Page numbers referenced within this brochure apply only to the printed brochure

Blue Open Access POS

www.anthem.com
Customer Service 844-423-9988

2022



IMPORTANT:
  • Rates
  • Changes for 2022
  • Summary of Benefits
  • Accreditations
A Health Maintenance Organization with a Point-of-Service

This plan’s health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. See page 7, FEHB Facts for details. This plan is accredited. See page 12 Section 1.  

Serving Central GA, including the following areas:  Athens, Atlanta Metro, Augusta, Columbus and Warner Robins.

Enrollment in this Plan is limited. You must live in our
geographic service area to enroll. See page 13 Section 1 for requirements.

 

Enrollment codes for this Plan: 
    QM1 High Option Self Only 
    QM3 High Option Self Plus One 
    QM2 High Option Self and Family 
  

   

Federal Employees Health Benefits Program seal
OPM Logo








Important Notice

Important Notice from Blue Open Access POS
About
Our Prescription Drug Coverage and Medicare

The Office of Personnel Management (OPM) has determined that the Blue Open Access POS prescription drug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all Plan participants and is considered Creditable Coverage. This means you do not need to enroll in Medicare Part D and pay extra for prescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as long as you keep your FEHB coverage.

However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate benefits with Medicare.

Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program.

Please be advised

If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that is at least as good as Medicare’s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1 percent per month for every month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug coverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the next Annual Coordinated Election Period (October 15 through December 7) to enroll in Medicare Part D.

Medicare’s Low Income Benefits

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA) online at www.socialsecurity.gov, or call the SSA at 800-772-1213, (TTY:  800-325-0778). 

You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places:

  • Visit www.medicare.gov for personalized help.
  • Call 800-MEDICARE 800-633-4227, TTY 877-486-2048.



Table of Contents

(Page numbers solely appear in the printed brochure)




Introduction

This brochure describes the benefits of Blue Open Access POS under contract (CS 2953) between Blue Cross and Blue Shield of Georgia, Inc. and the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law.  Customer service may be reached at 844-423-9988 or through our website: www.anthem.com. This Plan is underwritten by Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. The address for the Blue Open Access POS administrative office is:

Blue Open Access POS
Mail No. GA082E-0007
6087 Technology Pkwy
Midland, GA  31820

This brochure is the official statement of benefits.  No verbal statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One or Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available before January 1, 2022, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each Plan annually. Benefit changes are effective January 1, 2022, and changes are summarized on page 14. Rates are shown at the end of this brochure.




Plain Language

All FEHB brochures are written in plain language to make them easy to understand.  Here are some examples:

  • Except for necessary technical terms, we use common words. For instance, “you” means the enrollee and each covered family member, “we” means Blue Open Access POS.
  • We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States Office of Personnel Management. If we use others, we tell you what they mean.
  • Our brochure and other FEHB plans’ brochures have the same format and similar descriptions to help you compare Plans.



Stop Healthcare Fraud!

Fraud increases the cost of healthcare for everyone and increases your Federal Employees Health Benefits Program premium.

OPM’s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud – Here are some things that you can do to prevent fraud:

  • Do not give your Plan identification (ID) number over the phone or to people you do not know, except for your healthcare providers, authorized health benefits Plan, or OPM representative.
  • Let only the appropriate medical professionals review your medical record or recommend services.
  • Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
  • Carefully review explanations of benefits (EOBs) statements that you receive from us.
  • Periodically review your claim history for accuracy to ensure we have not been billed for services you did not receive.
  • Do not ask your doctor to make false entries on certificates, bills, or records in order to get us to pay for an item or service.
  • If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
    •  Call the provider and ask for an explanation. There may be an error.
    •  If the provider does not resolve the matter, call us at 888-451-1155 and explain the situation.
    •  If we do not resolve the issue:

CALL - THE HEALTHCARE FRAUD HOTLINE
1-877-499-7295
OR go to www.opm.gov/our-inspector-general/hotline-to-report-fraud-waste-or-abuse/complaint-form

The online reporting form is the desired method of reporting fraud in order to ensure accuracy, and a quicker response time.

You can also write to:
United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington, DC 20415-1100

  • Do not maintain as a family member on your policy: 
    • Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise)
    • Your child age 26 or over (unless they are disabled and incapable of self-support prior to age 26). 

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.

  • If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary Continuation of Coverage (TCC).
  • Fraud or intentional misrepresentation of material fact is prohibited under the Plan.  You can be prosecuted for fraud and your agency may take action against you.  Examples of fraud include falsifying a claim to obtain FEHB benefits, trying to or obtaining service or coverage for yourself or for someone else who is not eligible for coverage, or enrolling in the Plan when you are no longer eligible.  
  • 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 by your provider for services received.  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 is no longer eligible to use your health insurance coverage.



Discrimination is Against the Law

The Blue Open Access POS complies with all applicable Federal civil rights laws, including Title VII of the Civil Rights Act of 1964.

