Coverage under this plan qualifies as minimum essential coverage. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

See www.opm.gov/healthcare-insurance for enrollment information as well as:

• Information on the FEHB Program and plans available to you
• A health plan comparison tool
• A list of agencies that participate in Employee Express
• A link to Employee Express
• Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, give you other plans' brochures and other materials you need to make an informed decision about your FEHB coverage.  These materials tell you:

• When you may change your enrollment,
• How you can cover your family members,
• What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire,
• What happens when your enrollment ends,
• When the next Open Season for enrollment begins.

We determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office.  For information on your premium deductions, you must also contact your employing or retirement office.

Once enrolled in your FEHB Program Plan, you should contact your carrier directly for address updates and questions about your benefit coverage. 

Self Only coverage is only for the enrollee.  Self Plus One coverage is for the enrollee and one eligible family member.  Self and Family coverage is for the enrollee and one or more eligible family members. Family members include your spouse and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office.  Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family.  You may change your enrollment 31 days before to 60 days after that event. The Self and Family or Self Plus One enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member.  When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. Benefits will not be available to your spouse until you are married. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

Contact your employing or retirement office if you want to change from Self Only to Self Plus One or Self and Family. If you have a Self and Family enrollment, you may contact us to add a family member.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits.  Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26.  We will send written notice to you 60 days before we proactively disenroll your child on midnight of their 26th birthday unless your child is eligible for continued coverage because they are incapable of self-support due to a physical or mental disability that befan before age 26. 

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage.  For a complete list of QLE's, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events.  If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

Family members covered under your Self and Family enrollment are your spouse (including you spouse by a valid common-law marriage from a state that recognizes common-law marriages) and children as described in the chart below. A Self Plus One enrollment covers you and your spouse, or one other  eligible family member as described  below.

Family members covered under your Self and Family enrollment are your spouse (including your spouse by a valid common-law marriage from a state that recognizes common-law marriages) and children as described in the chart below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described below.

Natural children, adopted children, and stepchildren
Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday.

Foster children
Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children incapable of self-support
Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information.

Married children
Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday.

Children with or eligible for employer-provided health insurance
Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother's maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

OPM implements the Federal Employees Health Benefits Children’s Equity Act of 2000.  This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children.  If you do not do so, your employing office will enroll you involuntarily as follows:

• If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.
• If you have a Self Only enrollment in a Point of Service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self and Family, as appropriate, in the same option of the same plan; or
• If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.

As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children. 

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect.  Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child.  Contact your employing office for further information.

The benefits in this brochure are effective January 1.  If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1.  If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2024 benefits of your prior plan or option.  If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2023 benefits until the effective date of your coverage with your new plan.  Annuitants’ coverage and premiums begin on January 1.  If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage, (i.e. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid.  You may be billed for services received directly from your provider.  You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums.  It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage.

When you retire, you can usually stay in the FEHB Program.  Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service.  If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).

You will receive an additional 31-days of coverage, for no additional premium, when:

• Your enrollment ends, unless you cancel your enrollment, or
• You are a family member no longer eligible for coverage.

Any person covered under the 31-day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31^st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60^th day after the end of the 31-day temporary extension.

You may be eligible for spouse equity coverage or assistance with enrolling in a conversion policy (a non-FEHB individual policy).

If you are an enrollee, and your divorce or annulment is final, your ex-spouse cannot remain covered as a family member under your Self Plus One or Self and Family enrollment.  You must contact us to let us know the date of the divorce or annulment and have us remove your ex-spouse.  We may ask for a copy of the divorce decree as proof.  In order to change enrollment type, you must contact your employing or retirement office.  A change will not automatically be made.

If you were married to an enrollee and your divorce or annulment is final, you may not remain covered as a family member under your former spouse’s enrollment.  This is the case even when the court has ordered your former spouse to provide health coverage for you.  However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC).  If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices.  You can also visit OPM's website at https://www.opm.gov/healthcare-insurance/life-events/memy-family/im-separated-or-im-getting-divorced/#url=Health. We may request that you verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC).  For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, or if you are a covered child and you turn age 26.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC.  Get the RI 79-27, which describes TCC, from your employing or retirement office or from www.opm.gov/healthcare-insurance.  It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a of tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll.  Finally, if you qualify for coverage under another group health plan (such as your spouse’s plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program coverage.

You may convert to a non-FEHB individual policy if:

• Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);
• You decided not to receive coverage under TCC or the spouse equity law; or
• You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal or Tribal service, your employing office will notify you of your right to convert.  You must contact us in writing within 31 days after you receive this notice.  However, if you are a family member who is losing coverage, the employing or retirement office will not notify you.  You must contact us in writing within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, waiting period will not be imposed and your coverage will not be limited due to pre-existing conditions. When you contact us we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act's Health Insurance Marketplace in your state.  For assistance in finding coverage, please contact us at 800-235-7111 or visit our website at www.qualchoice.com.

If you would like to purchase health insurance through the ACA's Health Insurance Marketplace, please visit www.HealthCare.gov.  This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.

We will send you an identification (ID) card when you enroll.  You should carry your ID card with you at all times.  You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy.  Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at (800) 235-7111 or write to us at QualChoice, P.O. Box 25610, Little Rock, AR 72221.  You may also request replacement cards through our website: www.qualchoice.com.

Under High Option, you can use both In-Network and Out-of-Network Providers.  In-Network Providers will submit claims to us on your behalf and obtain any necessary preauthorization.  You have direct access to In-Network Providers without a referral.  Under the High Option Point of Service Plan, you can also get care from Out-of-Network Providers. It is your responsibility to obtain pre-authorizations for  Out-of-Network  services that require pre-authorizations.  If you use In-Network Providers, you will pay less.

Under Standard Option, you have direct access to see In-Network Providers without a referral.  You must use In-Network Providers under the Standard Option to be eligible for benefits, except in circumstances such as emergency care.  In-Network Providers will submit claims on your behalf and obtain any necessary preauthorization.

FEHB Carriers must have clauses in their in-network (participating) providers agreements.  These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount.  If an in-network provider bills you for covered services over your normal cost share (deductible, copay, co-insurance) contact your Carrier to enforce the terms of its provider contract.

Plan providers are In-Network Providers and other healthcare professionals in our service area that we contract with to provide covered services to our members.  Services by Plan Provides are covered when acting within the scope of their license or certification under applicable state law.  We credential Plan providers according to national standards.

Benefits are provided under this Plan for the services of covered providers, in accordance with Section 2706(a) of the Public Health Service Act.  Coverage of practitioners is not determined by your state's designation as a medically underserved area. 

We list Plan providers in the provider directory, which we update periodically.  The list is also on our website.

This plan recognizes that transgender, non-binary, and other gender diverse members require health care delivered by healthcare providers experienced in gender affirming health.

Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender.  

This plan provides Care Coordinators for complex conditions and can be reached at (800) 235-7111 or write to us at QualChoice, P.O. Box 25610, Little Rock, AR  72221 for assistance.  

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members.  We list these in the provider directory, which we update periodically.  The list is also on our website at www.qualchoice.com. 

Under High Option, you can go to any In-Network Provider you want to, but in some circumstances, we must approve your care in advance.  You also have Out-of-Network benefits under this Plan option.  If you receive care from Out-of-Network Providers, you will be responsible for a separate deductible and coinsurance amount and you will be responsible for any difference between our allowance and the billed amount.  Please refer to Section 4, “Your costs for covered services”, for related benefits information.

Under Standard Option, you must use In-Network Providers in order to receive benefits, except under the special situations listed below.  In addition, we must approve certain types of care in advance.  Please refer to Section 4, “Your costs for covered services”, for related benefit information.

1. Medical emergency or accidental injury care in a hospital emergency room and related ambulance transport as described in Section 5(d), Emergency services/accidents
2. Professional care provided at In-Network facilities by  Out-of -Network radiologists, anesthesiologists, certified registered nurse anesthetists (CRNAs), laboratory, pathologists, emergency room physicians, and assistant surgeons
3. Special provider access situations

Unless otherwise noted in Section 5, when services of Out-of-Network Providers are covered in a special exception, you are responsible for the applicable deductible, coinsurance or copayment.

Your primary care provider can be any one of the following provider types; a) Family or General Practitioner, b) Internal Medicine, c) Pediatrician, d) Geriatrics.  We encourage you to utilize an In-Network Primary Care Provider to assist in the coordination of your healthcare services under this Plan. The utilization of an In-Network Primary Care Provider is a matter you control and you are not required to notify us of your In-Network Primary Care Provider relationship. If you want to change primary care physicians or if your primary care physician leaves the Plan, call us.  We will help you select a new one. 

You are always encouraged to seek care directly from an In-Network Primary Care Provider first. You may also seek care with any In-Network Provider under this Plan without a Referral.  The Specialty Care benefits will apply to services provided to you by a Specialty Care Provider, as described in Section 5.

