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.

Our health coverage meets the minimum value standard of 60% established by the ACA. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.

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;
• When your enrollment ends; and
• When the next Open Season for enrollment begins.

We do not 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 membes. Family members include your spouse, and your dependent children under the 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 Plus One or Self and Family 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 to Self Plus One or Self and Family. If you have 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 began 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 QLEs, visit the FEHB website at www.opm.gov/insure/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 your spouse by a valid common-law marriage from a state that recognizes common-law marriages) and children as described 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 fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or 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 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-packet 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.

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 situation for care or treatment on the 31st 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 60th day after the end of the 31-day temporary extension

You may be eligible for spouse equity coverage or Temporary Continuation coverage (TCC), or 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 are 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 to 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 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, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). The Affordable Care Act (ACA) did not eliminate TCC or change the TCC rules. 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, if you are a covered dependent child and you turn 26, regardless of marital status, etc.

You may not elect TCC if you are fired from your Federal job or Tribal 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 new kind 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 FEHBP coverage.

The Affordable Care Act Health Insurance Marketplace is not available in our service area. 

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 apply in writing to us 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 apply in writing to us 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, a 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 671-477-9808 or visit our website at www.calvos.net.

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.

The Affordable Care Act Health Insurance Marketplace is not available in our service area.

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 (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 671-477-9808 or write to us at      P.O. Box FJ, Hagatna, Guam 96932. 

You get care from “Plan providers” and “Plan facilities.” You will only pay copayments, deductibles, and/or coinsurance. How much you pay depends on whether you use a Plan/Participating provider and facility or non-network provider or facility. If you use your out-of-network program, you can get care from non-Plan providers but it will cost you more.

We look at some or all of the following criteria to determine if a provider is recognized and approved by us:

• Is the provider accredited by a recognized accrediting agency?
• is the provider appropriately licensed?
• Is the provider certified by the proper government authority?
• Are the services rendered within the lawful scope of the provider's respective licensure, certification, and/or accreditation?

Medicare beneficiaries may only receive covered services at a Plan participating Medicare-contracted facility in Guam, Saipan, Hawaii, and the Continental United States. Medicare eligible care and services which are rendered at a facility which is not a Medicare contracted facility, or which is rendered by a physician who is not a Medicare contracted physician will not be covered.

Out-of-Network/Non-Plan providers are physician and other health care professionals who are not under contract with this Plan. You can get care from Out-of-Network/non-Plan providers, but it will likely cost you more.

Certain services always require prior approval, regardless of whether they are rendered in-network or out-of-network (see Section 3 You need prior Plan approval for certain services). If you self-refer to a provider and/or facility for services which require prior authorization, those services will not be covered.

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, copayment, co-insurance) contact your Carrier to enforce the terms of its provider contract.

In-Network/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.

In-Network/Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. Services by Plan Providers are covered when acting within the scope of their license or certification under applicable local law. We credential In-Network/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 In-Network/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 expererienced 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 (671) 477-9808 for assistance.

It depends on the type of care you need. First, you and each family member must choose a primary care provider. This decision is important since your primary care provider provides or arranges for most of your health care.

Your primary care provider be a family practitioner, internist, obstetrician/gynecologist, or pediatrician for children under 18 years of age . Your primary care provider will provide most of your healthcare, or give you a referral to see a specialist.

If you want to change primary care provider or if your primary care provider leaves the Plan, call us. We will help you select a new one.

Your primary care provider, and in some situations, a specialist, will refer you to a specialist for needed care. When you receive a referral from your primary care provider, you must return to the primary care provider after the consultation, unless your primary care provider authorized a certain number of visits without additional referrals. The primary care provider must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care provider gives you a referral. However, you may see an OB/GYN within our provider network without a referral.

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

• If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will decide what treatment you need. Your primary care provider will arrange for you to see your specialist for a certain number of visits without additional referrals.
• Your primary care provider will use our criteria when deciding on your treatment. The physician may have to get an authorization or approval beforehand.
• If you are seeing a specialist when you enroll in our Plan, talk to your primary care provider. Your primary care provider will decide what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your current specialist.
• If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.
• If you are seeing a specialist and your specialist leaves the Plan, call your primary care provider, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.
• 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; or
  • Drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program Plan; or
  • 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 specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

Your Plan 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.

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 baby.

Note: When a newborn requires 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.

We pay for covered services form 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 671-477-9808. 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 your 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; or
• The 92^nd day after you become a member of this Plan, whichever happens first.

Your primary care provider arranges most referrals to specialists and inpatient hospitalization and sends the referrals to the Plan for approval. The pre-service claim approval process applies to care shown under Other Services.

The pre-service claim approval process for services is 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 pre certification or prior approval and (2) will result in a denial or reduction of benefits if you do not obtain precertification or prior approval. 

Precertification is the process by which - prior to your inpatient hospital admission - we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition.

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

• Allergy testing and allergy serum
• All diagnostic and surgical procedures performed in a surgical facility
• Audiological exams
• Bariatric surgery
• Bone density studies
• Certain drugs listed in our Prescription Drug Formulary (see Section 5(f))
• Chemotherapy Agents
• CT scans
• Durable medical equipment
• Genetic Testing
• Growth Hormone Therapy (GHT)
• Home Health services
• Hospitalization
• Infertility Services and Infertility Drugs
• MRIs
• Non-routine mammograms
• Off-island services (except for preventive service) and consultations
• Oncology consultations
• Orthopedic, Prosthetic, and Implantable devices
• Out-of-area hospitalization
• Plastic/reconstructive consultation and procedures
• Occupational therapy, physical therapy, speech therapy
• Podiatry consultations and procedures
• Sleep studies
• Specialty care procedures
  
• Transplants
• Ultrasounds, sonograms including echocardiogram
• Other procedures including colonsocopy and endoscopy (except for preventive services)

Emergency services do not require pre-certification. However, you or your family member must notify the Plan within 48 hours, or as soon as is reasonably possible, in order for the services to be covered.

You or your representative must also contact us within two business days following the date of service or as soon as is reasonably possible when you receive primary or specialty care services from in-network or out-of-network providers when you are outside of the service area and that were not approved in advance by the Plan. Failure to notify the Plan may result in denial or reduction of benefits.

The list of services requiring prior approval may change periodically. To ensure your treatment or procedure is covered, call us at 671-477-9808.

First, your physician, your hospital, or your representative, must call us at 671-477-9808 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 any hospital admission outside of our service area and/or at non-participating providers, that was not prior authorized, you, your representative, the physician, or the hospital must contact us within two business days following the day of the admission or as soon as is reasonably possible, even if you have been discharged from the hospital. Failure to notify the Plan may result in a denial of benefits.

For non-urgent care claims, we will then 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 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 have an urgent care claim (i.e. when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability 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 you of 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 and urgent care claims by applying the judgement of a prudent 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) 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 671-477-9808. You may also call OPM's Health Insurance 3 at 202-606-0737 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 671-477-9808. 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 contact us within two business days following the day of the emergency admission, even if you have been discharged from the hospital.

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.

Failure to obtain prior approval may result in a denial of benefits if the services or devices do not meet Calvo's SelectCare payment determination criteria.

Under certain circumstances such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care.

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 claims is in reference to a contraceptive , call (671) 477-9808.

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 six 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 health care 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 six 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.

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request. We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by telephone, electronic mail, facsimile, or other expeditious methods.

After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure.

Coinsurance is the percentage of our allowance that you must pay for your care. 

Example: In our Plan, you pay 30% of eligible charges and any difference between eligible charges and billed charges for out-of-network services.

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services.

Example: When you see your primary care provider, you pay a copayment of $15 per office visit, and when you go in the hospital, you pay $200 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.

• In-network - No deductible.
• Out-of-network - The calendar year deductible is $500 per person under the High and Standard Option. 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 out-of-network deductible for your enrollment reach $500 under High and Standard Option. 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 out-of-network deductible for your enrollment reach $1,000 under High and Standard Option. Under a Self and Family 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 out-of-network deductible for your enrollment reach $1,500 under High and Standard Option.

A Calvo's SelectCare deductible claim form should be filled out immediately and kept safe to ensure accurate and complete information on all doctors, lab or pharmacy visits. It is your responsibility to track and submit deductible expenses (e.g. encounter tickets, invoices, receipts) and the required documentation. All claims forms should be submitted to the Calvo's SelectCare Customer Service Department.

