicated, chronic illness
• Treatments or procedures and related
If this type of care is appropriate for your materials that are investigational or
situation, a nurse consultant contacts your experimental in nature, as determined
doctor or social worker at the hospital to by the claims administrator
begin case management. You may also call • Occupational conditions, ailments or
Member Services at the number on your ID injuries for which coverage is provided
card to discuss whether case management by Workers’ Compensation or by
is appropriate for your situation. Early a similar law
identification allows the patient, family, • Additional expenses for a private room
physician, social worker and case manager in a hospital
to work together to arrange appropriate • Private duty nursing while confined
care in a timely manner. • Custodial care, rest centers, nursing
homes or assisted living centers
What’s Not Covered By Your • Treatment of a condition caused by
Medical Benefits war (declared or undeclared) or any
The following is a general list of Plan act of war
exclusions: • Items listed in other sections as not-
• Charges that exceed the reasonable covered expenses
and customary limit, as determined
by the claims administrator
13UPS
HEALTH • Treatment of a condition incurred • Claims that the Plan is not required
while committing an unlawful act of to pay under the current collective
PROGRAM aggression, including a misdemeanor bargaining agreement
or a felony • Contraceptive medications and devices,
• Services or supplies for which benefits regardless of medical necessity
Schedule are provided by any government law
115 • Services or supplies that are provided
by reason of past or present service PRESCRIPTION DRUG
in the armed forces of any government BENEFITS
• Services provided before coverage
becomes effective or after coverage Your medical coverage provides prescrip-
ends tion drug benefits. The reasonable and cus-
• Dietary supplements, including any tomary cost (as determined by the claims
supplement for newborn infants administrator) of prescription drugs is cov-
• Any preventive or routine care ered at 100 percent.
• Services or supplies related to any eye Prescription drug benefits are administered
surgery mainly to correct refractive by Aetna. You pay for the full amount of
errors each prescription and submit a completed
• Services or supplies for or related to claim form to be reimbursed. Claim forms
sex change surgery or any treatment may be obtained from your local Human
of gender identity disorders Resources department or by calling the
• Reversal of a sterilization procedure Member Services number on your Aetna
• Expenses related to the purchase of ID card.
orthopedic shoes or related corrective
devices and appliances Prescription drug benefits cover:
• Personal hygiene or convenience • Drugs approved by the federal
items, such as air conditioners, humid- government
ifiers and physical fitness equipment • State-restricted drugs
• Items to accommodate your home, • Insulin—by prescription only
office or vehicle as a result of an injury • Insulin needles, syringes and chem
or illness, such as wheelchair lifts, strips—by prescription only
hand rails or stair risers • Over-the-counter diabetic supplies
• Weight reduction programs, unless • Compounded medications
approved by the claims administrator
• Charges for a missed or broken Prescription drug benefits do not cover:
appointment • Contraceptive medications unless
• Charges for the doctor’s travel medically necessary
• Claims received more than 24 months • Contraceptive devices
from the date of service • Drugs not approved by the federal
• Charges for or related to services, government
treatment, educational testing or train- • Drugs used for cosmetic purposes
ing related to learning disabilities or • Viagra
developmental delays • Therapeutic devices or appliances
14UPS
• Drugs labeled “Caution—limited Replacement lenses are covered once every HEALTH
by federal law to investigational use,” 12 months if required because of a change
or experimental drugs, even though in prescription. Replacement frames are PROGRAM
a charge is made to the individual covered after the first prescription is filled
• Medication for which the cost is only if the existing frames cannot be used
recoverable by Workers’ Compensation, for a new pair of lenses that are prescribed Schedule
occupational disease law, any state or at a later date. 115
governmental agency, or medication
furnished by any other drug or medical When Benefits Are Not Payable
service for which no charge is made Beside the general medical exclusions
to the participant noted earlier in this booklet, your vision
benefit does not cover the following:
• Any prescription refilled in excess
of the number of refills specified by • Visual analysis that does not include
the physician, or any refill dispensed a complete eye refraction
after one year from the physician’s • Frames or lenses costing more than
original order the Plan allows
• Dietary supplements, including any • Tinted or photochromatic lenses,
supplement for newborn infants except for pink tints 1 and 2
• Growth hormones without prior • Coated lenses
authorization • Contact lenses (except as described)
• Over-the-counter medications (other • Multifocal plastic lenses
than diabetic supplies) • No-line, blended bifocal lenses
• Orthoptics or vision training
• Subnormal vision aids
VISION BENEFITS
• Aniseikonic lenses
You and your eligible dependents are eligi- • Two pair of glasses instead of bifocals
ble for one complete eye examination and, • Replacement of lost or broken lenses
if your prescription changes, one pair of or frames
new single-vision, bifocal or trifocal eye- • Medical or surgical treatment of eyes
glasses every 12 months. The eye exam • Services or materials provided as a
is covered up to reasonable and customary result of Workers’ Compensation or
limits, as determined by Aetna, the claims similar legislation or provided through
administrator. Eyeglasses, including lenses a government agency or program
and frames, are covered according to the
• Duplicate or spare glasses
following schedule:
• Eye exams, glasses or contacts provided
Lenses (per pair) by any other vision care plan
Single vision $30 • Vision care services, materials or
Bifocal $40 procedures covered by other provi-
Trifocal $50 sions of the UPS Health Program.