Here are some other things you should know about specialty care:

If you have a medical condition that needs special services, you may need to see an In-Network specialist. If you require certain complex covered services for which expertise is not available In-Network, we may direct you to an Out-of-Network Provider.  In-Network Benefits will only be paid if the Out-of-Network Provider and services are approved by us.  Call (800) 235-7111 to request review.  The following do not constitute approval for Benefits:

• A referral, whether written or oral, by your In-Network Provider to an Out-of-Network Provider
• An order or prescription for services to an Out-of-Network Provider

If you have a chronic and disabling condition and lose access to your specialist because we:

• terminate our contract with your specialist for other than cause 
• drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program plan
• reduce our Service Area and you enroll in another FEHB plan 

You may be able to continue seeing your specialist for up to 90 days after you receive notice of the change.  Contact us, or if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your provider based on the above circumstances, you can continue to see your provider until the end of your postpartum care, even if it is beyond the 90 days. 

Your primary care provider or specialist will make necessary hospital arrangements and supervise your care.  This includes admission to a skilled nursing or other type of facility.  

We pay for covered services from the effective date of your enrollment.  However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at (800) 235-7111.  If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of coverage.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

• you are discharged, not merely moved to an alternative care center
• the day your benefits from your former plan run out
• the 92^nd day after you become a member of this Plan, whichever happens first

These provisions apply only to the benefits of the hospitalized person.  If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply.  In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.

You must get prior approval for certain services.  Failure to do so for out-of-network services, on the High Option, will result in the service not being eligible for coverage. 

Since we do not have a primary care provider requirement and we allow you to use non-Plan providers if you select the High Option plan, if you seek services from a non-Plan provider you need to obtain our approval before you receive certain services. The pre-service claim approval processes for inpatient hospital admissions (called precertification) and for other services, are detailed in this Section. A pre-service claim is any claim, in whole or in part, that requires approval from us in advance of obtaining medical care or services. In other words, a pre-service claim for benefits
(1) requires precertification or prior approval and (2) will result in a denial or reduction of benefits if you do not obtain precertification or prior approval.

Pre-authorization is a determination made prior to services or supplies being provided on whether the services or supplies are medically necessary. We must receive sufficient clinical information to establish medical necessity. The medical necessity for an Out-of-Network Referral will include the absence of or the exhaustion of all In-Network resources. Pre-authorizations are all time-limited.

Your primary care provider has authority to refer you for most services.  For certain services, however your physician must obtain prior approval from us.  Before giving approval, we consider if the service is covered, medically necessary, and follows general accepted medical practice. 

You must obtain prior-authorization for services such as those listed below: 

• Equipment such as Bone stimulators, DME
• All Inpatient services, including Hospice
• Home Care 
• Medications, such as “off  label” usage, Injectables, specialty medications
• Certain Outpatient Services, and out-of-network outpatient services 
• Specialized scanning diagnostic exams, and advanced imaging procedures such as, MRI, CT Scans and PET Scans
• Surgical treatments
• Transplants  
• Out of Network Services [Applies to Point-of-Service (POS) benefit/available only if enrolled in the High Option]

For a complete list of services requiring authorization go to www.qualchoice.com.

First, your physician, your hospital, you or your representative, must call us at (800) 235-7111 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

• enrollee's name and Plan identification number;
• patient's name, birth date, identification number and phone number;
• reason for hospitalization, proposed treatment or surgery;
• name and phone number of admitting physician;
• name of hospital or facility; and
• number of days requested for hospital stay.

For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization.  We will make our decision within 15 days of receipt of the pre-service claim.  If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period.  Our notice will include the circumstances underlying the request for extension and the date when a decision is expected.

If we need an extension because we have not received necessary inforamtion from you, our notice will describe the specific information required and we will allow you up to 45 days from the receipt of the notice to provide the information.

If you have an urgent care claims (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or abiliity to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify youof our decision within 72 hours.  If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgement of a prudnet layperson that possesses an average knowledge of health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim.  You will then have up to 48 hours to provide the required information.  We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM.  Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at (800) 235-7111.  You may also call OPM’s Health Insurance 3 at (202)606-0755 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us at (800)235-7111. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

A concurrent care claim involves care provided over a period of time or over a number of treatments.  We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision.  This does not include reduction or termination due to benefit changes or if your enrollment ends.  If we believe a reduction or termination is warranted we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must telephone us within 24 hours or the next business day following the day of the emergency admission, even if you have been discharged from the hospital. 

You do not need precertification of a maternity admission for a routine delivery.  However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days.  Further, if your baby stays after you are discharged, your physician or the hospital must contact us for precertification of additional days for your bably.

Note: When a newborn required definitive treatment during or after the mother's hospital stay, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below.  If your claim is in reference to a contraceptive, call 800-228-7111.  

If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.  Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to

1. Precertify your hospital stay or if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply or

2. Ask you or your provider for more information.

You or your provider must send the information so that we receive it within 60 days of our request.  We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due.  We will base our decision on the information we already have.  We will write to you with our decision.

3.  Write to you and maintain our denial.

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.  Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

A co-payment is a fixed amount of money you must pay to the provider, facility, pharmacy, etc., when you receive certain services. Co-payment amounts do not apply to the satisfaction of the deductible amounts.  Medical and Prescription Drug Co-payments do apply to satisfaction of catastrophic out-of-pocket limits for each enrollee or family. Please see your Benefits Summary for a list of those benefits to which co-payments apply.

Example: When you see your primary care provider, you pay a co-payment of $20 per office visit, and when you go in the hospital, you pay $100 per admission.

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them.  Copayments do not count toward any deductible. 

• Under Standard Option, there is no calendar year deductible
• Under High Option, the calendar year deductible for In-Network Providers is $500 per person.  Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $500.  Under a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $1,000.  Under a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reaches $1,000.  The calendar year deductible for Out-of-Network Providers is $1,000 per person($3,000 Self Plus One and Self Plus Family). Deductibles for In-Network providers and Out-of-Network providers are accumulated separately.

Note: If you change plans during Open Season, you do not have to start a new deductible under your prior plan between January 1 and the effective date of your new plan.  If you change plans at another time during the year, you must begin a new deductible under your new plan.

If you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option.

Coinsurance is the percentage of our allowance that you must pay for your care.  Coinsurance does not begin until you have met your calendar year deductible.

Our "Plan allowance" is the amount we use to calculate our payment for certain types of covered services.  Often, the provider’s bill is more than the plan’s allowance.

In-Network providers. These providers have agreements with QualChoice to limit what they bill our members. Because of that, when you use an In-Network provider, your share of the provider’s bill for covered care is limited.

• Under High Option, your cost consists only of your deductible and coinsurance or copayment. Here is an example involving a copayment:  You see an In-Network physician who charges $150, but our allowance is $100.  You pay just $20 of our $100 allowance. Because of the agreement, your In-Network provider will not bill you for the $50 difference between our allowance and his/her bill.
• Under Standard Option, your cost consists only of your copayment or coinsurance amount, since there is no calendar year deductible. Here is an example involving a copayment: You see an In-Network specialist provider who charges $150 for covered services subject to a $40 copayment. Even though our allowance may be $100, you still pay just the $40 copayment. Because of the agreement, your Preferred physician will not bill you for the $110 difference.Under Standard Option, there is no Out-of-Network benefit. If you choose to receive care from an out-of-network provider, you will be responsible for all charges.  See page 17 for the exceptions to this requirement.
• Under High Option/Point-of-Service (POS) benefit, when you use an Out-of-Network provider, you will pay your deductible and coinsurance –plus any difference between our maximum plan allowance and the charges on the bill (except in certain circumstances – see pg. 12). For example, you see an Out-of-Network provider who charges $150. The Plan allowance is again $100, and you have met your deductible. You are responsible for your coinsurance, so you pay 40% of the $100 Plan allowance or $40. Plus, because there is no agreement between the Non-participating physician and us, the physician can bill you for the $50 difference between our allowance and his/her bill. Out-of-Network providers. These providers have no agreement to limit what they will bill you.

You should also see section Important Notice About Surprise Billing – Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.

• Standard Option-After your (copayments and coinsurance) total $5,500 for Self Only or $11,000 for Self Plus One and Self Plus Family any calendar year, you do not have to pay any more for covered for services. The maximum annual limitation on cost sharing listed under Self Only of $5,500 applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.
• High Option-After your (copayments and coinsurance) total $5,000 for Self Only or $10,000 for Self Plus One and Self Plus Family in any calendar year, you do not have to pay any more for covered services.  The Out-of-Network Out-of-Pocket limit under the High Option Plan is $13,200 for Self Only enrollment and $26,400 for Self Plus One and Self Plus Family enrollment. The maximum annual limitation on cost sharing listed under Self Only of $5,000 applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

Example Scenario:  Your plan has a $5,000 Self Only maximum out-of-pocket limit and a $10,000 Self Plus One or Self and Family maximum out-of-pocket limit.  If you or one of your eligible family members has out-of-pocket qualified medical expenses of $5,000 or more for the calendar year, any remaining qualified medical expenses for that individual will be covered fully by your health plan.  With a Self and Family enrollment out of pocket maximum of $10,000, a second family member, or an aggregate of other eligible family members, will continue to accrue out-of-pocket qualified medical expenses up to a maximum of $5,000 for the calendar year before their qualified medical expenses will begin to be covered in full.