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.

For most medical services, we calculate our payment and your copayment/coinsurance based on eligible charges. The eligible charge is the lower of either the provider's actual charge or the amount we established as the maximum allowable fee.

Non-plan providers are not under contract to limit their charges to our eligible charges. You are responsible for any charges in excess of eligible charges.

High Option: After your medical copayments and coinsurance for in-network covered services total $2,000 for Self Only or $2,000 per person for Self Plus One or $6,000 per Self and Family enrollment in any calendar year, you do not have to pay any more for in-network covered medical services. However, please note that the Plan does not have out-of-pocket maximums for any out-of-network services.

Standard Option: After your medical copayments and coinsurance for in-network covered services total $3,000 for Self Only or $3,000 per person for Self Plus One or $8,000 per Self and Family enrollment in any calendar year, you do not have to pay any more for in-network covered medical services. However, please note that the Plan does not have out-of-pocket maximums for any out-of-network services.

There is a separate out-of-pocket maximum for prescription drugs. After your prescription copayments and coinsurance at in-network pharmacies total $2,000 for Self Only or $2,000 per person for Self Plus One or $4,000 per family enrollment in any calendar year, you do not have to pay any more for covered prescription drugs at in-network pharmacies.

Be sure to keep accurate records of your copayments/coinsurance. We will also keep records of your in-network coinsurance/copayments and track your in-network catastrophic protection maximums.

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.

Facilities of the Department Government Affairs, the Department of Defense and the Indian Health Services are entitled to seek reimbursement from for certain services and supplies they provide to you or a family member. They may not seek more than the governing laws allow. You may be responsible to pay for certain services and charges. Contact the government facility directly for more information.

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 recive 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

Balance billing happens when you receive a bill from the nonparticipating provider, facility, or air ambulance service for 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.calvos.net or contact the health plan at (671) 477-9808.

• Healthcare FSA (HCFSA) - Reimburses you for eligible our-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision nad 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.

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed amount per visit after deductible is met

In-network: Nothing

In-network: $15 copayment per office visit

Preferred Provider: $5 copayment per office visit

Copayment is waived at in-network providers in the Philippines

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed amount per visit after deductible is met

In-network: $20 copayment per office visit

Preferred Provider: $10 copayment per office visit

Copayment is waived at in-network providers in the Philippines 

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed amount per visit after deductible is met

In-network: $40 copayment per office visit

Copayment is waived at in-network providers in the Philippines

In-network: $40 copayment per office visit

Copayment is waived at in-network providers in the Philippines 

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed amount per visit after deductible is met

Emergency Services In Area

• Doctor's Office or Urgent Care Center

Emergency Services In Area

• Hospital Emergency Room

Emergency Services Out of Area

• Doctor's Office or Urgent Care Center

Emergency Services Out of Area

• Hospital Emergency Room

Retail (30-day supply)

$10 for Generic

$25 for Preferred Brand

50% of Average Wholesale Price (AWP) for Non-preferred Brand

$100 for Specialty 

Mail Order (90-day supply)

Nothing for Generic

$25 for Preferred Brand

$100 for Non-Preferred Brand

$200 for Specialty

Retail (30-day supply)

$15 for Generic

$40 for Preferred Brand

50% of Average Wholesale Price (AWP) for Non-Preferred Brand

$150 for Specialty

Mail Order (90-day supply)

Nothing  for Generic

$50 for Preferred Brand

$150 for Non-Preferred

$250 for Specialty 

In-network: $100 copayment (includes doctor's services) per visit

Copayment is waived at in-network providers in the Philippines.

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed chargesafter deductible is met

In-network: 20% coinsurance per visit

Coinsurance is waived at in-network providers in the Philippines.

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met
 

In-network: $200 copayment per admission

Copayment is waived at in-network providers in the Philippines.

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met

In-network: 20% coinsurance per admission

Coinsurance is waived at in-network providers in the Philippines.

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met

In-network: All charges above $25 per visit and all charges after 20th visit

No out-of-network benefit.

In-network: All charges above $25 per visit and all charges after 20th visit

No out-of-network benefit.

Member pays all charges above $100

Member pays all charges above $100

In-network: Nothing for preventive services. All other dental services are not covered.

Out-of-network:  30% coinsurance of covered charges for preventive services plus any difference between eligible charges and billed charges. All other dental services are not covered.

In-network: Nothing for preventive services. All other dental services are not covered.

After your out-of-pocket expenses for in-network services, including any applicable deductibles, copayments and coinsurance total  $2,000 for Self Only, or $4,000 for a Self Plus One or $6,000 Self and Family enrollment in any calendar year, you do not have to pay any more for in-network covered services. The maximum annual limitation on cost sharing for in-network services listed under Self Only of $2,000 applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

There is a separate out-of-pocket maximum for prescription drugs obtained at in-network pharmacies. After your out-of-pocket expenses for in-network prescription drugs obtained at in-network pharmacies, including any applicable deductibles, copayments and coinsurance, total  $2,000 for Self Only, or $4,000 for a Self Plus One or Self and Family enrollment in any calendar year, you do not have to pay any more for covered prescription drugs obtained at in-network pharmacies. The maximum annual limitation on cost sharing for in-network services listed under Self Only of $2,000 applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

After your out-of-pocket expenses for in-network services, including any applicable deductibles, copayments and coinsurance total  $3,000 for Self Only, or $6,000 for Self Plus One or $8,000 Self and Family enrollment in any calendar year, you do not have to pay any more for in-network covered services. The maximum annual limitation on cost sharing for in-network services listed under Self Only of $3,000 applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

There is a separate out-of-pocket maximum for prescription drugs obtained at in-network pharmacies. After your out-of-pocket expenses for prescription drugs obtained at in-network pharmacies, including any applicable deductibles, copayments and coinsurance total  $2,000 for Self Only, or $4,000 for a Self Plus One or Self and Family enrollment in any calendar year, you do not have to pay any more for covered prescription drugs obtained at in-network pharmacies. The maximum annual limitation on cost sharing for in-network services listed under Self Only of $2,000 applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

Outpatient professional services of physicians

• In physician’s office
• In an urgent care center
• Office medical consultations
• Second opinion
• Advance care planning
• Injections - intramuscular and subcutaneous
• IV Infusion therapy
• Growth Hormone (GHT) therapy

In-network:

$15 copayment per PCP office visit

 $40 copayment per specialist visit

Preferred In-network: $5 copayment per PCP office visit

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

Note: Additional copayments shall apply (e.g. administration of medication, laboratory services, per diagnostic/imaging service, facility fees, etc.)

Note: Infusion therapy and injections (except for contraceptive injections) require a separate copayment.

Note: Copayment is waived at in-network providers in the Philippines.

In-network:

$20 copayment per PCP office visit

 $40 copayment per specialist visit

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

Note: Additional copayments or coinsurance shall apply (e.g. administration of medication, laboratory services, imaging services, facility fees, etc.)

Note: Infusion therapy and injections (except for contraceptive injections) require an additional separate copayment or coinsurance.

Note: Copayment is waived at in-network providers in the Philippines.

Inpatient professional services of physicians

• During a hospital stay
• In a skilled nursing facility

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

In-network: 20% coinsurance per Inpatient Hospital admission

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

Note: Coinsurance is waived at in-network providers in the Philippines.

Not covered: Medical services and supplies required for obtaining or continuing employment or insurance, attending schools or camp, or travel.

Not covered: Certain medical supplies such as surgical trays.

Telehealth consultations through the following telehealth vendor:

• Teladoc® - available to members for medical conditions via Teladoc's mobile app (video), Teladoc's website or by telephone at Teladoc's toll-free number

Nothing

Nothing

• Blood tests
• Urinalysis
• Non-routine pap tests
• Pathology
• Electrocardiogram and EEG
• X-rays

Note: See Section 5 (c) for Services billed by a facility for inpatient and outpatient services.

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met.

Note: Coinsurance is waived at in-network providers in the Philippines.

• CT Scan
• Echocardiogram
• MRI
• Non-routine mammograms
• Ultrasound

Note: Prior authorization is required for ultrasounds and all high end radiology procedures, such as but not limited to CT scans, echocardiogram, PET scans, MRIs, and other diagnostic tests.  See Section 3 Other Services for more information.