For example, vision therapy after
Frames $30 cataract surgery is covered by your
medical benefits.
If for cosmetic reasons you choose contact
lenses in lieu of glasses, the Plan will pay
up to the scheduled benefit for single-vision
lenses and frames ($60).
15UPS
HEALTH DENTAL BENEFITS Preventative Services
These services are covered in full:
PROGRAM Services performed by a legally qualified • Oral exams (once every six months)
dentist and dental hygienist are covered. • Prophylaxis (once every six months)
Schedule Deductible
• Topical fluoride applications for
children until the end of the year
115 Basic and major restorative services
in which the child turns 15 (once
are subject to the Plan’s major medical
every six months)
deductible. The deductible does not apply
to preventative services or orthodontia. See • X-rays
the section titled “Major Medical” for more —Full-mouth or panoramic
information about the deductible. (once every 36 months)
—Bitewing (once every six months)
Reasonable and Customary • Sealants for children until the end of
All eligible dental expenses are subject to the year in which the child turns 14
reasonable and customary limits—charges —One application per tooth per
within the normal range of fees in your 36-month period
geographic area for similar services and
—Permanent first and second
similar supplies, as determined by the claims
molars only
administrator. If your dentist charges more
than the R&C limit, you’re required to pay
any amounts considered above that limit.
Predetermination of Benefits
The Plan has a provision that lets you know,
in advance, what benefits will be paid. If
you anticipate that charges for a course
of dental treatment will be more than $300,
you should submit an itemization of the
proposed treatment (including recent pre-
treatment X-rays) to the claims adminis-
trator before work begins. A dental consultant
will review the proposed treatment, and the
administrator will inform you and your den-
tist of the amount of covered charges. This
way, you’ll understand the benefits that will
be paid and have the opportunity to discuss
possible treatment options with your dentist
before treatment begins. While predetermi-
nation is not required, unless it’s an emer-
gency, you may not wish to begin a course
of treatment until you know what amount
the Plan will pay.
16UPS
Basic Services —Other surgical procedures HEALTH
These services are covered at 80 percent
Sialolithotomy—removal
after the Plan deductible has been met: of salivary calculus PROGRAM
• Visits and exams
Closure of salivary fistula
—Professional visit after hours
—Consultation by a specialist
Dilation of salivary duct Schedule
Transplantation of tooth or tooth bud
—Emergency palliative treatment
Removal of foreign body from
115
• X-ray and pathology bone (independent procedure)
—Single films (up to 13)
Maxillary sinusotomy for removal
—Intra-oral, occlusal view, maxillary of tooth fragment or foreign body
or mandibular
Closure of oral fistula of maxillary
—Upper or lower jaw, extra-oral sinus
—Biopsy and examination of oral tissue
Sequetrectomy for osteomyelitis
—Study models or bone abscess, superficial
—Microscopic examination
Condylectomy of temporo-
mandibular joint
• Oral surgery, including local anesthet-
ics and routine postoperative care
Meniscectomy of temporo-
mandibular joint
—Extractions
Radial resection of mandible
Uncomplicated
with bone graft
Surgical removal of erupted tooth
Crown exposure to aid eruption
Postoperative visit (sutures and
Removal of foreign body from
complications) after multiple
soft tissue
extractions and impaction
Frenectomy
—Impacted teeth
Suture of soft tissue injury
Removal of tooth
Injection of sclerosing agent into
—Alveolar or gingival reconstructions
temporomandibular joint
Alveolectomy (edentulous) per
Treatment of trigeminal neuralgia
quadrant
by injection into second and third
Alveolectomy (in addition to divisions
removal of teeth) per quadrant
• General anesthetics—when provided
Alveoplasty with ridge extension, in conjunction with an eligible surgical
per arch procedure
Removal of exostosis • Periodontics
Excision of hyperplastic tissue, —Emergency treatment (periodontal
per arch abscess, acute periodontitis, etc.)