However, the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments and coinsurance for these services:

• Eyeglass and or contact lense discount plan

Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the maximum.

If you changed to this Plan during Open Season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan’s catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan.  If you have already met your prior plan’s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan.  If you have not met this expense level in full, your prior plan will first apply your covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan.  Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

Note:  If you change options in this Plan during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your old option to the catastrophic protection limit of your new option.

The No Surprises Act (NSA) is a federal law that provides you with protections against "surprise billing" and "balance billing" for out-of-network emergency services; out-of-network non-emergency services provided with respect to a visit to a participating health care facility; and out-of-network air ambulance services. 

A surprise bill is an unexpected bill you receive for

• emergency care - when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services furnished by nonparticipating providers with respect to patient visits to participating health care facilities, or for
• air ambulance services furnished by non-participating providers of air ambulance services. 

Balance billing happens when you receive a bill from the nonparticipating provider, facility, or air ambulance service from the difference between the nonparticipating provider's charge and the amount payable by your health plan.

Your health plan must comply with the NSA protections that hold you harmless from surprise bills.

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.qualchoice.com or contact the health plan at 800-228-7111.  

Healthcare FSA(HCFSA) - Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you, your tax dependents, and your adult children (through the end of the calendar year in which they turn 26).

FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans.  This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.  

Professional services of physicians:

• In physician's office
• In an urgent care center
• Office medical consultations
• Second surgical opinion
• At home

$20 copayment for a primary care provider (No deductible)

$35 copayment for a specialist physician (No deductible)

$20 copayment for a primary care provider

$40 copayment for a specialist physician

Inpatient professional services:

• During a hospital stay
• In a skilled nursing facility

Not Covered:

• Inpatient private duty nursing
• Standby physicians
• Routine radiological and staff consultations required by hospital rules and regulations 

• Online and telephonic medical evaluation and management services:

$20 copayment for a primary care physician (No deductible)

$35 copayment for a specialist physician (No deductible)

$20 copayment for a primary care physician

$35 copayment for a specialist physician

Diagnostic tests provided, or ordered and billed by a physician, such as:

• Blood tests or Laboratory test in the office
• Urinalysis
• Pathology
• X-ray (Basic Imaging)
• Bone density tests – screening or diagnostic (for women over age 50 and men over age 75)

Genetic testing

Note:  Genetic Testing requires pre-authorization.

20% Of the Plan allowance after deductible

30% of the Plan allowance

Advanced imaging such as:

• CT/CAT Scan, MRI, MRA, DEXA, PET, SPECT
• Radiation therapy
• Blood tests or laboratory tests in an outpatient or inpatient facility
• Diagnostic mammograms

Note : See Section 5(c) for services billed for by a facility, such as the outpatient department of a hospital.

Routine physical every year.

The following preventive services are covered at the time interval recommended at each of the links below.

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/Tdap, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/
• Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations

   

• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of preventive care benefits for women please visit the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder 

Nothing

Nothing

• Routine prostate specific antigen (PSA) test - one annually for men age 40 and older

Nothing

• Routine mammogram - covered

Nothing

Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.

• Medical Nutrition Therapy and Intensive Behavioral Therapy for the prevention of obesity related comorbidities.

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Nothing

Nothing

Not covered:

• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams or travel.
• Immunizations, boosters, and medications for travel or work-related exposure.

• Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
• Immunizations such as DTaP/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html
• You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Nothing

Nothing

Complete maternity (obstetrical) care such as:

• Screening for gestational diabetes
• Prenatal and Postpartum care
• Delivery
• Screening and counseling for prenatal and postpartum depression

We cover up to three (3) ultrasounds without prior approval.  All other ultrasounds must be preauthorized. This is the responsibility of your In-Network provider. If you use a Non-In-Network provider, it is your responsibility to tell your physician to call for the preauthorization.

Note: We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.

Nothing for prenatal care or the first postpartum care visit; $20 per office visit for all postpartum care visits thereafter.

Nothing for inpatient professional delivery services.

Nothing for prenatal care or the first postpartum care visit; $20 per office visit for all postpartum care visits thereafter.

Nothing for inpatient professional delivery services.

Breastfeeding support, supplies and counseling for each birth

Note: Here are some things to keep in mind:

• You do not need to pre-certify your vaginal delivery; see page 50 for other circumstances, such as extended stays for you and your baby.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will cover an extended stay if medically necessary.
• We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the child under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

Note: When a newborn requires definitive treatment during or after the mother's confinement, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

Not Covered:

• No benefits for surrogate mothers

A range of voluntary family planning services, limited to:

• Surgically implanted contraceptive
• Voluntary sterilization (See Surgical Procedures Section 5(b)
• Injectable contraceptive drugs (such as Depo Provera)
• Intrauterine devices (IUDs)
• Diaphragms
• Tubal ligation

Note:  We cover oral contraceptives under the prescription drug benefit.

Nothing

Nothing

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling

Diagnosis and treatment of infertility is covered except for services in the Not Covered section of this document.

Artificial insemination

• Intravaginal insemination (IVI)
• Intrauterine insemination (IUI)
• Intracervical insemination (ICI)

Iatrogenic Infertility Preservation

Note: Fertility preservation treatment is limited to persons facing iatrogenic infertility associated with medical and surgical gender transition treatment.  Storage is limited to one (1) year and benefits are limited to one cycle of fertility preservation per covered person during the entire period the member is enrolled with QualChoice. 

Note: All infertility testing, fertility drugs (See Section 5f), preservation and treatment related services require preauthorization.

Not covered:

Assisted reproductive technology (ART) procedures, such as:

• In vitro fertilization (IVF)
• Embryo transfer and gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
• Infertility services after voluntary sterilization
• Cost of donor sperm
• Cost of donor egg

• Testing and treatment
• Allergy injections

Note: Certain allergy testing requires preauthorization. For allergy injections only you owe nothing.

$20 copayment for a primary care physician (No deductible)

$35 copayment for a specialist physician (No deductible)

$20 copayment for a primary care physician

$40 copayment for a specialist physician

Inpatient and outpatient treatment therapies:

• Chemotherapy and radiation therapy

Note:  High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on pg. 44.

• Respiratory and inhalation therapy
• Cardiac rehabilitation following qualifying event/condition is provided for up to 36 sessions
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion therapy – Home IV and antibiotic therapy
• Applied behavior analysis (ABA) Children with autism spectrum
• Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit.  

Note: We only cover GHT when we preauthorize the treatment.  We will ask you to submit information that establishes that the GHT is medically necessary.  Ask us to authorize GHT before you begin treatment.  We will only cover GHT services and related services and supplies that we determine are medically necessary.  See Other services under You need prior Plan approval for certain services on page 18.

Habilitative and Rehabilitative services

The following therapies are covered:

• Physical therapy
• Occupational therapy
• Cardiac rehabilitation

Note: We only cover therapy when a physician:

• orders the care 
• identifies the specific professional skills the patient requires and the medical necessity for skilled services; and
• indicates the length of time the services are needed.

Benefits are limited to 60 visits or two consecutive months, per condition for physical, or occupational, or a combination of both.

$20 copayment for services provided by a licensed physical or occupational therapist

$35 copayment for a specialist physician who is not a licensed physical or occupational therapist (No deductible)

$20 copayment for services provided by a licensed physical or occupational therapist

$40 copayment for a specialist physician who is not a licensed physical or occupational therapist

Not covered:

• Recreational or education therapy, and any related diagnostic testing except as provided by a hospital as part of a covered inpatient stay
• Maintenance or palliative rehabilitative therapy
• Exercise programs
• Hippotherapy (exercise on horseback)
• Services provided by a massage therapists

Habilitative and Rehabilitative benefits are limited to 60 visits or two consecutive months per person, per calendar year.

Note:  Habilitative services require pre-authorization

$20 copayment when provided by a licensed speech therapist

$35 copayment for a specialist physician who is not a licensed speech therapist(No deductible)

$20 copayment when provided by a licensed speech therapist

$40 copayment for a specialist physician who is not a licensed speech therapist

• For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist

Note: For routine hearing screening performed during a child’s preventive care visit, see Section 5(a) Preventive care, children.

• External hearing aids
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants

Note: For benefits for the devices, see Section 5(a) Orthopedic and prosthetic devices.

Not covered:

• Hearing services that are not shown as covered

• Routine vision exam covered 1 every 24 months
• Bi-annual eye refractions
• Eye examinations related to a specific medical condition
• Nonsurgical treatment for amblyopia and strabismus, for children from birth through age 18

Note: See Preventive care, children for eye exams for children.

$20 copayment for a primary care physician (No deductible)

$35 copayment for a specialist physician (No deductible)

$20 copayment for a primary care physician

$40 copayment for a specialist physician

Benefits are limited to one pair of eyeglasses, replacement lenses, or contact lenses per incident prescribed:

• To correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts);
• If the condition can be corrected by surgery, but surgery is not an appropriate option due to age or medical condition.