You may also file a civil rights complaint with OPM by mail at:  Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, Attention:  Assistant Director, FEIO, 1900 E Street NW, Suite 3400 S, Washington, D.C. 20415-3610




Preventing Medical Mistakes

Medical mistakes continue to be a significant cause of preventable deaths within the United States. While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments. Medical mistakes and their consequences also add significantly to the overall cost of healthcare.  Hospitals and healthcare providers are being held accountable for the quality of care and reduction in medical mistakes by their accrediting bodies.  You can also improve the quality and safety of your own healthcare and that of your family members by learning more about and understanding your risks.   Take these simple steps:

1.  Ask questions if you have doubts or concerns.

  • Ask questions and make sure you understand the answers.
  • Choose a doctor with whom you feel comfortable talking.
  • Take a relative or friend with you to help you take notes, ask questions, and understand answers.

2.  Keep and bring a list of all the medications you take.

  • Bring the actual medication or give your doctor and pharmacist a list of all the medications and dosage that you take, including non-prescription (over-the-counter) medications and nutritional supplements.
  • Tell your doctor and pharmacist about any drug, food, and other allergies you have, such as to latex.
  • Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your doctor or pharmacist says.
  • Make sure your medication is what the doctor ordered. Ask your pharmacist about the medication if it looks different than you expected.
  • Read the label and patient package insert when you get your medication, including all warnings and instructions.
  • Know how to use your medication. Especially note the times and conditions when your medication should and should not be taken.
  • Contact your doctor or pharmacist if you have any questions.
  • Understand both the generic and brand names of your medication. This helps ensure you do not receive double dosing from taking both a generic and a brand. It also helps prevent you from taking a medication to which you are allergic.

3.  Get the results of any test or procedure.

  • Ask when and how you will get the results of tests or procedures. Will it be in person, by phone, mail, through the Plan or Provider’s portal?
  • Don’t assume the results are fine if you do not get them when expected. Contact your healthcare provider and ask for your results. 
  • Ask what the results mean for your care.

4.  Talk to your doctor about which hospital or clinic is best for your health needs.

  • Ask your doctor about which hospital or clinic has the best care and results for your condition if you have more than one hospital or clinic to choose from to get the healthcare you need.
  • Be sure you understand the instructions you get about follow-up care when you leave the hospital or clinic.

5.  Make sure you understand what will happen if you need surgery.

  • Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.
  • Ask your doctor, “Who will manage my care when I am in the hospital?”
  • Ask your surgeon
    •   "Exactly what will you be doing?" 
    •   "About how long will it take?" 
    •   "What will happen after surgery?" 
    •   "How can I expect to feel during recovery?"
  • Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reactions to anesthesia, and any medications or nutritional supplements you are taking.

Patient Safety Links

For more information on patient safety, please visit:

  • www.jointcommission.org/speakup.aspx.  The Joint Commission’s Speak Up™ patient safety program.
  • www.jointcommission.org/topics/patient_safety.aspx. The Joint Commission helps healthcare organizations to improve the quality and safety of the care they deliver. 
  • www.ahrq.gov/patients-consumers/.  The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality healthcare providers and improve the quality of care you receive.
  • www.bemedwise.org.  The National Council on Patient Information and Education is dedicated to improving communication about the safe, appropriate use of medications.
  • www.leapfroggroup.org.  The Leapfrog Group is active in promoting safe practices in hospital care.
  • www.ahqa.org.  The American Health Quality Association represents organizations and healthcare professionals working to improve patient safety.

Preventable Healthcare Acquired Conditions (“Never Events”)

When you enter the hospital for treatment of one medical problem, you do not expect to leave with additional injuries, infections, or other serious conditions that occur during the course of your stay. Although some of these complications may not be avoidable, patients do suffer from injuries or illnesses that could have been prevented if doctors or the hospital had taken proper precautions. Errors in medical care that are clearly identifiable, preventable and serious in their consequences for patients, can indicate a significant problem in the safety and credibility of a healthcare facility. These conditions and errors are sometimes called “Never Events” or “Serious Reportable Events.”

We have a benefit payment policy that encourages hospitals to reduce the likelihood of hospital-acquired conditions such as certain infections, severe bedsores, and fractures, and to reduce medical errors that should never happen. When such an event occurs, neither you nor your FEHB plan will incur costs to correct the medical error. Should an event occur and you were required to make payments to the provider you will be reimbursed for your out-of-pocket costs. The Plan considers Never Events to include 2 categories: major surgical never events or Hospital Acquired Conditions (HAC) as defined by The Centers for Medicare & Medicaid Services (CMS).




FEHB Facts

Coverage information




TermDefinition
  • No pre-existing condition limitation
We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.
  • Minimum essential coverage (MEC)

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.

  • Minimum value standard
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.
  • Where you can get information about enrolling in the FEHB Program

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, and give you brochures for other Plans and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

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

We 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,  disability leave, pensions, etc., 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

  • Types of coverage available for you and your family

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

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. The Self 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 carrier to obtain a Certificate of Creditable Coverage (COCC) or to add a dependent when there is already family Coverage.

