rred for medical costs must exceed the
Annual Non-Sharable Amount established for your Program to be eligible for sharing (See Section 5.02
for details). Medical expenses must be submitted for sharing in the manner and form specified by
Universal HealthShare. This includes the standard industry billing forms (HCFA 1500 and/or UB 92) and
relevant/required medical records.
The following Sections are designed to allow you to quickly check, based on type of health care facility,
provider, service, product, treatment or physical/medical condition, to confirm whether a particular medical
expense is generally sharable. Members share costs as addressed below, subject to both your prior
payment of the applicable Annual Non-Sharable Medical Amount and all exclusions, restrictions and
limitations set forth in these Guidelines. Any services not specifically referenced herein as either eligible
or ineligible for sharing must be submitted to Universal HealthShare in advance for consideration and
receive prior confirmation of general sharability to be eligible for sharing.
i. Sharing for Facilities, Providers & Services
Members generally share costs for the following health care facilities, providers, and services, as
specifically described below. Note: All applicable Sharing Guidelines terms and limits of your sharing
program, including the requirement for you to use an in-network provider and meet your Non-Sharable
Amount apply.
(a) Annual Routine Physical Exam.
An Annual Routine Physical or Well Child Exam is sharable.
(b) Ambulance.
Emergency land or air ambulance transportation to the nearest medical facility capable of providing care
that is medically necessary for a medical condition with symptoms of sufficient severity that the absence
of immediate medical attention would reasonably be expected to result in death or serious jeopardy to the
health of the individual (or, with respect to a pregnant woman, the woman’s unborn child) involving
serious impairment to bodily functions or serious dysfunction of any bodily organ or part; provided,
however, that air ambulance transportation is not sharable in situations where the use of a less expensive
form of emergency transport could have been employed without materially increasing the risk of seriously
jeopardizing your life or long-term health.
(c) Audiological Procedures.
N/A
(d) Audiological Therapy.
N/A
(e) Chiropractic Therapy.
N/A
(f) Cologuard.
After a 180-day waiting period, a Cologuard® noninvasive colon cancer screening test prescribed by a
Physician may be sharable once every three (3) years for Members who are 45 or older, up to $650 perUHFR093021E100121 Page 108
test for each Member, and the combined Preventive Care sharing limit will not apply to sharing for such
tests.
(g) Colonoscopy.
A diagnostic colonoscop