Not covered:

• Eyeglasses or contact lenses, except as shown above
• Eye exercises and orthoptics, except for nonsurgical treatment of amblyopia and strabismus as described above 
• Radial keratotomy and other refractive surgery

Routine foot care when you are under active treatment for metabolic or peripheral vascular disease, such as diabetes.

20% of the Plan allowance after deductible

30% of the Plan allowance

Not covered:

• Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)
• Orthotripsy

Orthopedic braces and prosthetic appliances such as:

• Artificial limbs and eyes
• Prosthetic sleeve or sock
• Functional foot orthotics when prescribed by a physician
• Rigid devices attached to the foot or a brace, or place in shoe
• Replacement, repair, and adjustment of covered devices
• Following a mastectomy, breast prostheses and surgical bras, including necessary replacements
• Hearing aids for adults and children limited to one hearing aid per ear per 36-month period
• Hearing aids and testing to fit them
• Surgically implanted penile prostheses to treat erectile dysfunction

Note:  We provide benefits for internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants and surgically implanted breast implants following mastectomy. 

Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b) Surgical procedures.  For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services provided by a hospital or other facility, and ambulance services.

Note:  Hearing aids are not subject to deductible and coinsurance and Cochlear implants are limited to $20,000 per implant.

20% of the Plan allowance after deductible

20% of the Plan allowance

• Wigs (scalp hair prosthesis) due to hair loss due to chemotherapy for the treatment of cancer

Note: Benefits for wigs are paid at 100% of the billed amount, limited to $350 for one wig. Pre-authorization required.

Not covered:

• Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Prosthetic replacements provided less than 3 years after the last one we covered Shoes and over-the-counter orthotics
• Wigs (including cranial prostheses), except for scalp hair prosthesis for hair loss due to chemotherapy for the treatment of cancer, as stated above

Durable medical equipment (DME) is equipment and supplies that:

• Are prescribed by your attending physician (i.e., the physician who is treating your illness or injury)
• Are medically necessary
• Are primarily and customarily used only for a medical purpose
• Are generally useful only to a person with an illness or injury
• Are designed for prolonged use
• Serve a specific therapeutic purpose in the treatment of an illness or injury
• Medical foods and low protein food products for a person with Single Gene Inborn Errors of Metabolism

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include:

• Oxygen,
• Dialysis equipment,
• Hospital beds,
• Wheelchairs,
• Crutches,
• Walkers,
• Blood glucose monitors, 
• Insulin pumps, and
• Speech-generating devices.

Note:  Call us at (800) 235-7111 as soon as your Plan physician prescribes this equipment.  We will arrange with a healthcare provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

Not covered:

• Exercise and bathroom equipment
• Lifts, such as seat, chair, or van lifts
• Car seats
• Air conditioners, humidifiers, dehumidifiers, and purifiers
• Breast pumps

Note: Electric breast pumps can be covered for a limited time at a rental rate for mothers that have newborn babies in extended stays in the hospital.

• Communications equipment, devices, and aids (including computer equipment) such as “story boards” or other communication aids to assist communication-impaired individuals
• Equipment for cosmetic purposes
• Topical hyperbaric oxygen therapy (THBO)
• Tanning beds

Home healthcare ordered by a In-Network physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), or licensed therapist.

Services include:

• Intravenous therapy
• Wound care
• Therapy
• Medications

Note: Home health services are limited to 40 visits per year

20% of the Plan allowance after deductible

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient’s family;
• Home care for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative.

• Manipulation of the spine and extremities
• Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

Note: Chiropractic x-ray’s require preauthorization

Limits:

• 20 visits annual benefit maximum for chiropractic care

Biofeedback is covered for a limited number of diagnoses:

• Urinary incontinence; female
• Tension headaches (muscle, thermal or skin biofeedback only; EEG biofeedback is considered experimental and investigational for this indication)
• Temporomandibular joint (TMJ) syndrome
• Neuromuscular rehabilitation of stroke and traumatic brain injury (TBI) (see note below)
• Fecal incontinence
• Raynaud’s disease
• Irritable bowel syndrome
• Refractory severe subjective tinnitus
• Levator ani syndrome
• Treatment of migraine headaches when chemoprophylaxsis has been ineffective
• Hypnotherapy (No visit limits)

Not covered:

• Naturopathic services 
• Biofeedback except as stated above
• AutoMove AM800

Coverage is provided for:

• Tobacco Cessation programs, including individual/group/telephone counseling, and for over the counter (OTC) and prescription drugs approved by the FDA to treat tobacco depedence.

Nothing for counseling for up to two quit attempts per year.

Nothing for OTC and prescription drugs approved by the FDA to treat tobacco dependence.

Nothing for counseling for up to two quit attempts per year.

Nothing for OTC and prescription drugs approved by the FDA to treat tobacco dependence.

• Diabetes self management for one educational course
• Multicomponent, family centered programs focused on childhood obesity that are part of intensive behavioral interventions (behavior change counseling for healthy diet and physical activity)

QualChoice offers health coaching, call a coach at (800) 235-7111

Note: Further diabetic education sessions will be covered if medically necessary according to our medical criteria and approved by a care manager

Nothing

Nothing

Not covered:

• Marital, family, educational, or other counseling or training services when performed as part of an educational class or program
• Premenstrual syndrome (PMS), lactation, headache, eating disorder (except as described above), and other educational clinics
• Recreational or educational therapy, and any related diagnostic testing except as provided by a hospital as part of a covered inpatient stay
• Services performed or billed by a school or halfway house or a member of its staff

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre-and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery )
• Insertion of internal prosthetic devices.  See 5(a) for Orthopedic and prosthetic devices for device coverage information
• Surgical treatment of severe obesity (bariatric surgery)
• Voluntary sterilization (e.g., tubal ligation, vasectomy)
• Treatment of burns

Note: You must get prior approval for surgery for obesity.  QualChoice offers Health coaching, call a coach at (800) 235-7111.  For consideration for this surgery, several criteria must be met, such as: 

• Have presence of severe obesity that has persisted for at least 3 years
• Be between the ages of 18-64; and
• Have been evaluated by a psychiatrist; and
• Has participated in clinically supervised nutrition and exercise program
• Before surgery, you must participate in organized multidisciplinary surgical preparatory regimen of at least three months duration.

See www.qualchoice.com for more policy detail regarding obesity (bariatric surgery).

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done.  For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker. 

See 5(a) – Orthopedic and prosthetic devices for device coverage information

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot (see Foot care)
• Services of a standby physician
• Cosmetic Surgery
• LASIK, INTACS, radial keratotomy and other refractive surgery

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • the condition produced a major effect on the member's appearance, and
  • the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm.  Examples of congenital anomalies are; protruding ear deformities, cleft lip, cleft palate, birth marks and webbed fingers and toes.
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • Surgery to produce a symmetrical appearance of breasts;
  • Treatment of any physical complications, such as lymphedemas;
  • Breast prostheses and surgical bras and replacements (see Prosthetic devices

Medically necessary Gender Reassignment Surgical services to treat gender dysphoria will be covered as follows:

•  Gender Affirming surgery, consisting of any combination of the following: hysterectomy, salpingo-oophorectomy; ovariectomy , or orchiectomy are considered medically necessary when all of the medical necessity criteria are met; or
•  Gender Affirming surgery, consisting of any combination of the following: metoidioplasty, phalloplasty, vaginoplasty, penectomy, clitoroplasty, labiaplasty, vaginectomy, scrotoplasty, urethroplasty, or placement of testicular prostheses are considered medically necessary when all of the medical necessity criteria are met.
• Gender Affirming chest surgery is considered medically necessary when all of the medical necessity criteria are met.

• Surgeries that are considered reconstructive when used to improve the gender specific appearance of an individual who has undergone or is planning to undergo gender reassignment surgery.

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

Note: Gender Affirming Surgery requires the member to meet criteria outlined in the QualChoice Medical Policies and pre-authorization for all services related to the treatment or surgical procedures.  

Not covered:

• Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

All charges

All charges

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones;
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
• Removal of stones from salivary ducts;
• Excision of leukoplakia or malignancies;
• Excision of cysts and incision of abscesses when done as independent procedures; and
• Benefits are provided for surgical treatment of temporomandibular joint and craniomandibular disorders, or other conditions of the joints linking the jawbone and skull, including the complex of muscles, nerves, and other tissues related to that joint.
• Other surgical procedures that do not involve the teeth or their supporting structures.

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
• Orthognathic surgery 

These solid organ transplants are subject to medical necessity and experimental/investigational review by the plan. See Other services in Section 3 for prior authorization procedures.  Solid organ transplants are limited to:

• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
• Cornea
• Heart
• Heart/lung
• Intestinal transplants
  • Isolated small intestine
  • Small intestine with the liver
  • Small intestine with multiple organs, such as the liver, stomach, and pancreas
• Kidney
• Kidney-pancreas
• Liver
• Lung: single/bilateral/lobar
• Pancreas

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan.  Refer to Other services in Section 3 for prior authorization procedures.