Contact your employing or retirement office if you are changing from Self to Self Plus One or Self and Family or to add a newborn if you currently have a Self Only plan.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, nor will we. Please tell us immediately of changes in family member status including your marriage, divorce, annulment, or when your child reaches 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/healthcare-insurance/life-events.  If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

  • Family member coverage 

Family members covered under your Self and Family enrollment are your spouse (including your spouse by 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.

  • Children’s Equity Act

OPM has implemented 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 your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a Plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child. Contact your employing office for further information.

  • When benefits and premiums start

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 2022 benefits of your prior Plan or option.  If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option.  However, if your prior Plan left the FEHB Program at the end of the year, you are covered under that Plan’s 2021 benefits until the effective date of your coverage with your new Plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

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

  • When you retire

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




When you lose benefits




TermDefinition
  • When FEHB coverage ends

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

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

Any person covered under the 31 day extension of coverage who is confined in a hospital or other institution for care or treatment on the 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 of Coverage (TCC) or a conversion policy (a non-FEHB individual policy).

  • Upon divorce

If you are divorced from a Federal employee, or annuitant, you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices. You can also visit OPM’s website at www.opm.gov/healthcare-insurance/healthcare/plan-information/.  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.

  • Temporary Continuation of Coverage (TCC)

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC).  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, etc.

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

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

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a 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.

  • Converting to individual coverage

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

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

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

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, 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 844-423-9988 or visit our website at www.anthem.com.

  • Health Insurance Marketplace

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.




Section 1. How This Plan Works

This Plan is a Health Maintenance Organization (HMO) with a Point of Service (POS). OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. Blue Open Access POS holds the following accreditations: Accredited status with NCQA. To learn more about this plan’s accreditation(s), please visit the following websites: National Committee for Quality Assurance (www.ncqa.org).

We require you to see specific physicians, hospitals, and other providers that contract with us.  Our Plan providers will coordinate your health care services. When you receive services from network providers, you will not have to submit claim forms or pay bills. You pay only the copayments, coinsurance, and deductibles described in this brochure. However, if you use non-network providers you may be responsible for filing claims and may be required to pay for the charges at the time of services.  We are solely responsible for the selection of these providers in your area. Contact us for a copy of our most recent provider directory.

Blue Open Access POS emphasizes preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.

You should join an HMO because you prefer the plan’s benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will be available and/or remain under contract with us.

We have Open Access benefits

Our HMO offers Open Access benefits. This means you can receive covered services from a network provider without a referral.

We have Point of Service (POS) benefits option

Our Plan offers Point-of-Service (POS) benefits. This means you can receive covered services from a non-network provider. However, out-of-network benefits may have higher out-of-pocket-costs than our in-network benefits.

How we pay providers

Network Providers

We negotiate rates with doctors and other health care providers.  We refer to these providers as "Network Providers".  These negotiated rates are our Plan allowances for network providers.  We calculate your coinsurance using these negotiated rates.  You are not responsible for amounts billed by network providers that are greater than our Plan allowance.

Non-Network Providers

Because they do not participate in our networks, non-network providers are paid based on an out-of-network Plan allowance.  You are responsible for the deductible, coinsurance or copayment, as well as the difference between our Plan allowance and the billed charge. 

Your rights and responsibilities

OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, and our providers. OPM’s FEHB website (www.opm.gov/insure) lists the specific types of information that we must make available to you. Some of the required information is listed below.

  • Years in existence
  • Profit status

You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan.  You can view the complete list of these rights and responsibilities by visiting our website, Blue Open Access POS at www.anthem.com.   You can also contact us to request that we mail a copy to you.

If you want more information about us, call 844-423-9988, or write to Blue Open Access POS, Mail Location: GA082E-0007, 6087 Technology Pkwy, Midland, GA 31820.  You will find important information about your member rights and responsibilities, and how we evaluate new technology for covered services at www.anthem.com.  Go to Customer Support, then go to FAQs.  You may also visit our website at www.anthem.com/federal-employees/health-plans-ga/.

By law, you have the right to access your protected health information (PHI).  For more information regarding access to PHI, visit our website at www.anthem.com to obtain our Notice of Privacy Practices. You can also contact us to request that we mail you a copy of that Notice.

Your medical and claims records are confidential

We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.

Service Area

To enroll in this Plan, you must live in our service area.

Our service area covers the following Georgia counties:

Banks, Barrow, Bartow, Bibb, Butts, Carroll, Chattahoochee, Cherokee, Clarke, Clayton, Cobb, Columbia, Coweta, Crawford, Dawson, DeKalb, Douglas, Fayette, Forsyth, Fulton, Gwinnett, Hall, Haralson, Harris, Heard, Henry, Houston, Jackson, Lamar, Madison, McDuffie, Meriwether, Monroe, Muscogee, Newton, Oconee, Oglethorpe, Paulding, Peach, Pickens, Pike, Richmond, Rockdale, Spalding, Talbot, Taliaferro, Troup, Upson, Walton and Wilkes.

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay for emergency care benefits.  We will not pay for any other healthcare services out of our service area unless the services have prior plan approval, see Section 3.

If you or a covered family member move outside our service area, you can enroll in another Plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service Plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change Plans. Contact your employing or retirement office.