Excision of pericoronal gingiva —Subgingival curettage or root plan-
Odontogenic cysts and neoplasms ing and scaling, per quadrant (not
Incision and drainage of abscess prophylaxis), limited to four quad-
Removal of odontogenic cyst rants per year
or tumor —Correction of occlusion related to
periodontal surgery, per quadrant
—Gingivectomy (including post-
surgical visits) per quadrant
17UPS
HEALTH —Gingivectomy, treatment per tooth —Crowns
(fewer than five teeth)
Stainless steel (when tooth cannot
PROGRAM —Osseous or muco-gingival surgery be restored with a filling material)
(including post-surgical visits)
Crown build-up—will be reviewed
—Crown lengthening—reviewed on by a dental consultant for necessity
Schedule a per claim basis. Predeterminations —Full and partial denture repairs
115 are suggested.
Broken dentures, no teeth involved
• Endodontics
Partial denture repairs (metal)
—Pulp capping
Replacing missing or broken teeth
—Therapeutic pulpotomy (in addition except congenitally missing teeth
to restoration) —Adding teeth to partial denture to
—Vital pulpotomy replace extracted natural teeth
—Remineralization (calcium hydrox-
Teeth and clasps
ide, temporary restoration) as a sep- —Recementation
arate procedure only
Inlay
—Root canals (devitalized teeth only),
Crown
including necessary X-rays and cul-
tures, but excluding final restoration
Bridge
Canal therapy (traditional or —Repairs—crowns and bridges
Sargenti method) • Space maintainers including all adjust-
Single rooted ments within six months after installation
Bi-rooted —Fixed space maintainer (band type)
Tri-rooted —Removable acrylic with round wire
rest only
Apicoectomy (separate procedure)
—Removable inhibiting appliance
• Basic restorations excluding inlays,
to correct thumb sucking
crowns (other than stainless steel) and
bridges. Multiple restorations in one —Fixed or cemented inhibiting appli-
surface are considered as a single ance to correct thumb sucking
restoration.
Major Services
—Restorations (involving one, These services are covered at 80 percent
two or three or more surfaces) after the Plan deductible has been met:
Amalgam filling • Major restorative—gold restorations,
Silicate cement filling inlays, onlays and crowns are covered
Plastic filling only for treatment of decay or traumatic
Composite filling—the alternate injury and only when teeth cannot be
benefit of an amalgam filling restored with a filling material or when
will be given when placed on the tooth is an abutment to a fixed bridge
posterior teeth or partial denture. Only restorations
—Pins needed for severe attrition, abrasion
or erosion are covered.
Pin (retention) when part of the
restoration used instead of gold —Inlays and onlays
or crown restoration
One or more surfaces
18UPS
—Crowns
Additional clasps HEALTH
Acrylic
Stress breakers
Acrylic with gold
Stayplate, base-additional clasps PROGRAM
Acrylic with non-precious metal
Office reline, cold cure, acrylic
Porcelain
Laboratory reline Schedule
Porcelain with gold Special tissue conditioning,
115
Porcelain with non-precious metal per denture
Non-precious metal (full cast)
Denture duplication (jump case),
Gold (full cast) per denture
Gold (3/4 cast)
Adjustment to denture more than
six months after installation
Gold dowel pin
• Other services
• Prosthondontics
—Precision attachments (eligible
—Bridge abutments
with dentures if they are func-
(see inlays and crowns)
tionally necessary)
—Pontics
—Implants (if specifically approved
Cast gold (sanitary) in advance and the teeth are extracted
Cast non-precious metal or missing while covered by the Plan)
Slotted facing
Slotted pontic
Alternate Benefit Provision
Porcelain fused to gold
In some circumstances, an alternate service
Porcelain fused to non-precious or supply may be suitable to treat or restore
metal a dental condition, other than the service
—Removable bridge (unilateral) or supply recommended by your dentist.
One piece casting, chrome cobalt In this case, the Plan will pay only for the
alloy clasp attachment (all types), alternate service or supply. If you choose
including pontics the recommended course of treatment,
—Dentures and partials (fees for den- you’ll be responsible for the difference
tures, partial dentures and relining between the recommended course and the
include adjustments within six alternate benefit. For example: Your dentist
months after installation. Special- may recommend a composite (white) fill-
ized techniques and characteriza- ing for a posterior tooth. An appropriate
tions are not eligible.) alternate treatment is an amalgam filling.