• Autologous tandem transplants for
  • AL amyloidosis
  • Multiple myeloma (de novo and treated)
  • Recurrent germ cell tumors (including testicular cancer)

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below:

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced myeloproliferative disorders (MPDs)
  • Advanced neuroblastoma
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myleogenous leukemia
  • Hematopoietic Stem Cell Transplant (HSCT)
  • Hemoglobinopathy
  • Infantile malignant osteopetrosis
  • Marrow failure and related disorders (i.e. Fanconi's paroxysmal nocturnal hemoglobinuria, pure red cell aplasia)
  • Mucolipidosis (e.g., Gaucher's disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  • Mycopolysaccharidosis (e.g., Hunter's syndrome, Hurler's syndrome, Sanfillippo syndrome, Maroteaux-Lamy)
  • Myelodysplasia/myelodysplastic syndromes
  • Paroxysmal nocturnal hemoglobinuria
  • Phagocytic/hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell anemia
  • X-linked lymphoproliferative syndrome
• Autologous transplants for:
• Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
• Advanced Hodgkin’s lymphoma with recurrence (relapsed)
• Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
• Amyloidosis
• Breast cancer
• Ependymoblastoma
• Epithelial ovarian cancer
• Multiple myeloma
• Neuroblastoma
• Testicular, mediastinal, retroperitoneal, and ovarian germ cell tumors

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan.

Refer to Other services in Section 3 for prior authorization procedures:

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin's lymphoma with recurrence (relapsed)
  • Advanced myeloproliferative disorders (MPDs)
  • Advanced non-Hodgkin's lymphona with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e., Fanconi's, PNH, pure red cell aplasia)
  • Myelodysplasia/myelodysplastic syndromes
  • Paroxysmal nocturnal hemoglobinuria
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
• Autologous transplants for
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin's lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Neuroblastoma

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of Health approved clinical trial or a Plan-designated center of excellence if approved by the Plan’s medical director in accordance with the Plan’s protocols.

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient's condition) if it is not provided by the clinical trial.  Section 9 has additional information on costs related to clinical trials.  We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

• Allogeneic transplants for:
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Beta thalassemia major
  • Chronic inflammatory demyelination polyneuropathy (CIDP) 
  • Early state (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Sickle Cell anemia
• Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning or RIC) for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin's lymphona
  • Advanced non-Hodgkin's lymphoma
  • Chronic lymphocytic leukemia
  • Chronic myelogenous leukemia
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Early state (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Myelodysplasia/Myelodysplastic Syndromes
  • Myeloproliferative disorders (MDDs)
  • Non-small cell lung cancer
  • Ovarian cancer
  • Prostate cancer
  • Renal cell carcinoma
  • Sarcomas
  • Sickle cell anemia
  • Myelodysplasia/myelodysplastic syndromes
• Autologous Transplants for:
  • Advanced childhood kidney cancers
  • Advanced Ewing sarcoma
  • Advanced Hodgkin’s lymphoma
  • Aggressive non-Hodgkin’s lymphoma (Mantle Cell lymphoma, adult T-cell leukemia/lymphoma, peripheral T-cell lymphomas and aggressive Dendritic cell neoplasms)
  • Breast Cancer
  • Childhood rhabdomyosarcoma
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Epithelial ovarian cancer
  • Mantle cell (non-Hodgkin lymphoma)
  • Multiple sclerosis
  • Small cell lung cancer
  • Systemic lupus erythematosus
  • Systemic sclerosis

Note: We cover related medical and hospital expenses of the donor when we cover the recipient.  We cover donor testing for the actual solid organ donor or up to four bone marrow/stem cell transplant donors in addition to the testing of family members.

Not covered:

• Donor screening tests and donor search expenses, except as shown above
• Implants of artificial organs
• Transplants not listed as covered

Professional services provided in:

Hospital (inpatient)

Note: QualChoice will provide Benefits for anesthesia and facilities for dental procedures which would ordinarily be done under local anesthesia provided:

1. The procedure is performed in a Network Facility; and
2. The situation meets Medical Necessity criteria, and the patient is:

• A Child under 7 years of age who is determined by two network dentists to be unable
  to undergo the procedure without general anesthesia and who cannot wait until an
  older age for the procedure, when undergoing the procedure without general
  anesthesia would be possible;
• A person with a serious mental health condition that prevents use of local anesthesia
  for the procedure;
• A person with a serious physical condition making hospital care necessary for the
  safe performance of dental work; or
• A person with a significant behavioral problem (as certified by a Network Physician)
  which precludes safe performance of the dental work under local anesthesia.

Professional services provided in:

• Hospital outpatient department
• Skilled nursing facility
• Ambulatory surgical center
• Office

Room and board, such as

• Ward, semiprivate, or intensive care accommodations;
• General nursing care,
• Meals and special diets.

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate. 

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Dressings , splints , casts , and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home (Note: calendar year deductible applies.)

Not covered:

• Custodial care
• Non-covered facilities, such as nursing homes, schools
• Personal comfort items, such as telephone, television, barber services, guest meals and beds
• Private nursing care

Outpatient surgery and related medical services performed and billed by a hospital or freestanding ambulatory facility, such as:

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests, X-rays , and pathology services
• Administration of blood, blood plasma, and other biological
• Blood and blood plasma , if not donated or replaced
• Pre-surgical testing
• Dressings, casts , and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

Not Covered: Blood and blood derivatives not replaced by the member.

Extended care benefit/Skilled nursing facility (SNF)

• Includes inpatient rehab

Note: Skilled nursing facility has a limit of 60 days per calendar year

$100 copayment per day up to a maximum of $500 per admission

$200 copayment per day up to a maximum of $1,000 per admission

Not Covered:

• Custodial care

The following hospice services, when ordered by a physician, are covered during the period when the hospice has admitted an Enrollee to its program, provided the hospice program was pre-authorized:

• In-patient care in a freestanding hospice, a hospice unit within a hospital or skilled nursing facility, or in an acute care hospital bed; and
• Home care services provided by the hospice either directly or under arrangements with other licensed providers, including, but not limited to, the following:
  • Intermittent nursing care by registered nurses, licensed practical nurses, or home health aides;
  • Respiratory therapy;
  • Social services;
  • Nutritional services;
  • Laboratory examinations;
  • Chemotherapy and radiation therapy when require for control of symptoms;
  • Medical supplies; and
  • Medical care provided by a physician

Not covered:

• Independent nursing
• Homemaker services

When an accident or other medical emergency occurs, we cover transport to the nearest hospital when emergency services are required.

We cover ambulance transportation from one hospital to another hospital for one of the reasons identified below as long as it is coordinated through our Care Management department:

• To access equipment or expertise necessary to care for you properly;
• To receive a test or service which is not available at the hospital where you have been admitted and you return after the test or service is completed;
• To transport you from a Out-of-Network Provider hospital to a In-Network Provider; and
• To transport you directly from an acute care setting to an alternate level of care.

Note: Air/Sea Ambulance benefit is limited to $10,000 per trip

Ground: $100 copayment per trip

Air/Sea: $150 copayment per trip

Ground: $100 copayment per trip

Air/Sea: $150 copayment per trip

• Emergency care at a doctor’s office
• Emergency care at an urgent care center

$20 copayment for a primary care provider (No deductible)

$35 copayment for a specialist physician (No deductible)

$20 copayment for a primary care provider

$40 copayment for a specialist physician

• Emergency care as an outpatient at a hospital, including physician services

Note: We waive the ER copay if you are admitted to the hospital.

Not Covered: Elective care or non-emergency care.

• Emergency care at a doctor’s office
• Emergency care at an urgent care center

$20 copayment for a primary care provider (No deductible)

$35 copayment for a specialist physician (No deductible)

$20 copayment for a primary care provider

$40 copayment for a specialist physician

• Emergency care as an outpatient at a hospital, including physician services

Note:  We waive the ER copay if you are admitted to the hospital.

$150 copayment (No deductible)

$150 copayment

Not covered:

• Elective care or non-emergency care and follow-up care recommended by non-Plan providers that has not been approved by the Plan or provided by Plan providers
• Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
• Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

Professional ambulance service when medically appropriate.

Note: See 5(c) for non-emergency service

When an accident or other medical emergency occurs, we cover transport to the nearest hospital when emergency services are required.
We cover ambulance transportation from one hospital to another hospital for one of the reasons identified below as long as it is coordinated through our Care Management department:

• To access equipment or expertise necessary to care for you properly;
• To receive a test or service which is not available at the hospital where you have been admitted and you return after the test or service is completed;
• To transport you from a Out-of-Network Provider hospital to a In-Network Provider; and
• To transport you directly from an acute care setting to an alternate level of care.