Section 2. Changes for 2022

Do not rely only on these change descriptions; this Section is not an official statement of benefits. For that, go to Section 5. Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change benefits.

Program-wide changes

  • Effective in 2022, premium rates are the same for Non-Postal and Postal employees.

Changes to this plan for 2022

  • Your share of the premium rate will increase for Self Only, Self Plus One, and Self and Family.  See Rates-back page.
  • The In-network OOP maximum is $6,000 Self, $10,000 Self Plus One, and $10,000 Self and Family. The Out-of-network OOP maximum is $12,000 Self, $20,000 Self Plus One and $20,000 Self and Family.  See Page 22, Section 4.
  • The inpatient hospital copay will be $500 per day up to a maximum of 3 days ($1,500 per admission). See Page 47, Section 5(c).
  • The outpatient facility copay for surgery will be $350. See Page 48, Section 5(c).
  • Prescription drug cost shares will increase as follows: Retail Pharmacy Level 1 - Tier 2 $70 and Tier 3 $110; Level 2 - Tier 1 $20, Tier 2 $80, and Tier 3 $120; Tier 4 35% of the allowance up to $350 (Level 1 and 2); Mail Order Tier 1 $10, Tier 2 $ 175, and Tier 3 $275. See Page 56, Section 5(f).
  • Hospice care will be available when a terminally ill member’s life expectancy has reached 12 months or less. The member’s doctor must agree to care by the hospice and must be consulted in the development of the treatment plan. See Page 48, Section 5(c).
  • Applied Behavior Analysis (ABA) Therapy for Autism Spectrum Disorder is covered to age twenty. See Page 33, Section 5(a).
  • The Plan will cover nutritional counseling for a diagnosis of obesity/morbid obesity. See Page 37, Section 5(a).
  • Private-Duty Nursing is only covered under home health services as part of a combined 100-day limit, previously this was listed as a separate 82-day benefit. See Page 36, Section 5(a).

Clarification to this plan

  • Genetic testing will be subject to Medical Necessity review by the Plan and approved providers must be used. See Page 17, Other Services in Section 3 for prior authorization procedures.



Section 3. How You Get Care

TermDefinition

Identification cards

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 844-423-9988 or write to us at Blue Open Access POS, Mail Location: GA082E-0007, 6087 Technology Pkwy, Midland, GA 31820. You may also request replacement cards through our website at www.anthem.com/.

Where you get covered care

When you get care from “Plan providers” and “Plan facilities”.  You will only pay your cost-sharing (copayments, coinsurance, deductibles, and non-covered services and supplies), if you use our point-of-service program, you can also get care from non-Plan providers but it will cost you more.  Under the Blue Open Access POS you can receive covered services from a participating provider without a referral. 

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

How to Find a Provider in the Network

There are three ways you can find out if a Provider or Facility is in the network for this Plan. You can also find out where they are located and details about their license or training.

  • See your Plan’s directory of In-Network Providers at www.anthem.com/, which lists the Doctors, Providers, and Facilities that participate in this Plan’s network.
  • Call Customer Service to ask for a list of Doctors and Providers that participate in this Plan’s network, based on specialty and geographic area.
  • Check with your Doctor or Provider.

If you need help choosing a Doctor who is right for you, call the Customer Service number on the back of your Member Identification Card. TTY/TDD services also are available by dialing 711.  A special operator will get in touch with us to help with your needs.

  • Plan Providers

Plan providers are primary care physicians, specialists and other healthcare professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards.

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

This plan recognizes that transsexual, transgender, and gender-nonconforming members require health care delivered by healthcare providers experienced in transgender health. While gender reassignment surgeons (benefit details found in Section 5(b)) and hormone
therapy providers (benefit details found in Section 5(f)) play important roles in preventive care, you should see a primary care provider familiar with your overall health care needs.

Benefits described in this brochure are available to all members meeting medical necessity
guidelines.

  • Plan facilities

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 annually. The list is also on our website.

What you must do to get covered care

This health plan covers care provided by primary care physicians and specialty care providers. To see a primary care physician, simply visit any network physician who is a general or family practitioner, internist or pediatrician. This health plan also covers care provided by any network specialty care provider you choose.  Referrals are not needed to visit any network specialty care provider, including behavioral health.  However, there are certain services that may require prior approval by us; see page 17 Section 3.  Please note that Emergency and Urgent care services do not require prior approval from us.

To make an appointment call your physician’s office:

  • Tell them you are a Blue Open Access POS member.
  • Have your Member ID card handy. They may ask you for your group number, member I.D. number, or office visit copay.
  • Tell them the reason for your visit

When you go for your appointment, bring your Member ID card.

Primary care

Your primary care physician can be a general or family practitioner, internist, or pediatrician.  Your PCP will provide most of your healthcare.

Specialty care

You do not need a referral from your primary care physician. You may self-refer within the network for medically necessary care.

Here are some things you should know about specialty care:

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

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

Hospital care

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

If you are hospitalized when your enrollment begins

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 844-423-9988. 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 92nd day after you become a member of this Plan, whichever happens first.