Note: See Section 5 (c) for Services billed by a facility for inpatient and outpatient services.

In-network: $40 copayment in addition to regular office visit

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met

Note: Copayment is waived at in-network providers in the Philippines.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met

Note: Coinsurance is waived at in-network providers in the Philippines.

Routine physical once a 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/recommendations-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 services for women go to 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

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met.

Routine mammogram – covered

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met.

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

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.

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met.

• Medical Nutrition Therapy and Intensive Behavioral Therapy for the prevention of obesity related comorbidities as recommended under the U.S. Preventive Services Task Force (USPSTF) A and B recommendations
  

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met.

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met.

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.

All charges

• 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 may 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/recommendations-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 listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met.

Complete maternity (obstetrical) care, such as:

• Prenatal care and Postpartum care - doctor's visits and labs only

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met.

• Delivery

In-network: 

$100 copayment for birthing center

$200 copayment for hospital

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

In-network: 20% coinsurance for birthing center, 20% coinsurance for inpatient hospital admission

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

• Screening for gestational diabetes

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met.

• Postnatal care - doctor's visits and labs only

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met.

• Screening and counseling for prenatal and postpartum depression

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

Breastfeeding support and counseling for each birth

Note: Here are some things to keep in mind:

• You do not need to precertify your vaginal delivery unless you will be receiving services outside of our service area and/or services will be provided by non-participating providers; see below for other circumstances, such as extended stays for you or 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 extend your inpatient 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 infant under a Self Plus One or Self and Family enrollment.
• We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery benefits (Section 5b).
• The newborn must be enrolled within 60 days of birth.
• 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 his or her own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

Note: Breast pump and supplies are limited to:

• Purchase or rental of breastfeeding equipment up to a value of $100 per pregnancy. Member is responsible for all charges above $100.

Nothing

Nothing

Medical Foods

Special food products and formulas that are part of a diet prescribed by a doctor for the treatment of phenylketonuria (PKU) or other inborn errors of metabolism. You can get most formulas used in the treatment of PKU or other inborn errors of metabolism from a drugstore.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

Not covered:

• Sonograms that are deemed not medically necessary, including 3-D and 4-D

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met.

A range of voluntary family planning services, limited to:

• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo Provera)
• Intrauterine devices (IUDs)
• Diaphragms
• Tubal ligation

Note: We cover oral contraceptives, contraceptive patches and rings, contraceptive diaphragms, cervical caps, and intrauterine devices (IUDs) under the Presecription Drug Benefit, Section 5(f) Prescription Drug Benefits.

Note: For copayment information on professional fees for surgery and anesthesia services see Section 5(b) Surgical and Anesthesia Services and for copayment information on hospital and / or ambulatory surgery center benefits see Section 5(c) Services provided by a hospital or other facility. 

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

Note: Additional copayments shall apply (e.g. administration of medication, laboratory services, per diagnostic/imaging service, facility fees, etc.)

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met.

Note: Additional copayments shall apply (e.g. administration of medication, laboratory services, per diagnostic/imaging service, facility fees, etc.)

• Voluntary sterilization - (See Surgical procedures Section 5 (b))

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

Note: Additional copayments shall apply (e.g. administration of medication, laboratory services, per diagnostic/imaging service, facility fees, etc.)

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met.

Note: Additional copayments shall apply (e.g. administration of medication, laboratory services, per diagnostic/imaging service, facility fees, etc.)

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling except those services required by the United States Preventive Services Task Force (USPSTF) and the Health Resources and Services Administration (HRSA).

All Charges

The Plan defines infertility as a disease (an interruption, cessation, or disorder of the body functions, systems, or organs) of the reproductive tract which prevents the conception of a child or the ability to carry a pregnancy to delivery after egg-sperm contact. Infertility may also be established through an evaluation based on medical history and diagnostic testing.

Diagnosis and treatment of infertility, except as shown in Not covered, specific to:

• Initial diagnostic tests and procedures done only to identify the cause of infertility
• Fertility drugs, hormone therapy and related services (see Section 5(f) Prescription Drug Benefits)
• Medical or surgical procedures done to create or enhance fertility
• Services, drugs and supplies related to Assisted Reproductive Technology (ART) (see elsewhere in this Section).

Services (including lab tests), supplies and drugs related to ART procedures, except as shown in Not covered, specific to:

• Artificial insemination (AI) - for three cycles or more, as deemed medically necessary
• In vitro fertilization (IVF) - for three cycles or more, as deemed medically necessary
• Embryo transfer and gamete intrafallopian transfer (GIFT) and Zygote intrafallopian transfer (ZIFT) - for three cycles or more, as deemed medically necessary
• Intracytoplasmic sperm injection (ICSI) - for three cycles or more, as deemed medically necessary
• Intravaginal insemination (IVI) - for three cycles or more, as deemed medically necessary
• Intracervical insemination (ICI) - for three cycles or more, as deemed medically necessary
• Intrauterine insemination (IUI) - for three cycles or more, as deemed medically necessary

Note: Infertility services, supplies and drugs require prior approval.

Note: Injectable infertility drugs do not require an additional member copayment with an office visit copayment.

Note: We cover injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefits for three cycles or more, as deemed medically necessary.

Note: Fertility preservation procedures require prior approval (see elsewhere in this Section)

Note: For copayment information on professional fees for surgery and anesthesia services related to the above-mentioned services see Section 5(b) Surgical and Anesthesia Services and for copayment information on hospital and / or ambulatory surgery center benefits see Section 5(c) Services provided by a hospital or other facility.

In-network: $40 copayment per specialist visit

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

In-network: 50% coinsurance

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met.

Benefits for fertility preservation due to medical procedures that may cause irreversible infertility such as chemotherapy, radiation treatment, and bilateral oophorectomy due to cancer. Services include the following procedures, when provided by or under the care or supervision of a physician:

• Collection of sperm
• Cryo-preservation of sperm
• Ovarian simulation, retrieval of eggs and fertilization
• Oocyte  cryo-preservation
• Embryo cryo-preservation

Note: Coverage Limitations and Exclusions include the following:

• Benefits are not available for embryo transfer.
• Benefits are not available for long-term storage costs (greater than one year)
• Benefits for egg harvesting or embryo implantation procedures are not available beyond two attempts
• Provider access limited to direct-contract network providers

Note: Prior authorization is required for infertility services.

Note: For copayment information on professional fees for surgery and anesthesia services related to the above-mentioned services see Section 5(b) Surgical and Anesthesia Services and for copayment information on hospital and/or ambulatory surgery center benefits see Section 5(c) Services provided by a hospital or other facility.

In-network: $40 copayment per specialist visit

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

In-network: 50% coinsurance per specialist visit

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

Not covered:

• Infertility services after voluntary sterilization
• Services, supplies and drugs related to ART procedures not detailed above
• Costs of donor sperm and donor eggs
• Elective fertility preservation, such as egg freezing due to natural aging

• Testing and treatment
• Allergy injections

In-network:

$15 copayment per PCP office visit

$40 copayment per specialist visit

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

Note: Additional copayments shall apply (e.g. administration of medication, laboratory services, per diagnostic/imaging service, facility fees, etc.) 

Note: Copayment is waived at in-network providers in the Philippines.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

Note: Additional copayments or coinsurance all apply (e.g. administration of medication, laboratory services, per diagnostic/imaging service, facility fees, etc.) 

Note: Coinsurance is waived at in-network providers in the Philippines.

Allergy Serum

Note: Allergy testing and allergy serum require prior authorization.

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met

Not covered:

• Provocative food testing
• Sublingual allergy desensitization

• Chemotherapy and radiation therapy
• Dialysis – hemodialysis and peritoneal dialysis
• Respiratory and inhalation therapy
• Cardiac rehabilitation (for more information please see Section 5(a) page 42).
  
• Intravenous (IV) / /Infusion Therapy 
• Growth hormone therapy (GHT)
• Hyperbaric Oxygen therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 54.

Note: Growth hormone is covered under the prescription drug benefit. We only cover GHT when we preauthorize the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. See Section 3 Other services requiring our prior approval.

Note: For information on prescription drug benefits and copayments see Section 5(f) Prescription Drug Benefits.

Note: We cover self-administered injections and specialty drugs under the prescription drug benefit.

