2026 CODAC Benefit Summaries and Carrier Flyers

UTILIZATION REVIEW ORGANIZATION

The Utilization Review Organization is: UMR

DEFINITIONS

The following terms are used for the purpose of the UMR CARE section of this SPD. Refer to the Glossary of Terms section of this SPD for additional definitions.

Managed Care UnitedHealthcare Network Providers are providers participating in any UnitedHealthcare Network product with the exception of Options PPO.

Prior Authorization / Notification is the process of determining benefit coverage prior to a service being rendered to an individual member. A determination is made based on Medical Necessity criteria for drugs, supplies, tests, procedures, and other services that are appropriate and cost-effective for the member. This member-centric review evaluates the clinical appropriateness of requested services in terms of the type, frequency, extent, and duration of stay. The Prior Authorization / Notification requirements detailed within this section may be deemed satisfied for certain services, providers, and/or facilities meeting specific conditions or in a situation of a confirmed cyberattack that could result in a waiver only for a specified period of time. Utilization Management is the evaluation of the Medical Necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits Plan. This management is sometimes called “utilization review.” Such assessment may be conducted on a prospective basis (prior to treatment), concurrent basis (during treatment), or retrospective basis (following treatment). • Inpatient stays in Hospitals, Extended Care Facilities, or Residential Treatment Facilities • Partial hospitalization. • Organ and tissue transplants. • Home Health. • Durable Medical Equipment, excluding braces and orthotics, over $1,500 or Durable Medical Equipment rentals over $500. • Prosthetics over $1,000. • Chemotherapy (cancer diagnosis). • Non-Emergency air and ground transportation. • Genetic and molecular testing (except for standardized BRCA testing). • Dialysis. • Medical Specialty Drug Program. To encourage safe and cost-effective medication use, prior authorization may be required for some specialty drugs. Please visit Specialty Injectable | UMR for a list of Medical Specialty Drugs that may require prior authorization, including Site of Care when applicable (including select gene therapy drugs, orphan drugs, and CAR-T drugs). To request a copy of the Medical Specialty Drug list, call the toll-free number on the back of Your member identification card and the list will be provided free of charge. Prior authorization does not guarantee benefit payment. This Plan may exclude specific drugs on this list from coverage. Refer to the General Exclusions section of this SPD for possible Medical Specialty Drug exclusions. • Inpatient stays in Hospitals or Birthing Centers that are longer than 48 hours following normal vaginal deliveries or 96 hours following Cesarean sections. • Other outpatient or office services requiring Prior Authorization. • Radiation Treatment (all diagnosis). • Clinical Trials. SERVICES REQUIRING PRIOR AUTHORIZATION Call the Utilization Review Organization at the number on the back of Your ID card or complete a Prior Authorization search at www.umr.com before a Covered Person receives services for the following:

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