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

Balanced Billing Protection

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

You need prior Plan approval for certain services

Since your network primary care physician arranges most referrals to specialists and inpatient hospitalization, the pre-service claim approval process only applies to care shown under Other services.

If you choose an out-of-network provider, be sure to call us to see if you need pre-authorization. Providers who are not in the network may not do that for you. If you ever have a question about whether you need pre-authorization, just call the pre-authorization or precertification phone number on your member ID card.

Gender Affirming Services

Gender Reassignment Surgery require prior Plan approval to be covered. For the Plan to consider benefit coverage, you must have met each of the following requirements:

• Be 18 years of age

• Have the capacity to make fully informed decisions and consent for treatment

• Have been diagnosed with gender dysphoria

• Have reasonably controlled medical or mental health issues

• Have two qualified mental health referrals

Along with the requirements above, some surgeries have additional criteria and specifications that include, but are not restricted to the list below:

• Undergone 12 months of continuous hormonal therapy

• Completed at least 12 months of documented successful real-life experience in their new gender

• Participated in psychotherapy during the real-life experience when recommended by treating medical or behavioral practitioner

Gender reassignment surgery is considered not medically necessary when one or more of the criteria has not been met. For details on the medical necessity criteria contact us at 844-423-9988.

Inpatient hospital admission

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.

Other services

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

If you need services and a network provider is not available, we will provide authorization to seek care from a non-network provider.  In this case, the services that are authorized will be treated as in-network services and paid accordingly.

If you seek covered care from non-network providers under Blue Open Access POS, you are ultimately responsible for contacting us to obtain our prior approval before proceeding with the service(s). We call this review and approval process precertification. The following list includes, but is not limited to, services that require precertification:

  • All inpatient admissions (except for a normal delivery)
  • Newborn stays that go beyond the discharge of the mother
  • Office and outpatient physical, occupational and speech therapy
  • Transplants (Human Organ and Bone Marrow/Stem Cell)
  • Diagnostic Imaging such as, but not limited to: Computed Tomography (CT), Computed Tomographic Angiography (CTA), Magnetic Resonance Angiography (MRA), Magnetic Resonance Imaging (MRI), Nuclear Cardiology and Positron Emission Tomography (PET)
  • Certain Cardiovascular services such as, but not limited to: Cardiac Catheterization with Coronary Angiography, Echocardiograms, Arterial Ultrasound and Percutaneous Coronary Intervention (PCI)
  • Certain Radiation Therapy services such as, but not limited to: Intensity Modulated Radiation therapy (IMRT), Proton Beam radiation Therapy, Brachytherapy, Image Guided Radiation Therapy (IGRT) in association with External Beam Radiation Therapy
  • Outpatient Sleep Testing and Therapy services
  • Bariatric Surgery and other treatments for Clinically Severe Obesity
  • Behavioral Health and Substance Use Services for Intensive Outpatient programs (IOP), Partial Hospitalization Programs (PHP), Transcranial Magnetic Stimulation for Depression, and Residential Treatment
  • Prosthetic Devices
  • Powered Devices such as, but not limited to: mobility devices or robotic lower body exoskeleton devices
  • Reconstructive surgery
  • Transgender services
  • Treatment of temporomandibular (TMJ) disease
  • Genetic testing when medically necessary

How to request precertification for an admission or get prior authorization for Other services

First, your physician, your hospital, you, or your representative, must call us at 800-992-5498 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

Non-urgent care claims

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

Urgent care claims

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 an urgent care claim by applying the judgment 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 information.  We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.

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

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 844-423-9988. You may also call OPM’s FEHB 2 at 202-606-3818 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 844-423-9988. 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).

Concurrent care claims

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.

Emergency inpatient admission

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 phone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital.

Maternity care

For childbirth admissions, precertification is not required.  If there is a complication and/or the mother and baby are not discharged at the same time, precertification for an extended stay or for additional services is required.

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.

If your treatment needs to be extended

If you need 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.

The Federal Flexible Spending Account Program- FSAFEDS

  • HealthCare FSA (HCFSA)–Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you and your tax dependents, including 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.

What happens when you do not follow the precertification rules when using non-network facilities

If you use a non-network facility without prior approval or precertification, you may be financially responsible for the charges. You should always make sure that we have been contacted to perform precertification for non-network services.

Circumstances beyond our control Under certain extraordinary 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 disagree with our pre-service claim decision

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 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.

To reconsider a non-urgent care claim

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

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

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

2. Ask you or your provider for more information.

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

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

3. Write to you and maintain our denial.

To reconsider an urgent care claim

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

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 phone, electronic mail, facsimile, or other expeditious methods.

To file an appeal with OPM

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.




Section 4. Your Costs for Covered Services

This is what you will pay out-of-pocket for covered care.



TermDefinition
Cost-sharing

Cost-sharing is the general term used to refer to your out-of-pocket costs (i.e., deductible, coinsurance, and copayments) for the covered care you receive.

Copayments

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

Example:

  • When you see a Blue Open Acccess POS network primary care physician you pay a copayment of $20 per office visit.