Note: Air/Sea Ambulance benefit is limited to $10,000 per trip

Ground: $100 copayment per trip

Air/Sea: $150 copayment per trip

Ground: $100 copayment per trip

Air/Sea: $150 copayment per trip

When part of a treatment plan we approve, we cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders.  Services include:

• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Medication evaluation and management (pharmocotherapy)
• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
• Treatment and counseling (including individual or group therapy visits)
• Diagnosis and treatment of substance use disorders including detoxification, treatment and counseling
• Professional charges for intensive outpatient treatment in a provider's office or other professional setting
• Electroconvulsive therapy

$20 copayment for a primary care provider (No deductible)

$35 copayment for a specialist physician (No deductible)

$20 copayment for a primary care provider (No deductible)

$40 copayment for a specialist physician (No deductible)

• Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment practitioner

$20 copayment for a primary care provider(No deductible)

$35 copayment for a specialist physician (No deductible)

$20 copayment for a primary care provider (No deductible)

$40 copayment for a specialist physician (No deductible)

• Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility

$100 copayment (No deductible)

$100 copayment (No deductible)

• Inpatient diagnostic tests provided and billed by a hospital or other covered facility

Nothing

Nothing

Inpatient services provided and billed by a hospital or other covered facility

• Room and board, such as semiprivate or intensive accomodations, general nursing care, meals and special diets, and other hospital services

Outpatient services provided and billed by a hospital or other covered facility

• Services in approved treatment programs, such as partial hospitalization, half-way house, residential treatment, full-day hospitalization, or facility-based intensive outpatient treatment

We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order program:

• Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase except those listed as Not covered.
• Insulin
• Diabetic supplies limited to:
  • Disposable needles and syringes for the administration of covered medications

Drugs for sexual dysfunction

• Drugs to treat gender dysphoria
• Hormone Therapy

Fertility drugs or any drugs used for the purpose of enhancing the probability of conception.  A minimum of three (3) cycles each year. 

• Oral and self-injectable drugs as part of in vitro fertilization (IVF) or Artificial Insemination (AI) may be covered when deemed medically necessary and prior authorization requirements are met.  

The Plan will provide Statins under the Tier 1, Tier 2 and Tier 3 pharmacy benefit at no cost to the member.

Retail Pharmacy

$10 Tier I

$40 Tier II

$60 Tier III

Self-Administered Specialty Drugs

$100 per fill Tier IV

Mail Order (90-day supply Maintenance medications only)

$0 Tier I

$120 Tier II

$180 Tier III

Retail Pharmacy

$10 Tier I

$40 Tier II

$60 Tier III

Self-Administered Specialty Drugs

$100 per fill Tier IV

Mail Order (90-day supply Maintenance medications only)

$15 Tier I

$120 Tier II

$180 Tier III

Contraceptives drugs and devices as listed in the ACA/HRSA site.  Contraceptive coverage is available at no cost to FEHB members.  The contraceptive benefit includes at least one option in all methods of contraception (as well as the screening, education, counseling, and follow-up care).  Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process described blow.

If your provider prescribes a non-covered contraceptive prescription drug, the provider may ask for an exception to the formulary by calling 833-616-0136 or faxing a QualChoice General Pre-authorization Form to 888-904-1149.  

Reimbursement for over-the counter contraceptives are not provided.  

Note: The "morning after pill" is considered preventive service under contraceptives with no cost to the member if prescribed by a physician and purchased at a network pharmacy. 

Not Covered

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
• Nonprescription medications unless specifically indicated elsewhere

Nothing

Nothing

The following are covered:

• Aspirin (81 mg) for men age 45-79 and women age 55-79 and women of childbearing age
• Folic acid supplements for women of childbearing age 400 & 800 mcg
• Liquid iron supplements for children age 6 months-1 year
• Vitamin D supplements (prescription strength) (400& 1000 units) for members 65 or older
• Pre-natal vitamins for pregnant women
• Fluoride tablets, solution (not toothpaste, rinses) for children 0-6
• The Plan will provide designated low to moderate Statins under the pharmacy benefit at no cost to enrollees age 40-75 that meet the USPSTF Statin recommendation to treat hypertension and for the prevention of cardiovascular disease events.

Note: Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a healthcare professional and filled by a network pharmacy.  These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients.  For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
• Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them
• Nonprescription medications

Note: Over-the-counter and prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation program benefit. (See page 39)

We will provide coverage if an Enrollee has an Accidental Injury that damages a sound, natural tooth. Treatment must be pre-authorized. Benefits are subject to a maximum limit ($2,000) per enrollee per accident.  Dental services must be received from a Doctor of Dental Surgery (“D.D.S.”) or a Doctor of Medical Dentistry (“D.M.D.”). The damage must be severe enough that initial contact with a physician or dentist occurred within 72 hours of the accident.

The physician or dentist must certify that the injured tooth was:

• A virgin or un-restored tooth; or
• A tooth that has no decay, no filling on more than two surfaces, no gum disease associated with any bone loss, no root canal therapy, is not a dental implant and functions normally in chewing and speech.

Dental services for final treatment to repair the damage must be started within three months of the original accident date and completed within 12 months of the original accident date.

Please note that dental damage that occurs as a result of normal activities of daily living or extraordinary use of the teeth is not considered an “accident”. Benefits are not available for repairs to teeth that are injured as a result of such activities. The following limitations for treatments also apply to repair of damaged teeth:

• Only the sound and natural tooth or teeth avulsed or extracted as a direct result of the Accidental Injury will be considered for replacement;
• Orthodontic services are limited to the stabilization and re-alignment of the accident-involved teeth to their pre-accident position; reimbursement for this service will be based upon a Plan allowance per tooth;

All Charges

All Charges

• Double abutments are not covered
• Any health intervention related to dental caries or tooth decay is not covered
• Removal of teeth is not covered
• Dental implants of titanium osseointegrated fixtures or fixtures of any other material are not covered

All Charges

All Charges

Under the flexible benefits option, we determine the most effective way to provide services.

• We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative.  If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary.  Until you sign and return the agreement, regular contract benefits will continue.
• Alternative benefits will be made available for a limited time period and are subject to our ongoing review.  You must cooperate with the review process.
• By approving an alternative benefit, we do not guarantee you will get it in the future.
• The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
• If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change).  You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.  However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8).

The QCARE program is designed to give members the tools and information needed to help them better understand and manage their health. Services include:

• Education and information on diet, exercise and other topics that are important for your health
• Contact with your Care Manager at regular intervals to discuss your medication and other health needs or concerns
• The assurance that your health information will be kept confidential, and will not be shared with anyone other than those you request

Care Coach

This QualChoice representative serves as a support system to you and your family, providing information and guidance concerning your medical condition, treatment plans and available options.

Better Health Advisor

Got questions? Get answers. This tool lets you compare hospitals, learn about costs and find out more about procedures, chronic diseases and pharmaceuticals.

Teledoc

Access a Physician via electronic device such as a cell phone or a computer.

• Extensive online services provided to encourage healthy behavior at www.qualchoice.com
• Take our personal health assessment and identify your health risks
• We offer both eFitness and eDietitian to answer online diet and exercise questions
• Our health coaches can assist you in developing an action plan to make positive lifestyle choices
• We offer online journals so you can track your progress

• Learn about ways to keep your children healthy and active through material our health coaches can provide
• We also utilize material through www.Choosemyplate.gov that promotes healthy nutrition for children and preschoolers including interactive online games and coloring sheets encouraging healthy food selection
• Our health coaches will work with parents to plan healthy menus and build a healthy recipe selection

Special Additions Maternity Program is especially designed to provide you with guidance and information during your pregnancy.  When you enroll in the program you will receive informative education material that will keep you up to date on what to expect during your pregnancy. 

In most cases, providers and facilities file claims for you.  Provider must file on the form CMS-1500, Health Insurance Claim Form.  Your facility will file on the UB-04 form.  For claims questions and assistance, contact us at 800-235-7111 or at our website at www.qualchoice.com.

When you must file a claim – such as for services you received outside the Plan’s service area – submit it on the CMS-1500 or a claim form that includes the information shown below.  Bills and receipts should be itemized and show:

• Covered member’s name, date of birth, address, phone number and ID number
• Name and address of the provider or facility that provided the service or supply
• Dates you received the services or supplies
• Diagnosis
• Type of each service or supply
• The charge for each service or supply
• A copy of the explanation of benefits, payments, or denial from any primary payor – such as the Medicare Summary Notice (MSN)
• Receipts, if you paid for your services

Note:  Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills.

Submit your claims to:  QualChoice P.O. Box 25610, Little Rock, AR 72221,Little Rock, AR 72211

Submit your claims to:  QualChoice P.O. Box 25610, Little Rock, AR 72221, Little Rock, AR 72211

Send us all of the documents for your claim as soon as possible.  You must submit the claim by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations, of Government or legal incapacity, provided the claim was submit your claim as soon as reasonably possible.  Once we pay benefits, there is a five year limitation on the reissuance of uncashed checks.

We will notify you of our decision within 30 days after we receive your post-service claim.  If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 30-day period.  Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.

You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us.  For urgent care claims, we will permit a healthcare professional with knowledge of your medical condition will be permitted to act as your authorized representative without your express consent.  For the purposes of this section, we are also referring to your authorized representative when we refer to you.

If you live in a county where at least 10% of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language.  You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as telephone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language.  The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the healthcare provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes

Ask us in writing to reconsider our initial decision.  You must:

    a)     Write to us within 6 months from the date of our decision; and

    b)     Send your request to us at: QualChoice, PO Box 25610, Little Rock, AR 72221; and

    c)     Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

    d)     Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms; and

    e)    Include your email address, if you would like to receive OPM's decision via email.  Please note that by providing your email address, you may receive OPM's decision more quickly.