In-network: 

$40 copayment per specialist treatment

$100 copayment for outpatient facility

Out-of-network: 30% coinsurance of eligible charges and any diffeence between eligible charges and billed charges after deductible is met.

Note: Copayment is waived at in-network providers in the Philippines.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met.

Note: Coinsurance is waived at in-network providers in the Philippines.

Outpatient services of each of the following:

• qualified physical therapists and
• occupational therapists

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.

Note: Prior authorization of treatment is required.

In-network: 

$15 copayment per visit

Nothing for home visits

Nothing during covered inpatient admission

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met

Note: Copayment is waived at in-network providers in the Philippines. 

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met

Note: Coinsurance is waived at in-network providers in the Philippines.

Not covered:

• Long-term rehabilitative therapy
• Exercise programs, lifestyle modification programs
• Equipment, supplies or customized devices related to rehabilitative therapists, except those provided under Durable Medical Equipment
• Services provided by schools or government programs
• Developmental and Neuroeducational testing and treatment beyond initial diagnosis
• Hypnotherapy
• Psychological testing
• Vocational rehabilitation

In-network:

$15 copayment per treatment

Nothing for home visits

Nothing during covered inpatient admission

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

Note: Copayment is waived at in-network providers in the Philippines. 

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met.

Note: Coinsurance is waived at in-network providers in the Philippines.

Medically necessary health care services and health care devices that assist an individual in partially or fully acquiring or improving skills and functioning and that are necessary to address a health condition, to the maximum extent practical.

Not covered: Services such as, but are not limited to, respite care, day care, recreational care, residential treatment, social services, custodial care, or education services of any kind.

In network:

Member cost-share will be at parity with cost-share for rehabilitative services.

In-network: 

Member cost-share will be at parity with cost-share for rehabilitative services. 

Unlimited visits for the services of:

• Qualified speech therapist

Note: All therapies are subject to medical necessity and require prior authorization of treatment.

In -network: $15 copayment per treatment

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

Note: Copayment is waived at in-network providers in the Philippines. 

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met.

Note: Coinsurance is waived at in-network providers in the Philippines.

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.

Note: For copayment information on professional fees for surgery and anesthesia services see Section 5(b) Surgical and Anesthesia Services and for copayment information on hospital and / or ambulatory surgery center benefits see Section 5(c) Services provided by a hospital or other facility.

In-network: $40 copayment per specialist visit

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

Note: Additional copays shall apply (e.g. administration of medication, laboratory services, per diagnostic /imaging service, facility fee, etc).

Note: Copayment is waived at in-network providers in the Philippines.

In-network: $40 copayment per specialist visit

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met.

Note: Additional copays or coinsurance shall apply (e.g. administration of medication, laboratory services, imaging servcies, facility fee, etc).

Note: Copayment is waived at in-network providers in the Philippines. 

For the diagnosis and non-surgical treatment of diseases of the eye

• Annual eye exam - includes refraction exam

Note: For copayment information on professional fees for surgery and anesthesia services see Section 5(b) Surgical and Anesthesia Services and for copayment information on hospital and / or ambulatory surgery center benefits see Section 5(c) Services provided by a hospital or other facility.

In-network:

$15 copayment per PCP office visit

$40 copayment per specialst visit

Out-of-Network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

Note: Additional copays shall apply (e.g. administration of medication, laboratory services, per diagnostic/imaging service, facility fee, etc). 

Note: Copayment is waived at in-network providers in the Philippines.

In-network: 

$20 copayment per PCP office visit

$40 copayment per specialst visit

Out-of-Network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

Note: Additional copays or coinsurance shall apply (e.g. administration of medication, laboratory services, imaging servcies, facility fee, etc). 

Note: Copayment is waived at in-network providers in the Philippines. 

• Prescription lenses, eyeglass frames or contact lenses

Member pays all charges above $100.

Member pays all charges above $100.

Not covered:

• Eye exercise and orthoptics (vision therapy)
• Radial keratotomy and other refractive surgery, such as LASIK surgery

All charges

Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes and other podiatric services

Note: For copayment information on professional fees for surgery and anesthesia services see Section 5(b) Surgical and Anesthesia Services and for copayment information on hospital and / or ambulatory surgery center benefits see Section 5(c) Services provided by a Hospital or Other Facility.

In-network: $15 copayment per office visit

Out-of-Network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

Note: Copayment is waived at in-network providers in the Philippines.

In-network: $40 copayment per office visit

Out-of-Network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met.

Note: Copayment is waived at in-network providers in the Philippines. 

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)

• Artificial eyes
• Intraocular Lens (benefit is limited to conventional type)
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy. (benefit is limited to two per benefit year)
• Internal prosthetic devices, such as artificial joints, single and dual chamber pacemakers, and surgically implanted breast implant following mastectomy.
• Cardiac stents
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
• External hearing aids (benefit is limited to $300 per ear every two years)
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants (limited to direct-contracted network providers)
• Orthopedic devices such as braces
• Band for vertical-banded gastroplasty

Note: Prior authorization is required for orthopedic, prosthetic, and implantable devices.

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.

In-network: 10% of the cost of the device

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

Note: A benefit maximum for Hearing Aids applies.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met.

 Note: A benefit maximum for Hearing Aids applies.

Not covered:

• Orthopedic and corrective shoes
• Arch supports
• Foot orthotics
• Heel pads and heel cups
• Lumbosacral supports
• Over-the-counter (OTC) items
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Other internal prosthetics such as heart valves, automatic implantible carioverter defibrillator (AICD) and other implantable devices not specified above
• External prosthetic replacements provided less than 3 years after the last one we covered
• Services and supplies related to devices that are not covered

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

• Manual hospital beds (replacement limited to every 5 years)
• Standard manual wheelchairs (replacement limited to every 5 years)
• Crutches (replacement limited to every 5 years)
• Walkers (replacement limited to every 5 years)
• Blood glucose monitors (replacement limited to every 3 years)
• CPAP (Continuous Positive Airway Pressure) - (replacement limited to every 5 years)
• BIPAP (Bi-level Positive Airway Pressure) - (replacement limited to every 5 years)
• Oxygen and equipment for its administration (replacement supplies every three months)

Note: Prior authorization required for durable medical equipment.

Note: Supplies limited to initial dispensing of CPAP and BIPAP.

Note: Call us at 671-477-9808 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.

In-network: 20% coinsurance

No out-of-network benefit

Not covered:

• Motorized wheelchairs and scooters
  
• Insulin Pumps
• Devices or equipment not specified above

• Home healthcare ordered by a Plan physician and provided by a plan physician, registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide while under active treatment with a home health agency.
• Services include:
  • oxygen therapy, intravenous therapy and medications
  • Services ordered by physician for members who are confined to the home
  • Nursing
  • Medical supplies included in the home health plan of care
  • Physical therapy, speech therapy, occupational therapy, and respiratory therapy

Note: Home Health Services require prior authorization. 

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges
after deductible is met.

Not covered:

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

All charges

Chiropractic services - you may self refer to a participating chiropractor for up to 20 visits per calendar year. Services are limited to:

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

In-network: All charges above $25 per visit and all charges after the 20th visit

No out-of-network benefit

In-network: All charges above $25 per visit and all charges after the 20th visit

No out-of-network benefit

Acupuncture - by a doctor of medicine or osteopathy, or licensed or certified acupuncture practitioner up to 20 visits per calendar year.

In network: All charges above $25 per visit and all charges after 20th visit.

No out-of-network benefit.

In network: All charges above $25 per visit and all charges after 20th visit.

No out-of-network benefit.

Massage Therapy - You may self refer, in-network, to a participating, licensed massage therapist for up to 12 visits per benefit year.

In network: $10 copayment per visit.

Out-of-network: All charges

In network: $10 copayment per visit.

Out-of-network: All charges

Coverage is limited to programs administered through Calvo's SelectCare only:

• Cardiac risk management class
• Diabetes self management
• Wellness programs
• Fitness program
• Multicomponent, family centered programs focused on childhood obesity that are part of intensive behavioral interventions (behavior change counseling for healthy diet and physical activity)

• Tobacco cessation programs including individual/group/telephone counseling and over-the-counter (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

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

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
• Circumcision - up to 90 days from date of birth
• Removal of tumors and cysts
• Correction of congenital anomalies (Reconstructive surgery)
• Surgical treatment of severe obesity (bariatric surgery); surgery is limited to Roux-en-Y bypass and vertical banded gastroplasty
• Insertion of internal prosthetic devices . See 5(a) – Orthopedic and prosthetic devices for device coverage information
• Voluntary sterilization - vasectomy
• Insertion of internal prosthetic and implantable devices
• Treatment of burns

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

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.