Complete upper denture The Plan will only pay for the amalgam
Complete lower denture filling. If you wish to have the composite
filling, you must pay the difference between
Partial acrylic upper or lower with
the composite and the amalgam filling.
chrome cobalt alloy clasps, base,
While predetermination is not required,
all teeth and two clasps
you may wish to submit your course of
Partial lower or upper with treatment in advance so you know what
chrome cobalt alloy lingual or amount the Plan will pay (see “Predeter-
palatal bar and acrylic saddles, mination of Benefits”).
base, all teeth and two clasps
19UPS
HEALTH Orthodontia The Plan covers 50 percent of the R&C
The Plan allows benefits for orthodontics cost of TMJ therapy up to a $1,500 lifetime
PROGRAM for your dependent children under 19 years maximum. The $1,500 lifetime maximum
of age. Services provided by December 31 TMJ benefit is combined with the ortho-
of the year in which your child turns 19 dontia maximum for dependent children.
Schedule are covered, as long as the treatment began
What’s Not Covered By Your
115 before the child’s 19th birthday. The Plan
Dental Benefits
pays 50 percent of the R&C charges for
orthodontia, up to a $1,500 lifetime maxi- In addition to services not specifically listed
mum for each child. This maximum includes in the “Covered Expenses” section, the
treatment for TMJ syndrome (described following expenses are not covered by
below) for children under age 19. the dental portion of the Plan:
• Services not required for the treatment
Orthodontia benefits are not subject to the of a specific condition or to maintain
annual deductible. Orthodontic payments good dental hygiene, as determined by
are made on a monthly basis. The first pay- the claims administrator
ment is equal to 50 percent of the down • Services not reasonably necessary or
payment plus 50 percent of the fee for the customarily performed, as determined
diagnostic records. However, quarterly by the claims administrator
certification is required to verify that treat-
• Services not furnished by a licensed
ment is continuing. Payments begin when
dentist, except services provided by
an active appliance is installed in your
a licensed hygienist under the direction
child’s mouth.
of a dentist or X-rays ordered by
Covered orthodontic services are: a dentist
• Initial consultation • Services for which you would not
be required to pay in the absence
• Moldings and impressions
of dental coverage
• Installation of braces
• Charges covered by the Plan’s
• Regular visits medical options
Before treatment begins, the orthodontist • Treatment of a work-related injury
should submit a total treatment plan to the • Services furnished by or for the United
claims administrator for approval. In this States government or for any other
way, you and the orthodontist will know government, including a service that
what treatment will be covered. may be covered by a government plan
• Charges for a missed or broken
Temporomandibular Joint appointment
(TMJ) Therapy • Charges for the dentist’s travel
Temporomandibular joint dysfunction is • Occlusal adjustment (unless following
covered for adults and dependent children. periodontal surgery) or retainers if
This coverage is for TMJ appliance therapy charged separately from orthodontic
(bite splints), adjustments and diagnostic treatment
materials (including impressions) only.
• Claims received more than 24 months
past the date of service
20UPS
• Intravenous sedation, except in certain • Replacement or modification of a HEALTH
circumstances. Call Member Services partial or fully removable denture,
to determine if covered. a removable bridge or fixed bridgework, PROGRAM
• Appliances, restoration or procedures or for adding teeth to any of these,
needed to alter vertical dimensions or for replacement or modification
or restore occlusion or for the purpose of an inlay, onlay, crown or cast Schedule
of splinting or correcting non-severe processed restoration, within five 115
attrition or abrasion years after installation
• Dentures and bridgework when they • Actisite
are for the replacement of teeth that • Local anesthesia or nitrous oxide
were extracted before the patient as a separate charge
was covered by the Plan • Any prescription drug
• Orthodontic treatment begun before • Full mouth debridement
covered by the Plan • Guided tissue regeneration
• Root canal therapy if the pulp chamber • Desensitization treatment
was opened before the patient was
• Precision attachments except as noted
covered by the Plan
under “Major Services”
• Relines and adjustments of dentures
• Infection control
and partial dentures within six months
after installation • Behavior management
• Cosmetic dental services and supplies, • Canal preparation, if submitted
including personalization or characteri- as a separate charge
zation of dentures • Rubber dam
• Prosthetic devices and appliances,
including bridges and crowns, and
expenses for fitting or modifying
them, if the patient is not covered by
the UPS Health Program when they
are ordered, when an impression was
made or when a tooth was prepared.
The above are also not covered if
installed or delivered more than 30
days after the patient’s coverage ends.
• Replacement of lost, stolen or broken
appliances
• Replacement of congenitally
missing teeth
• Dental implants (unless specifically
approved in advance)
• Education programs, such as plaque
control or oral hygiene instruction
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