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision.  We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date.  However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration.  You may respond to that new evidence or rationale at the OPM review stage described in step 4.

In the case of a post-service claim, we have 30 days from the date we receive your request to:

    a)     Pay the claim or  

    b)     Write to you and maintain our denial or

    c)    Ask you or your provider for more information

You or your provider must send the information so that we receive it within 60 days of our request.  We will then decide within 30 more days.

If we do not receive the information within 60 days we will decide within 30 days of the date the information was due.  We will base our decision on the information we already have.  We will write to you with our decision.

If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:

• 90 days after the date of our letter upholding our initial decision; or
• 120 days after you first wrote to us -- if we did not answer that request in some way within 30 days; or
• 120 days after we asked for additional information.

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, Health Insurance 3, 1900 E Street, NW, Washington, DC 20415-3630. 

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure
• Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms
• Copies of all letters you sent to us about the claim
• Copies of all letters we sent to you about the claim and
• Your daytime phone number and the best time to call
• Your email address, if you would like to receive OPM’s decision via email.  Please note that by providing your email address, you may receive OPM’s decision more quickly

 Note:  If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note:  You are the only person who has a right to file a disputed claim with OPM.  Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request.  However, for urgent care claims, a health care professional with knowledge of your medical condition may act as your authorized representative without your express consent.

Note:  The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct.  OPM will send you a final decision or notify you of the status of OPM's review within 60 days.  There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to sue.  If you decide to file a lawsuit, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval.  This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision.  This information will become part of the court record.

You may not file a lawsuit until you have completed the disputed claims process.  Further, Federal law governs your lawsuit, benefits, and payment of benefits.  The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision.  You may recover only the amount of benefits in dispute.

You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays healthcare expenses without regard to fault.  This is called “double coverage.”

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor  We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines.  For more information on NAIC rules regarding the coordinating of benefits, visit our website at www.qualchoice.com.

When we are the primary payor, we will pay the benefits described in this brochure.

When we are the secondary payor, we will determine our allowance.  After the primary plan processes the benefit, we will pay what is left of our allowance, up to our regular benefit.  We will not pay more than our allowance.

TRICARE is the healthcare program for eligible dependents of military persons, and retirees of the military.  TRICARE includes the CHAMPUS program.  CHAMPVA provides health coverage to disabled Veterans and their eligible dependents.  IF TRICARE or CHAMPVA and this Plan cover you, we pay first.  See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium.  (OPM does not contribute to any applicable plan premiums.)  For information on suspending your FEHB enrollment, contact your retirement office.  If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under TRICARE or CHAMPVA.

Every job-related injury or illness should be reported as soon as possible to your supervisor.  Injury also means any illness or disease that is caused or aggravated by the employment as well as damage to medical braces, artificial limbs and other prosthetic devises.  If you are a federal or postal employee, ask your supervisor to authorize medical treatment by use of form CA-16 before you obtain treatment.  If your medical treatment is accepted by the Dept. of Labor Office of Workers' Compensation (OWCP), the prover will be compensated by OWCP.  If your treatment is determined not to be job-related, we will process your benefit according to the terms of this plan, including use of in-network providers.  Take form CA-16 and form OWCP-1500/HCFA-1500 to your provider, or send it to your provider as soon as possible after treatment, to avoid complications about whether your treatment is covered by this plan or by OWCP.

We do not cover services that:

• You (or a covered family member) need because of a workplace-related illness or injury that the Office of Workers’ Compensation Programs (OWCP) or a similar federal or state agency determines they must provide; or
• OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these state programs, eliminating your FEHB premium.  For information on suspending your FEHB enrollment, contact your retirement or employing office.  If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the state program.

We do not cover services and supplies when a local, state, or federal government agency directly or indirectly pays for them.

We are entitled to reimbursement to the extent of the benefits we have paid or provided in connection with your injury or illness.  However, we will cover the cost of treatment that exceeds the amount of the payment you received.

Reimbursement to us out of the payment shall take first priority (before any of the rights of any other parties are honored) and is not impacted by how the judgment, settlement, or other recovery is characterized, designated, or apportioned.  Our right of reimbursement is not subject to reduction based on attorney fees or costs under the "common fund" doctrine and is fully enforceable regardless of wheather you are "made whole" or fully compensated for the full amount of the damages claimed.

We may, at our option, choose to exercise our right of subrogation and pursue recovery from any liable party as successor to your rights.

If you do pursue a claim or case related to your injury or illness, you must promptly notify us and cooperate with our reimbursement or subrogation efforts.

Some FEHB plans already cover some dental and vision services.  When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage.  FEDVIP coverage pays secondary to that coverage.  When you enroll in a dental and/or vision plan on BENEFEDS.com or by phone at 877-888-3337, (TTY 877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits.  Providing your FEHB information may reduce your out-of-pocket cost.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application. 

If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:

• Routine care costs – costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition, whether the patient is in a clinical trial or is receiving standard therapy.
• Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care.
• Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes.  These costs are generally covered by the clinical trials.  This plan does not cover these costs.

For more detailed information on "What is Medicare?" and "Should I Enroll in Medicare?" plaese contact Medicare at 1-800-MEDICARE (1-800-644-4227), (TTY 1-877-486-2048) or at www.medicare.gov.

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share.

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary. This is true whether or not they accept Medicare.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

Claims process when you have the Original Medicare Plan – You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payor, we process the claim first.

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 800-235-7111 or see our website at www.qualchoice.com.

We waive some costs if the Original Medicare Plan is your primary payor - We will waive some out-of-pocket costs as follows:

When Medicare Part A is primary -

• Under High Option, we will waive our:
  • Inpatient hospital per-day copayments; and
  • Inpatient Non-member hospital coinsurance.
• Under Standard Option, we will waive our:
  • Inpatient hospital per-day copayments.

When Medicare Part B is primary -

• Under High Option, we will waive our:
  • Calendar year deductible
  • Coinsurance for services and supplies provided provided by physicians and other covered health care professionals (inpatient and outpatient, including mental conditions and substance abuse care);
  • Copayments for office visits to In-network physicians and other health care professionals;
  • Outpatient facility coinsurance for medical, surgical, preventive, and mental conditions and substance abuse care; and
  • Copayments for professional care provided in an emergency room
• Under Standard Option, we will waive our:
  • Copayments and coinsurance for care received from covered professional and facility providers.

Note: We do not waive benefit limitations, such as the the 40-visit limit for home health visits. In addition, we do not waive any copayments for prescription drugs.

Please review the following examples which illustrates your cost share if you are enrolled in Medicare Part B. If you purchase Medicare Part B, your provider is in our network and participates in Medicare, then we waive some costs because Medicare will be the primary payor.

Benefit Description: Deductible
High Option you pay without Medicare: $500 Self Only/$1,000 Self Plus One or Self and Family
Standard Option you pay without Medicare: N/A
High Option you pay with Medicare: $500 Self Only/$1,000 Self Plus One or Self and Family
Standard Option you pay with Medicare: N/A

Benefit Description: Out-of-Pocket Maximum
High Option you pay without Medicare: $5,000 Self Only/$10,000 Self Plus One or Self and Family
Standard Option you pay without Medicare: $5,000 Self Only/$11,000 Self Plus One or Self and Family
High Option you pay with Medicare: $5,000 Self Only/$10,000 Self Plus One or Self and Family
Standard Option you pay with Medicare: $5,000 Self Only/$11,000 Self Plus One or Self and Family

Benefit Description: Part B Premium Reimbursement Offered
High Option you pay without Medicare: N/A
Standard Option you pay without Medicare: N/A
High Option you pay with Medicare: N/A
Standard Option you pay with Medicare: N/A

Benefit Description: Primary Care Provider
High Option you pay without Medicare: $20
Standard Option you pay without Medicare: $20
High Option you pay with Medicare: $0
Standard Option you pay with Medicare: $0

Benefit Description: Specialist
High Option you pay without Medicare: $40
Standard Option you pay without Medicare: $40
High Option you pay with Medicare: $0
Standard Option you pay with Medicare: $0

Benefit Description: Inpatient Hospital
High Option you pay without Medicare: $100
Standard Option you pay without Medicare: $200
High Option you pay with Medicare: $0
Standard Option you pay with Medicare: $0

Benefit Description: Outpatient Hospital
High Option you pay without Medicare: $100
Standard Option you pay without Medicare: $200
High Option you pay with Medicare: $0
Standard Option you pay with Medicare: $0

Benefit Description: Incentives Offered
High Option you pay without Medicare: N/A
Standard Option you pay without Medicare: N/A
High Option you pay with Medicare: N/A
Standard Option you pay with Medicare: N/A

You can find more information about how our plan coordinates benefits with Medicare at www.qualchoice.com.

You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask.  You must also tell us about other coverage you or your covered family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare.

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan.  These are private health care choices (like HMOs and regional PPOs) in some areas of the country.  To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (800-633-4227), (TTY: 800-486-2048) or at www.medicare.gov.