Note: Prior authorization required for surgical procedures.

In-network:

$15 copayment per PCP office visit

$40 copayment per Specialist office visit

Inpatient hospital admission - $200 copayment (includes doctors' services)

Outpatient surgical facility - $100 copayment (includes doctors' services)

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met

Note: Copayment is waived at in-network providers in the Philippines.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges 
after deductible is met.

Note: Coinsurance is waived at in-network providers in the Philippines.

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot; (see Foot care)
• Robotic 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; birthmarks; 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 lympedemas;
  • Breast prostheses and surgical bras and replacemetns (see Prosthetic devices)

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.

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.

In-network:

$15 copayment per PCP office visit

$40 copayment per Specialist office visit

Inpatient hospital admission - $200 copayment (includes doctors' services)

Outpatient surgical facility - $100 copayment (includes doctors' services)

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met

Note: Copayment is waived at in-network providers in the Philippines.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges 
after deductible is met.

Note: Coinsurance is waived at in-network providers in the Philippines.

• Gender Affirming Surgery
   

A comprehensive range of services, as required by WPATH Standards of Care such as:

• Surgeries related to gender re-assignment

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

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.

Note: Prior authorization is required for surgical procedures.

Note: There are no exclusions for WPATH Standards.

In-network:

$15 copayment per PCP office visit

$40 copayment per Specialist office visit

Inpatient hospital admission - $200 copayment (includes doctors' services)

Outpatient surgical facility - $100 copayment (includes doctors' services)

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met

Note: Copayment is waived at in-network providers in the Philippines.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

Note: Coinsurance is waived at in-network providers in the Philippines.

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
• Other surgical procedures that do not involve the teeth or their supporting structures.
• TMJ surgery and other related non-dental treatment

In-network: 

Inpatient hospital admission - $200 copayment (includes doctors' services)

Outpatient surgical facility - $100 copayment (includes doctors' services)

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met

Note: Copayment is waived at in-network providers in the Philippines.

In-network: 20% coinsurance per outpatient surgical facility and inpatient hospital admission

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges 
after deductible is met

Note: Coinsurance is waived at in-network providers in the Philippines.

Not covered:

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

All charges

These solid organ transplants are covered. 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 or lobar lung
• Pancreas

In-network: 

Inpatient hospital admission - $200 copayment (includes doctors' services)

Outpatient surgical facility - $100 copayment (includes doctors' services)

Out-of-netowrk: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met

Note: Copayment is waived at in-network providers in the Philippines.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges 
after deductible is met

Note: Coinsurance is waived at in-network providers in the Philippines.

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

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

In-network: 

Inpatient hospital admission - $200 copayment (includes doctors' services)

Outpatient surgical facility - $100 copayment (includes doctors' services)

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met

 Note: Copayment is waived at in-network providers in the Philippines.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges 
after deductible is met

Note: Coinsurance is waived at in-network providers in the Philippines.

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., myelogeneous) leukemia
• Acute myeloid leukemia
• Advanced Hodgkin’s lymphoma with recurrence (relapsed)
• Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
• Advanced Myeloproliferative Disorders (MPDs)
• Advanced neuroblastoma
• Amyloidosis
• Chronic lymphocytic leukemia/small lymphoma (CLL/SLL)
• Hemoglobinopathy
• Hematopoietic Stem Cell Transplant (HSCT)
• Infantile malignant osteoporosis
• Kostman's syndrome
• Leukocyte adhesion deficiencies
• 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)
• Mucopolysacharudosis (e.g. Hunter's sydrome, Hurler"s syndrome, Sanfillippo's syndrome, Maroteaux-Lamy syndrome variants)
• 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
• Ewing's sarcoma
• Hematopoietic Stem Cell Transplant (HSCT)
• Multiple myeloma
• Medulloblastoma
• Pineoblastoma
• Neuroblastoma
• Scleroderma
• Scleroderma-SSc (severe progressive)
• Testicular, Mediastinal, Retroperitoneal, and ovarian germ cell tumors

In-network: 

Inpatient hospital admission - $200 copayment (includes doctors' services)

Outpatient surgical facility - $100 copayment (includes doctors' services)

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met

Note: Copayment is waived at in-network providers in the Philippines.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges 
after deductible is met

Note: Coinsurance is waived at in-network providers in the Philippines.

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members over 60 years of age with a diagnosis listed below are subject to medical necessity review by the Plan.

Allogeneic transplants for:

• Acute lympocytic or nonlymphocytic (i.e. myelogenous leukemia)
• Acute myeloid leukemia
• Advanced Hodgkin's lymphoma with recurrence (relapsed)
• Advanced Myeloproliferative Disorders (MPDs)
• Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
• Amyloidosis
• Chronic lymphocytic leukemia/small lymphoma (CLL/SLL)
• Hemoglobinapathy
• Marrow failure and related disorders (i.e. Faconi's PNH, Pure Red Cell Aplasia)
• Myelodysplasia/Myelodysplastic syndromes
• Paroxysma 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

In-network: 

Inpatient hospital admission - $200 copayment (includes doctors' services)

Outpatient surgical facility - $100 copayment (includes doctors' services)

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met

Note: Copayment is waived at in-network providers in the Philippines.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges 
after deductible is met

Note: Coinsurance is waived at in-network providers in the Philippines.

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 trail.

• Allogeneic transplants for
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Beta Thalassemia Major
  • Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)
  • Early stage (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 nonlymphocytic (i.e. myelogenous) leukemia
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Breast cancer
  • Chronic lymphocytic leukemia
  • Chronic lymphocytic leukemia/small lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Colon cancer
  • Early stage (indolent or non-advanced) small cell lymphocyte
  • Multiple myeloma
  • Multiple sclerosis
  • Myelodysplasia/Myelodyplastic Syndromes
  • Myeloproliferative disorders (MDDs)
  • Non-small cell lung cancer
  • Ovarian cancer
  • Prostate cancer
  • Renal cell carcinoma
  • Sarcomas
  • Sickle cell anemia
• Autologous transplants for: 
  • Advanced Chidhood kidney cancers
  • Advanced Ewing sarcoma
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Aggressive non-Hodgkin's lymphoma
  • Breast cancer
  • Childhood rhabdomyosarcoma
  • Chronic lymphocytic leukemia/small lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Epithelial ovarian cancer
  • Mantle cell (non-Hodgkin's lymphoma)
  • Multiple sclerosis
  • Small cell lung cancer
  • 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.

In-network: 

Inpatient hospital admission - $200 copayment (includes doctors' services)

Outpatient surgical facility - $100 copayment (includes doctors' services)

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met

Note: Copayment is waived at in-network providers in the Philippines.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges 
after deductible is met

Note: Coinsurance is waived at in-network providers in the Philippines.

Not covered:

• Donor screening tests and donor search expenses, except those performed for the actual donor
• Implants of artificial organs
• Transplants not listed as covered

Professional services provided in –

• Hospital (inpatient)
• Hospital outpatient department
• Ambulatory surgical center
• Office

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges 
after deductible is met

Note: Coinsurance is waived at in-network providers in the Philippines.

Room and board, such as

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

Note: Pre-certification of hospital stay is required.

In-network: $200 copayment per inpatient hospital admission (includes doctors' services)

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met

Note: Copayment is waived at in-network providers in the Philippines.

In-network: 20% coinsurance per inpatient hospital admission

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges 
after deductible is met

Note: Coinsurance is waived at in-network providers in the Philippines.

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
• Rehabilitative therapies

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met

In-network: 20% coinsurance per inpatient hospital admission

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges 
after deductible is met

Note: Coinsurance is waived at in-network providers in the Philippines.

Not covered:

• Any hospitalization for dental procedures
• Blood and blood products, whether synthetic or natural, if not included in contracted facility packages
• Custodial care
• Internal prosthetics, except for those covered under Prosthetics and Orthopedic devices
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home
• Non-covered facilities, such as nursing homes, schools
• Personal comfort items, such as telephone, television, barber services, guest meals and beds
• Private nursing care
• Take home items

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests, X-rays and other radiology services, and pathology services
• Administration of blood: blood plasma, and other biologicals
• 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.