Deductible

A deductible is a fixed expense you must incur for covered services and supplies under the Blue Open Access POS benefits before we start paying for covered services from out of network providers.

Under the Blue Open Access POS Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $2,000. Under a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $4,000. Under a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $6,000.

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

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

Coinsurance

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

Example: 

  • Under the Blue Open Access POS benefits, you pay 30% of our allowance for covered non-network services.

Differences between our Plan allowance and the bill

When you receive covered services from non-network providers, you are responsible for the difference between the actual charge and the Plan's maximum allowable amount.  See Section 5(i) Point of Service Benefits for more details.

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.

Your catastrophic protection out-of-pocket maximum

For covered network services - after your network copayments and coinsurance totals $6,000 for Self Only or $10,000 for Self Plus One, or $10,000 for Self and Family enrollment for medical services in any calendar year, you do not have to pay any more for covered medical services.

For covered non-network services - after your deductible and coinsurance totals $12,000 for Self Only or $20,000 for Self Plus One, or $20,000 for Self and Family enrollment, you do not have to pay any further deductible and/or coinsurance for covered medical services. However, you may be responsible for the difference between the actual charge and the Plan's maximum allowable amount.

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

Carryover

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.

When Government facilities bill us

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

Important Notice About Surprise Billing - Know Your Rights

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” under certain circumstances. A surprise bill is an unexpected bill you receive from a nonparticipating health care provider, facility, or air ambulance service for healthcare. Surprise bills can happen when you receive emergency care – when you have little or no say in the facility or provider from whom you receive care. They can also happen when you receive non-emergency services at participating facilities, but you receive some care from nonparticipating providers.

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 unexpected bills. 

In addition, your health plan adopts and complies with the surprise billing laws of the State of Georgia.

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.anthem.com or contact the health plan at 844-423-9988.

Plans: Per section 2799A-5(c) of the PHS Act, section 9820(c) of the Internal Revenue Code, section 720(c) of the Employee Retirement Income Security Act -

Provide a link to plan website with information in plain language on:

(1) the restrictions on balance billing in certain circumstances,

(2) any applicable state law protections against balance billing,

(3) the requirements described under Code section 9816, ERISA section 716, and PHS Act section 2799A-1, and

(4) information on contacting appropriate state and federal agencies in the case that an individual believes that a provider or facility has violated the restrictions against balance billing.




Section 5. High Option Benefits

See page 14 Section 2 for how our benefits changed this year. Pages 84 and 85 contain our benefits summary. Make sure that you review the benefits that are available to you.




(Page numbers solely appear in the printed brochure)




Section 5. Benefits Overview

This Plan offers a High Option. The benefit package is described in Section 5. Make sure that you review the benefits that are available.

Section 5 is divided into subsections. Please read Important things you should keep in mind at the beginning of the subsections. Also read the general exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about our benefits, contact us at 844-423-9988 or on our website at www.anthem.com.

When you seek care from within our network, we offer the following features:

  • No referrals needed for care from network providers
  • No deductible
  • In-Network Out-of-pocket maximums of $6,000 for Self Only or $10,000 for Self Plus One, or $10,000 for Self and Family
  • No office visit copay for covered preventive care services
  • $20 primary care office visit copay for non-preventive care
  • $40 specialty care office visit copay
  • $500 copay per day for a maximum of 3 days per inpatient admission
  • $350 outpatient facility copay for surgery
  • $200 copay per visit to the emergency room
  • Retail pharmacy (30-day supply) Level 1 copays of $5 for Tier 1, $70 for Tier 2, or $110 for Tier 3
  • Retail pharmacy (30-day supply) Level 2 copays of $15 for Tier 1, $80 for Tier 2, or $120 for Tier 3
  • Mail order (90-day supply) copays of $20 for Tier 1, $175 for Tier 2, or $275 for Tier 3
  • Tier 4 drugs are 35% of our allowance up to a maximum out-of-pocket of $350 per prescription for a 30-day supply

When you seek care from non-network providers, we offer the following features:

  • Freedom of choice when accessing covered care from non-network providers
  • After the annual deductible of $2,000 for Self Only, $2,000 per person for Self Plus One or $6,000 for Self and Family you pay 30% coinsurance for covered services
  • When your out-of-pocket expenses for covered non-network services add up to $12,000 for Self Only, $20,000 for Self Plus One or $20,000 for Self and Family, we eliminate the 30% coinsurance for covered services.



Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • In order for network benefits to apply, Plan physicians must provide or arrange your care within the network.
  • There is a calendar year deductible for covered out-of-network services. The deductible is $2,000 for Self Only, $2,000 per person for Self Plus One and $6,000 for Self and Family enrollment.
  • The facility copayment or coinsurance will apply to services that appear in this section but are performed in an ambulatory surgical center or the outpatient department of a hospital. 
  • The services listed below are for the charges billed by a physician or other health care professional for your surgical care. See Section 5(c) for charges associated with the a facility (i.e., hospital or other outpatient facility, etc.).
  • Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost-sharing works. Also, read Section 9 Coordinating Benefits with Medicare and Other Coverage.