If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and another plan’s Medicare Advantage plan:  You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan.  We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers).

However, we will not waive any of our copayments, coinsurance, or deductibles.  If you enroll in a Medicare Advantage plan, tell us.  We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium.  (OPM does not contribute to your Medicare Advantage plan premium.)  For information on suspending your FEHB enrollment, contact your retirement or employing office.  If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.

• You have FEHB coverage on your own or through your spouse who is also an active employee

• You have FEHB coverage through your spouse who is an annuitant

• It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)

• It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD

• This Plan was the primary payor before eligibility due to ESRD (for 30-month coordination period)

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

• Medicare based on ESRD (for the 30-month coordination period)

• Medicare based on ESRD (after the 30-month coordination period)

The period from entry (admission) as an inpatient into a hospital (or other covered facility) until discharge. In counting days of inpatient care, the date of entry and the date of discharge count as the same day.

An authorization by you (the enrollee or covered family member) that is approved by us (the Carrier), for us to issue payment of benefits directly to the provider.
·We reserve the right to pay you directly for all covered services. Benefits payable under the contract are not assignable by you to any person without express written approval from us, and in the absence of such approval, any assignment shall be void.

·Your specific written consent for a designated authorized representative to act on your behalf to request reconsideration of a claim decision (or, for an urgent care claim, for a representative to act on your behalf without designation) does not constitute an Assignment.

·OPM’s contract with us, based on federal statute and regulation, gives you a right to seek judicial review of OPM's final action on the denial of a health benefits claim but it does not provide you with authority to assign your right to file such a lawsuit to any other person or entity. Any agreement you enter into with another person or entity (such as a provider, or other individual or entity) authorizing that person or entity to bring a lawsuit against OPM, whether or not acting on your behalf, does not constitute an Assignment, is not a valid authorization under this contract, and is void.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration (FDA); or is a drug trial that is exempt from the requirement of an investigational new drug application.

If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:

• Routine care costs - costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient's condition, whether the patient is in a clinical trial or is receiving standard therapy
• Extra care costs - costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient's routine care
• Research costs - costs related to conducting the clinical trial such as research, physician and nurse time, analysis of results, and clinical tests performed only for research purposes.  These costs are generally covered by the clinical trials.  This plan does not cover these costs.

See Section 4, page 21

See Section 4, page 21

See Section 4, page 21

See Section 4, page 21

A drug, device, or biological product is experimental or investigational if the drug, device, or biological product cannot be lawfully marketed without approval of the U.S. Food and Drug Administration (FDA); and, approval for marketing has not been given at the time it is furnished. Note: Approval means all forms of acceptance by the FDA.

A medical treatment or procedure, or a drug, device, or biological product, is experimental or investigational if:

1. Reliable evidence shows that it is the subject of ongoing phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or
2. Reliable evidence shows that the consensus of opinion among experts regarding the drug, device, or biological product or medical treatment or procedure, is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis.

Reliable evidence shall mean only:

• Published reports and articles in the authoritative medical and scientific literature;
• The written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, or biological product or medical treatment or procedure; or
• The written informed consent used by the treating facility or by another facility studying substantially the same drug, device, or biological product or medical treatment or procedure.

QualChoice has a Medical Review department that determines whether a claimed service is experimental or investigational after consulting with internal or external experts or nationally recognized guidelines in a particular field or specialty.

A physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with state law.

“Maintenance Medications” are defined as follows:

A.   A drug that is usually administered continuously, rather than intermittently, and for longer than 90 days, typically for the remainder of one’s life. This means the patient taking the medication on a scheduled basis year round and not as needed or seasonally.

B.   A drug in which the most common use is to treat a chronic disease state when a therapeutic endpoint cannot be determined. Therapy with the drug is not considered curative.

C.   A drug that has a low probability for dosage or therapy changes due to side effects, serum drug concentration monitoring, or therapeutic responses over a course of prolonged therapy.

D.   While certain drugs may sometimes be used on a chronic basis, the drug will only meet the above definition if it is most commonly used in this way. The most common examples of maintenance medications are medicines used to treat high blood pressure, diabetes, high cholesterol, or hypothyroidism.

E.   Drugs in the following classes are considered to be Maintenance Medications. If your medication falls in one of these categories you will be able to get a 90 days supply either from your retail pharmacy (if it participates in the 90-day network) or from the mail order pharmacy. You will need a prescription from your doctor with enough refills to allow 90 days. One Co-payment will be charged for each 31 day supply.

    i. Alzheimer Disease medication

    ii. Antipsychotic medication

    iii. Antivirals for HIV

    iv. Asthma and other respiratory medication

    v. Benign Prostatic Hyperplasia (BPH) medication

    vi. Blood pressure medication (e.g., beta blockers, calcium channel blockers, diuretics, ACE-inhibitors)

    vii. Cholesterol lowering drugs

   viii. Diabetes medication

    ix. Glaucoma medication

    x. Heart medication

    xi. Organ transplant medication

    xii. Osteoporosis medication

    xiii. Parkinson's Disease medication

    xiv. Potassium supplements

    xv. Seizure medication

    xvi. Thyroid medication

We determine whether services, drugs, supplies, or equipment provided by a hospital or other covered provider are:

1. Appropriate to prevent, diagnose, or treat your condition, illness, or injury;
2. Consistent with standards of good medical practice in the United States;
3. Not primarily for the personal comfort or convenience of the patient, the family, or the provider;
4. Not part of or associated with scholastic education or vocational training of the patient; and
5. In the case of inpatient care, cannot be provided safely on an outpatient basis.

Plan allowance is the amount we use to determine our payment and your coinsurance or deductible (if applicable) for covered services.  Plans determine their allowances in different ways.  We determine our allowance by our contracted rate with In-Network providers.

(High Option/POS Only) You may seek Covered Services directly from a physician or other provider who is not in the Network under the Point of Service (POS) benefit if you are enrolled in the High Option. Services provided by an Out-of-Network Provider will be covered and reimbursed under your Out-of-Network Benefits unless prior authorization for coverage as an In-Network Benefit is received from us. The amounts allowed for Covered Services accessed under your Out-of-Network Benefits will be subject to the Maximum Allowable Payment. You will be responsible for the applicable Cost-Sharing Amounts related to such Covered Services and the difference between the charges billed by the Out-of-Network Provider and the Maximum Allowable Payment.  This does not apply to emergency services In-Network or Out-of-Network.  They will always be covered under the In-Network emergency benefit.  

You should also see Important Notice About Surprise Billing - Know Your Rights in Section 4 that describes your protections against surprise billing under the No Surprises Act.  

A carrier's pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or workers' compensation program or insurance policy, and the terms of the carrier's health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided.  The right of reimbursement is cumulative with and not exclusive of the right of subrogation. 

Specialty Drugs are defined as specialized therapies developed for chronic, complex illnesses and:

• may have special handling, storage, shipping requirements
• may require nursing services or special programs to support patient compliance
• require disease-specific treatment programs
• may have limited distribution requirements
• may be injections, infusions, or oral products
• are high cost, typically > $500 per treatment episode

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:

• Waiting could seriously jeopardize your life or health;
• Waiting could seriously jeopardize your ability to regain maximum function; or
• In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims usually involve Pre-service claims and not Post-service claims.  We will evaluate whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at (800) 235-7111.  You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

An unexpected bill you receive for

• emergency care - when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services furnished by nonparticipating providers with respect to patient visits to participating health care facilities, or for
• air ambulance services furnished by nonparticipating providers of air ambulance services. 

The failure to conceive or produce conception through egg-sperm contact and carry a baby to term after 12 months for individuals under age 35 and 6 months for individuals age 35 and older. Infertility may also be established through an evaluation based on medical history and diagnostic testing.

Self Only deductible is $500.  Self Plus One and Self and Family deductible is $1,000.

22

Office visit copay: $20 primary care; $35
specialist

27

$100 copayment per day up to a maximum of
$500 per admission

48

$100 copayment

50

$150 per Emergency Room visit

54

Ground: $100 copayment per trip;
Air/Sea: $150 copayment per trip; $10,000
limit per trip

54

Regular cost-sharing

56

Nothing after $5,000 for Self Only. Nothing
after $10,000 for Self Plus One and Self and
Family.
Out-of-Network: $13,200 for Self Only.
Nothing after $26,400 for Self Plus One and
Self and Family

23

$10 Tier I, $40 Tier II, $60 Tier III

59

$100 per fill Tier IV

59

$0 Tier I, $120 Tier II, $180 Tier III

59

Office visit copay: $20 primary care; $40 specialist

28

$200 copayment per day up to a maximum of
$1,000 per admission

49

$200 copayment

50

$150 per Emergency Room visit

54

Ground: $100 copayment per trip;
Air/Sea: $150 copayment per trip; $10,000
limit per trip

54

Regular cost-sharing

56

Nothing after $5,500 for Self Only. Nothing
after $11,000 for Self Plus One and Self and
Family.

23

$10 Tier I, $40 Tier II, $60 Tier III

59

$100 per fill Tier IV

59

$15 Tier I, $120 Tier II, $180 Tier III

59