In-network: $100 copayment for outpatient facility (includes doctors' services)

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met

Note: Copayment is waived at in-network providers in the Philippines.

In-network: 20% coinsurance for outpatient facility

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges 
after deductible is met

Note: Coinsurance is waived at in-network providers in the Philippines.

The Plan provides a comprehensive range of benefits when full-time skilled nursing care and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan. All necessary services are covered including:

• Bed, board, and general nursing care
• Drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor

In-network: Nothing up to 100 days per plan year

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met

In-network: 20% coinsurance up to 60 days per calendar year

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges 
after deductible is met

Not covered:

High Option

• Custodial care
• Care beyond 100 days per plan year

Standard  Option 

• Custodial care
• Care beyond 60 days per plan year

Supportive and palliative care for a terminally ill member is covered in the home, hospital or hospice facility when approved by the Utilization Department. Services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six months or less.

Services include:

• Inpatient and outpatient care
• Family counseling

In-network: Nothing

No out-of-network benefit

In-network: 20% coinsurance

No out-of-network benefit

Emergency ambulance service 

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met

In-network: 20% coinsurance

No out-of-network benefit

Not covered:

• Non-emergency ground ambulance services
• Air ambulance
  

All charges

• Emergency care at a doctor’s office

$15 copayment per doctor's office  visit

• Emergency care as an outpatient at a hospital, including doctor's services

$100 copayment per emergency room visit

• Urgent Care Services at Primary Care or Urgent Care Clinics

In-network: $15 copayment per clinic visit

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

In-network: $20 copayment per clinic visit

Out-of-network: 30% coinsurance of eligible charges and any difference between eligibile charges and billed charges after deductible is met.

• Urgent Care Services as an outpatient in Hospital Urgent Care department
  

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

In-network: $50 copayment per visit

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges after deductible is met.

In-network: $75 copayment per clinic visit

Out-of-network: 30% coinsurance of eligible charges and any difference between eligibile charges and billed charges after deductible is met.

All Charges

• Emergency care at a doctor’s office

$50 copayment per doctor's office visit and any difference between eligible charges and billed charges

• Emergency care as an outpatient at a hospital, including doctor's services

$200 copayment per emergency room visit and any difference between eligible charges and billed charges

• Urgent Care Services at Primary Care Clinic or Urgent Care Center

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

In-network: $15 copayment per clinic visit
Out-of-network: 30% coinsurance per clinic visit and any difference between eligible charges and billed charges

In-network: $20 copayment per clinic visit
Out-of-network: 30% coinsurance per clinic visit and any difference between eligible charges and billed charges

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
  

Emergency ambulance service 

In-network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges

• Air ambulance
• Non-emergency ground ambulance services

We cover professional services by licensed professional mental health and substance use disorder 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 (pharmacotherapy)
• 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

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Telehealth consultations through the following telehealth vendor:

• Teladoc® - available to members for mental health/substance use disorders via Teladoc's mobile app (video), Teladoc's website or by telephone at Teladoc's toll-free number.

Nothing

Nothing

Applied Behavioral Therapy Benefit

• Required Diagnosis of ASD (Autsm Spectrum Disorder) by a provider qualified to make the diagnosis: Board Certified Behavior Analyst (BCBA), psychiatrist, pediatrician.
• Initiation of treatment and on-going treatment and intensity of treatment must be medically necessary and appropriate for the child.
• Available to children through age 21 (coverage limitations apply).
• A Functional Behavioral Assessment must be submitted prior to treatment and must demonstrate appropriateness of ABA Therapy.
• Services must be directed by a Board Certified Behavior Analyst and services may be provided by Board Certified Assistant Behavior Analysts (BCaBA) or Registered Behavior Technicians (RBTs).
• Approval of on-going services requires demonstrated and documented involvement by family.
• Services provided by the school are not reimbursable by the Plan.

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Coverage is limited to $75,000 for eligible dependent children through age 15 and $25,000 for children age 16 through 21 based on Guam mandated benefit.

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Coverage is limited to $75,000 for eligible dependent children through age 15 and $25,000 for children age 16 through 21 based on Guam mandated benefit.

• Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder practitioner
• Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility
• Inpatient diagnostic tests provided and billed by a hospital or other covered entity

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

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

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

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

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

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Not covered:

Services that require pre-authorization but are not pre-authorized before the services are rendered.

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.
• Disposable needles and syringes for the administration of covered medications;
• Diabetic supplies including
  
  • Disposable needles, syringes, lancets, urine and blood glucose testing reagents; a copayment charge applies per item per each 30-day supply
• Drugs to treat gender dysphoria

Retail Pharmacy (30-day supply)

$10 for Generic

$25 for Preferred Brand

50% of Average Wholesale Price (AWP) for Non-Preferred Brand

$100 for Specialty 

Mail Order (90-day supply)

Nothing for Generic

$25 for Preferred Brand

$100 for Non-Preferred Brand

$200 for Specialty 

Note: If there is no generic equivalent available, you will still have to pay the non-preferred copayment.

Note: For prescription drugs purchased at overseas pharmacies, members are responsible for a 20% coinsurance of the cost of the medication.

Retail Pharmacy (30-day supply)

$15 for Generic

$40 for Preferred Brand

50% of Average Wholesale Price (AWP) for Non-Preferred Brand

$150 for Specialty 

Mail Order (90-day supply)

Nothing for Generic

$40 for Preferred Brand

$150 for Non-Preferred Brand

$250 for Specialty 

Note: If there is no generic equivalent available, you will still have to pay the non-formulary copayment.

Note: For prescription drugs purchased at overseas pharmacies, members are responsible for a 20% coinsurance of the cost of the medication.

Insulin

Retail Pharmacy (30-day supply)

Nothing for Generic

Nothing for Preferred Brand

50% of Average Wholesale Price (AWP) for Non-Preferred Brand

$100 for Specialty 

Mail Order (90-day supply)

Nothing for Generic

Nothing for Preferred Brand

$100 for Non-Preferred Brand

$200 for Specialty 

Note: If there is no generic equivalent available, you will still have to pay the non-preferred copayment.

Note: For prescription drugs purchased at overseas pharmacies, members are responsible for a 20% coinsurance of the cost of the medication.

Retail Pharmacy (30-day supply)

Nothing for Generic

Nothing for Preferred Brand

50% of Average Wholesale Price (AWP) for Non-Preferred Brand

$150 for Specialty 

Mail Order (90-day supply)

Nothing for Generic

Nothing for Preferred Brand

$150 for Non-Preferred Brand

$250 for Specialty 

Note: If there is no generic equivalent available, you will still have to pay the non-formulary copayment.

Note: For prescription drugs purchased at overseas pharmacies, members are responsible for a 20% coinsurance of the cost of the medication.

Contraceptive 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 below.

• Contraceptives that are not covered are available to members after non-formulary review and based on medical necessity.
• Reimbursement for over-the-counter contraceptives can be submitted by mail to Calvo's SelectCare Customer Service Department, P.O. Box FJ, Hagatna, Guam 96932.

In-network:  Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges

In-network:  Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges

• Growth hormone

$100 copayment for 30-day supply

$100 copayment for 30-day supply

• Drugs for sexual dysfunction are covered when Plan criteria is met
• Oral fertility drugs

50% of Average Wholesale Price (AWP) per prescription unit or refill 

50% of Average Wholesale Price (AWP) per prescription unit or refill 

Preventive Care medications to promote better health as recommended by ACA

The following drugs and supplements are covered without cost-share, even if over-the-counter, are prescribed by a healthcare professional and filled at a network pharmacy.

• Asprin (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
• Fluoride tablets, solution (not toothpaste, rinses) for children age 0 - 6
• Statin Use for the Primary Prevention of Cardiovascular Disease in Adults

Note: To receive this benefit a prescription from a doctor must be presented to pharmacy.

Note: Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a health care 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/BroseRec/Index/browse-recommendations

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

In-network:  Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges

In-network:  Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges

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
• Drugs not approved the Food and Drug Administration (FDA)
• Medical supplies such as dressings and antiseptics
  
• Non-prescription and over-the-counter (OTC) medications
  
• Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them
• Replacement of lost, stolen or destroyed medication

Accidental Injury Benefit - We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury.