Benefit Description : Diagnostic and treatment servicesHigh Option (You pay )

Professional services of physicians

  • In physician’s office
  • Office medical consultations
  • Second surgical opinion

Network:  $20 per office visit to your PCP or $40 per office visit to a Specialist

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

  • Injectable or infused medications given by the doctor in the office

Note: This does not include immunizations prescribed by your primary care physician nor allergy injections.

Network: 20% of our allowance

POS Non-Network: After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

  • Retail Health clinic 

Network: $20 PCP office visit

POS Non-Network: After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

 Professional services of physicians

  • During a hospital stay
  • In a skilled nursing facility

Network:  Nothing

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

  • In an urgent care center
$40 per visit
At home

Network:  $20 per visit by your PCP or $40 per visit by a Specialist

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Benefit Description : TelehealthHigh Option (You pay )

Online clinic visit

Note: Online clinic visits include visits with your physician or with a provider through LiveHealth Online.  To get started visit the website at www.livehealthonline.com.

$20 per visit

Benefit Description : Lab, X-ray and other diagnostic testsHigh Option (You pay )

Laboratory tests, such as:

  • Blood tests
  • Urinalysis
  • Non-routine pap tests
  • Pathology
  • Genetic testing when medically necessary

Note: Genetic testing will be subject to Medical Necessity review by the Plan, and approved providers must be used. Refer to Other Services in Section 3 for prior authorization procedures.

Diagnostic tests, such as:

  • X-rays
  • Non-routine mammograms
  • Ultrasound/Sonogram – one routine ultrasound/sonogram for a normal pregnancy
  • Electrocardiogram and EEG

Network:  Nothing

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

  •  CT Scans (including CTA), MRI, MRA, PET, MRS, nuclear cardiology imaging studies and non-maternity related ultrasounds

Note: Prior approval is required. See Section 3.

Network:  20% of our allowance per test

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Benefit Description : Preventive care, adultHigh Option (You pay )

Routine physical every year.  The following preventive services are covered at the time interval recommended at each of the links below:

  • Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, 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
  • Individual counseling on prevention and reducing health risks
  • Well woman care 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 Well Women preventive care services please visit the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/
  • To build your personalized list of preventive services go to https://health.gov/myhealthfinder

Network:  Nothing

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

  • Routine mammogram

Network:  Nothing

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

  • Adult immunizations 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.

Network:  Nothing 

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

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
Benefit Description : Preventive care, childrenHigh Option (You pay )

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, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html
  • You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org
  • To build your personalized list of preventive services go to https://health.gov/myhealthfinder

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.

Network:  Nothing

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

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
Benefit Description : Maternity careHigh Option (You pay )

Complete maternity (obstetrical) care, such as:

  • Prenatal care
  • Screening for gestational diabetes for pregnant women
  • Delivery
  • Postnatal care

Network: $20 per visit (office visit copay applies to the first prenatal visit)

Non-Network: After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

 

Breastfeeding support, supplies and counseling for each birth

Note: Here are some things to keep in mind:

  • You do not need to precertify your vaginal delivery; see page 20 Section 3 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. Surgical benefits, not maternity benefits, apply to circumcision.
  • We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
  • Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

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

Nothing
Benefit Description : Family planning High Option (You pay )
Contraceptive counselingNothing

A range of voluntary family planning services, limited to:

  • Voluntary sterilization (See Surgical procedures Section 5(b))
  • Surgically implanted contraceptives
  • Injectable contraceptive drugs and patches
  • Intrauterine devices (IUDs)
  • Diaphragms

Note: We cover oral contraceptives under Section 5(f) Prescription Drug Benefits.

Network:  Nothing for family planning services, otherwise $20 per office visit to your PCP or $40 per office visit to a Specialist

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Not covered:

  • Reversal of voluntary surgical sterilization
All charges
Benefit Description : Infertility servicesHigh Option (You pay )
  • Services limited to:
    • Intravaginal insemination (IVI)
    • Intracervical insemination (ICI)
    • Intrauterine insemination (IUI)

Network:  Nothing for infertility services, otherwise $20 per office visit to your PCP or $40 per office visit to a Specialist

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Not covered:

  • Treatment for infertility following voluntary sterilization (unless due to chemotherapy or radiation treatment)
  • Costs associated with cryo-preservation, collection and storage of sperm, eggs and Embryos; provided however, subsequent procedures of a medical nature necessary to make use of the cryo-preserved substance will not be similarly excluded if deemed non-experimental and non- investigational
  • Non-medical costs of an egg or sperm Donor
  • Infertility treatments rendered to dependents under the age of 18
  • Fertility drugs
  • Any treatment not specified as covered
All charges
Benefit Description : Allergy careHigh Option (You pay )
  • Testing and treatment

Network:  $20 per office visit to your PCP or $40 per office visit to a Specialist and 20% of our allowance for testing and treatment

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

  • Allergy injections

Network:  $5 per visit

Note:  The $20 PCP office visit or $40 Specialist office visit copay applies if other services are rendered during your visit to a network provider.