Note: If you are outside the service area and receive services from an out-of-network dentist, we will reimburse you up to $100.00

In network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges

In network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges

Preventive services listed below:

• Exams (once every six months)
• Fluoride treatment (for children age 15 and under, once a year)
• Prophylaxis (cleaning of teeth once every six months)
• Sealants (for permanent molars of children age 15 and under)
• Space maintainers (for children age 15 and under, includes adjustments within six months of installation
• X-rays (bite wing)
• X-rays (full mouth, once every three years)

We have no other dental benefits.

In network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed charges

In network: Nothing

Out-of-network: 30% coinsurance of eligible charges and any difference between eligible charges and billed 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 a stated time period (unless circumstances change). You may request and 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 airfare benefit applies when a member has a catastrophic illness which requires Qualified Medical Treatment or Procedures that are not available on Guam. This benefit cannot be used in conjunction with the Travel Benefit.

When approved in advance by Calvo’s SelectCare, the Airfare Benefit specifically covers the economy round-trip airfare for the member, a companion, and a medical attendant, if required. If the member qualifies for the Airfare Benefit, Calvo’s SelectCare will only pay or reimburse the member the actual cost or the lowest medical economy rate, whichever is lower. Airfare penalties are excluded from this benefit.

The Plan will only pay charges under this benefit if the proposed services are performed at direct-contracted Network Providers AND if the proposed services meet one of the following Qualifying Conditions / Procedures: Open Heart Surgery, Oncology Surgery, Aneurysmectomy, Pneuctomy, Intra-cranial Surgery, Acute Leukemia, Gamma Knife Surgery,  NICU level III care.

FEHB Members covered by Medicare: Medicare beneficiaries may only receive services at a Plan participating Medicare-contracted facility in Guam, Saipan, Hawaii, and the Continental United States. Medicare eligible care and services which are rendered at a facility which is not a Medicare contracted facility, or which is rendered by a physician who is not a Medicare contracted physician will not be covered. FEHB members with Medicare as their primary payer are only eligible for the Airfare Benefit to direct-contracted Network providers in the Continental United States.

For more information about this benefit, contact Calvo's SelectCare Customer service at (671) 477-9808.

For pre-authorized, elective, in-patient or out-patient 

• Surgical procedures
• High-level specialist consultations (including but not limited to cardiology, gastroenterology, hepatology, hematology, nephrology, neurology, oncology, orthopedic services, pulmonology, etc.)
• High-level radiology diagnostic services (including but not limited to PET scans, MRIs, etc.)

at participating providers in the Philippines and Taiwan, (excluding emergencies, preventive services, home health, hospice or maternity-related services), Calvo's SelectCare offers a travel benefit of up to $500 per member (one travel benefit per member per year) on a reimbursement basis and to be applied toward the cost of round-trip airfare between Guam and Manila, Philippines or between Guam and Taipei, Taiwan, or ground transportation between airport and the hospital or lodging in the Philippines  or Taiwan during the same time period as the procedure / consultation / diagnostic service. This benefit cannot be used in conjunction with the Airfare Benefit. Benefit is limited to one (1) travel benefit per member per year.

Some services may not be eligible for the travel benefit reimbursement.

 In order for the procedure, service or specialist consultation to be prior authorized as a covered benefit and eligible for the travel benefit, the following are required:

• Referrals and medical notes from primary care providers (or specialists, if applicable) to determine medical necessity
• Must meet medical necessity criteria
• Must be a covered benefit and
• Approval request for the procedure/consultation/diagnostic service must be submitted to and approved by Plan prior to departure to the Philippines or Taiwan

Upon return from the Philippines or Taiwan, members must submit to Calvo's SelectCare the following documents for reimbursement:

• Completed Calvo's SelectCare reimbursement form
• Pre-authorization document from the Plan
• Letter of authorization from the Plan's Philippine offices or Guam office , and
• Receipts for airfare or lodging or transportation which clearly detail dates of travel / stay / transfers, amounts paid, and names of persons who made payments

Members are responsible for making their travel arrangements. Members are also responsible for any transportation and lodging expenses in excess of $500 and any penalties/fees incurred due to member changes. Calvo's SelectCare will reimburse members up to the $500 allowance under this travel benefit.

FEHB members covered by Medicare: Medicare beneficiaries may only receive services at a Plan participation Medicare-contracted facility in Guam, Saipan, Hawaii, and the continental United States. Medicare eligible care and services which are rendered at a facility which is not a Medicare contracted facility or which is rendered by a physician who is not a Medicare contracted physician will not be covered. FEHB members with Medicare as their primary payer are not eligible for the Travel Benefit to the Philippines or Taiwan.

A fifty percent (50%) discount is offered for air ambulance transportation services from Guam, the CNMI, and Palau to the Philippines, Japan, Taipei, or Honolulu for certain qualifying medical conditions. Pre-arrangements must be made with the plan and the air ambulance company.

Calvo's SelectCare provides 100% coverage of the cost of gym memberships (subscribers and dependents) only at partner fitness centers in Guam and Saipan . Coverage is limited to benefit year (January to December 2024). Members are limited to enrolling in one partner gym per year.

The Lifestyle Club is a Membership Rewards Program for Calvo's SelectCare FEHB members (subscriber and one adult dependent only). Members enjoy benefits and discounts from participating shopping, dining, gym, gas partners.

Go to www.calvosinsurance.com for more information about the program.

Calvo's SelectCare provides a program that offers members the encouragement and rewards to help members, 18 years old and above, improve or maintain their health. The Plan offers multiple wellness incentives that will allow members to earn up to a maximum  of $75 per member, $150 per self plus one enrollment and $200 for self and family enrollment per benefit year for completing preventive services such as the online health risk assessment, annual physicals, doctor's visits for chronic conditions, breast cancer screening, cervical cancer screening, colorectal cancer screening, and smoking cessation classes.

Incentive amounts will be calculated 60 days after the end of the current policy period and checks will be processed within 30 days after the calculation date. Members must complete a claim reimbursement form and submit to Calvo’s SelectCare along with proper documentation in order to claim benefit. Claims must be submitted to us no later than 90 days after the end of the policy period.

Calvo's SelectCare offers a dental plan to supplement the dental coverage provided in the Calvo's SelectCare FEHB plan option you have selected. Supplemental dental coverage will be coordinated with your FEHB dental coverage. Enrollment in supplemental dental coverage is required every Open Season. This coverage does not automatically renew.

The supplemental dental plan provides coverage as follows:

RESTORATIVE SERVICES, SIMPLE EXTRACTIONS, ENDODONTICS, PERIODONTICS, ORAL SURGERY

20% coinsurance of covered charges

60% coinsurance of Usual, Customary, and Regular (UCR) charges plus and difference between UCR charges and billed charges

PROSTHODONTICS

75% coinsurance of Usual, Customary, and Regular (UCR) charges plus and difference between UCR charges and billed charges

SEDATION

20% coinsurance of covered charges

40% coinsurance of Usual, Customary, and Regular (UCR) charges plus and difference between UCR charges and billed charges

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 671-477-9808 or at our website at www.calvos.net.

When you must file a claim – such as for services you received outside the Plan’s service area and/or from non-participating providers – submit it on the CMS-1500 or a claim form that includes the information shown below. Claims forms, bills and receipts should be itemized, translated in English when originals are in another language and show:

• Covered member’s name 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;
• Medications
• A copy of the explanation of benefits, payments, or denial from any primary payer – such as the Medicare Summary Notice (MSN);
• Receipts, if you paid for your services;
• Medical records

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

Mail your claims to:    Calvo's SelectCare Customer Service, P.O. Box FJ, Hagatna, Guam   96932

Or

Submit your claims at: Calvo's SelectCare Customer Service, 115 Chalan Santo Papa, Hagatna, Guam 96910           

Mail your claims to: Calvo's SelectCare Customer Service, P.O. Box FJ, Hagatna, Guam 96932

Or

Submit your claims at: Calvo's SelectCare Customer Service, 115 Chalan Santo Papa, Hagatna, Guam 96910

Mail your claims to: Calvo's SelectCare Customer Service, P.O. Box FJ, Hagatna, Guam 96932

Or

Submit your claims at: Calvo's SelectCare Customer Service, 115 Chalan Santo Papa, Hagatna, Guam 96910

Send us all of the documents for your claim as soon as possible. You must submit the claim and all required information (translated in English when originals are in another language) 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 submitted as soon as reasonably possible.

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 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 Calvo's SelectCare Customer Service Department, P.O. Box FJ, Hagatna, Guam 96932; 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.

e) Include your email address (optional for member), if you would like to receive our decision via email. Please note that by giving us our email, we may be able to provide our 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 your 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; 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 fo file a disputed claim with OPM. Parties acting as you 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 yrou 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 within 60 days. There are no other administrative appeals.

If you do not agree with OPM's decision, your only recourse is to file a lawsuit. If you decide to sue, 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 have coverage under any other health plan or have 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 payer and the other plan pays a reduced benefit as the secondary payer. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ guidelines. For more information on NAIC rules regarding the coordinating of benefits, visit our website at www.calvos.net.

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

When we are the secondary payer, 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 Program, contact your 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 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 devices. If you are 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 provider will be compensated by OWCP. If your treatment is determined not 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 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 connections 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 judgement, 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 whether you are "made whole" or fully compensated for the full amount of damages claimed.

We may, at our option, choose to exercise our right of subrogation and pursue a 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?" please contact Medicare at 1-800-MEDICARE (1-800-633-4227) 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 payer, we process the claim first.

When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. You will not need to do anything. To find out if you need to do something to file your claim, call us at 671-477-9808 or see our Web site at www.calvos.net.

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

• Medical services and supplies provided by physicians and other healthcare professionals
• Outpatient surgery

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. Members must use providers who accept Medicare's assignment.

Benefit Description: Deductible
You pay without Medicare: $0
You pay with Medicare Part B: $0

Benefit Description: Primary Care Provider
You pay without Medicare: High Option $15 copayment / Standard Option $20 copayment 
You pay with Medicare Part B: $0

Benefit Description: Specialist
You pay without Medicare: High Option $40 copayment / Standard Option $40 copayment 
You pay with Medicare Part B: $0

Benefit Description: Inpatient Hospital 
You pay without Medicare: High Option $200 copayment / Standard Option 20% coinsurance 
You pay with Medicare Part B: High Option $200 copayment / Standard Option 20% coinsurance 

Benefit Description: Outpatient Surgery -Hospital
You pay without Medicare: High Option $100 copayment (includes professional fees) / Standard Option 20% coinsurance 
You pay with Medicare Part B: $0

Benefit Description: RX (30-day supply)
You pay without Medicare: 
High Option: $10 for generic, $25 for preferred brand, 50% of AWP for non-preferred brand, $200 for Specialty
Standard Option: $20 for generic, $40 for preferred brand, $100 for non-preferred brand, $250 for Specialty
You pay with Medicare Part B: 
High Option: $10 for generic, $25 for preferred brand, 50% of AWP for non-preferred brand, $200 for Specialty
Standard Option: $20 for generic, $40 for preferred brand, $100 for non-preferred brand, $250 for Specialty

Benefit Description: RX (90-day supply - one copayment)
You pay without Medicare: 
High Option: $10 for generic, $25 for preferred brand, 50% of AWP for non-preferred brand, $200 for Specialty
Standard Option: $20 for generic, $40 for preferred brand, $100 for non-preferred brand, $250 for Specialty
You pay with Medicare Part B: 
High Option: $10 for generic, $25 for preferred brand, 50% of AWP for non-preferred brand, $200 for Specialty
Standard Option: $20 for generic, $40 for preferred brand, $100 for non-preferred brand, $250 for Specialty

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

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 healthcare choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 1-800-MEDICARE (1-800-633-4227) 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 office 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)

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; or is a drug trial that is exempt from the requirement of an investigational new drug application.

• 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 25.

See Section 4, page 25.

See Section 4, page 25.

Helps you meet your daily living activities. This type of care does not require the continuing attention and assistance of licensed medical or trained paramedical personnel. Custodial care lasting 90 days or more is sometimes known as long term care.

See Section 4, page 25.

Services, supplies, devices, procedures, drugs, or treatment that is not yet accepted as common medical practice.

An insurance plan that provides health care coverage to a select group of people

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

Medical necessity refers to medical services or hospital services which are determined by us to be:

• Rendered for the treatment or diagnosis of an injury or illness; and
• Appropriate for the symptom, consistent with diagnosis, and otherwise in accordance with sufficient scientific evidence and professionally recognized standards; and
• Not furnished primarily for the convenience of the member, the attending physician, or other provider of service; and 
• Furnished in the most economically efficient manner which may be provided safely and effectively to the member.

Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways. We determine our allowance as follows:

The payment we would make if the healthcare services had been obtained within our Service Area and/or by an In-Network provider, or a special negotiated payment or Medicare rates.

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.

Any claims that are not pre-service claims. In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits.

Those claims (1) that require precertification, prior approval, or a referral and (2) where failure to obtain precertification, prior approval, or a referral results in a reduction of benefits.

 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 a 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.

A carrier's pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier's health benefits plan.

Us and We refer to Calvo's SelectCare

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 without the care or treatment that is the subject of the claim.

Urgent care claim usually involve Pre-service claims and not Post-service claims. We will determine whether or not a claim is an urgent care claim by applying the judgement 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 by telephone at 671-477-9808 or by mail at P.O. Box FJ, Hagatna, Guam 96932. 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. 

High Option

In-network: $15 copayment per PCP office visit; $40 copayment per specialist visit

Preferred In-network: $5 copayment per PCP office visit

Standard Option

In-network: $20 copayment per PCP office visit; $40 copayment per specialist visit

 Preferred In-network: $10 copayment per PCP office visit

33

High Option

In-network: $200 copayment per inpatient hospital admission (includes doctors' services)

Standard Option

In-network: 20% coinsurance per inpatient hospital admission

60

High Option

In-network: $100 copayment per outpatient surgical facility (includes doctors' services)

Standard Option

In-network: 20% coinsurance per outpatient surgical facility visit

61

High Option

$100 copayment per emergency room visit (hospital)

Standard Option

20% coinsurance per emergency room visit (hospital)

63

High Option

$200 copayment per emergency room visit (hospital) and any difference between eligible charges and billed charges

Standard Option

20% coinsurance per emergency room visit (hospital) and any difference between eligible charges and billed charges

64

High and Standard Options

Member's cost-sharing responsibilities are no greater than for other illnesses or conditions.

66

High Option

$10 copayment for Generic 

$25 copayment for Preferred Brand 

50% of Average Wholesale Price (AWP) for Non-Preferred Brand 

$100 copayment for Specialty 

Standard Option

$15 copayment for Generic 

$40 copayment for Preferred Brand 

50% of Average Wholesale Price for Non-Preferred

$150 copayment for Specialty 

70

High Option

Nothing for preventive dental care

Standard Option

Nothing for preventive dental care

74

High Option

In-network: $15 copayment per PCP visit, $40 per specialist visit for annual eye exam (includes refraction)

Standard Option

In-network: $20 copayment per PCP visit, $40 per specialist visit for annual eye exam (includes refraction)

46

High and Standard Options
When criteria are met and when approved in advance by Calvo’s SelectCare, the Airfare Benefit covers only the economy round-trip airfare for the member, a medical attendant and a companion, if required. This benefit cannot be used in conjunction with the Travel Benefit.

75

High and Standard Options
Incentives to reward you for completing a Health Risk Assessment (HRA) and other selected health screenings.

77

High and Standard Options
The Plan will reimburse members up to $500 (one time per member per year) for round-trip airfare, ground transportation, or lodging in the Philippines. This benefit covers pre-authorized, elective in-patient or out-patient procedures at participating providers in the Philippines, excluding emergencies, preventive services, home health, hospice, or maternity-related services. This benefit cannot be used in conjunction with Airfare Benefit.

75

High Option

Medical - Nothing after $2,000 for Self Only, $4,000 for Self Plus One, and $6,000 for Self and Family

Prescription Drugs - Nothing after $2,000 for Self Only and $4,000 for Self Plus One and Self and Family

Standard Option

Medical - Nothing after $3,000 for Self Only, $6,000 for Self Plus One, and $8,000 for Self and Family

Prescription Drugs - Nothing after $2,000 for Self Only and $4,000 for Self Plus One and Self and Family 

14