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

  • Allergy serum

Network:  Nothing

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Not covered:

  • Provocative food testing
  • Sublingual allergy desensitization
All charges
Benefit Description : Treatment therapiesHigh Option (You pay )
  • Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Section 5(b). Organ/Tissue Transplants on pages 41-45.

Network:  $20 per office visit to your PCP or $40 per office visit to a Specialist plus 20% of our allowance

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

  • Respiratory and inhalation therapy
  • Cardiac rehabilitation following qualifying event/condition is provided for up to 36 visits when rendered as physician home visits and office services or outpatient services, unless additional visits are approved by us in advance. 
  • Dialysis – hemodialysis and peritoneal dialysis

Network:  $20 per PCP visit or $40 per Specialist visit or $40 per outpatient facility visit

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

  • Intravenous (IV)/Infusion Therapy performed in a physician’s office

Network:  $20 per PCP visit or $40 per Specialist visit and 20% of our allowance

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

  • Applied Behavior Analysis (ABA) Therapy for Autism Spectrum Disorder to age twenty.

Note: Applied Behavior Analysis (ABA) Therapy is limited to services for members to age twenty.

Network:  $20 per office visit to your PCP or $40 per office visit to a Specialist

POS Non-Network: After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Not covered:

  • Therapy that is not listed as covered in this booklet. For example, massage therapy or exercise conditioning.
All charges
Benefit Description : Physical, occupational and speech therapiesHigh Option (You pay )

20 visits of rehabilitative and habilitative physical, occupational and speech therapy per calendar year by: 

  • Occupational therapists
  • Speech therapists
  • Physical therapists (including licensed Athletic Trainers)

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:  See Section 3, Other services for prior authorization requirements.

Network: $20 per visit to your PCP or $40 per visit to a Specialist or $40 per outpatient facility visit

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

  • Pulmonary rehabilitation - 20 visits when rendered as physician home visits and office services or outpatient services, unless additional visits are approved by us in advance. 

Network: $20 per office visit to your PCP or $40 per office visit to a Specialist or $40 per outpatient facility visit 

POS Non-Network: After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Not covered:

  • Long-term rehabilitative therapy
  • Exercise programs
All charges
Benefit Description : Hearing services (testing, treatment, and supplies)High Option (You pay )
  • Routine hearing screening
  • Newborn hearing screenings, re-screenings, audiology assessment and follow-up

Network:  Nothing for screenings, otherwise $20 per visit to your PCP or $40 per visit to a Specialist

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Not covered:

  • Hearing aids, testing and examinations for them
All charges
Benefit Description : Vision services (testing, treatment, and supplies)High Option (You pay )
  • Routine eye exam or refraction (one per calendar year)

$20 per visit to your PCP or $40 per visit to a Specialist

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between your payment and the billed charge.

Medical and surgical treatment of injuries and/or diseases affecting the eye

Network:  $20 per office visit to your PCP or $40 per office visit to a Specialist

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

The first pair of eyeglasses, including frames, or contact lenses are covered when they replace the function of the human lens for conditions caused by cataract surgery or injury

Network:  $20 per office visit to your PCP or $40 per office visit to a Specialist plus 20% for first pair of lenses

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Not covered:

  • Eye exercises and vision training
  • Radial keratotomy and other refractive surgery
  • Photo-Refractive keratectomy (PRK) 
All charges
Benefit Description : Foot careHigh Option (You pay )

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

Note: See Orthopedic and prosthetic devices for information on podiatric shoe inserts

Network:  $20 per office visit to your PCP or $40 per office visit to a Specialist

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Not covered:

  • 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)
All charges
Benefit Description : Orthopedic and prosthetic devices High Option (You pay )

Covered services may include, but are not limited to:

  • Artificial limbs and accessories
  • One pair of glasses or contact lenses used after surgical removal of the lens(es) of the eyes
  • Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
  • Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
  • Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy.

Note: Benefits include purchase, fitting, adjustments, repairs and replacements.

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.

Network:  $20 per office visit to your PCP or $40 per office visit to a Specialist plus 20% of our allowance.

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

  • One wig, when necessitated by hair loss due to cancer treatment

Network:  Nothing

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Not covered:

  • Orthopedic shoes (except therapeutic shoes for diabetes)
  • Heel pads and heel cups
  • Foot support devices, such as arch supports and corrective shoes unless they are an integral part of a leg brace
  • Orthotic devices used primarily for convenience, comfort or for participation in athletics
All charges
Benefit Description : Durable medical equipment (DME)High Option (You pay )

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include but are not limited to:

  • Oxygen
  • Hospital beds
  • Wheelchairs
  • Crutches, walkers
  • Blood glucose monitors
  • Medical supplies, such as surgical dressings and colostomy bags and casting supplies

Note: Rental cost must not be more than purchase price.  Call us at 844-423-9988 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.

Network:  $20 per office visit to your PCP or $40 per office visit to a Specialist plus 20% of our allowance.

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Not covered: 

  • Replacement or repair of purchased or rental equipment because of misuse, abuse, or loss/theft
  • Surgical supports, corsets, or articles of clothing unless needed to recover from surgery or injury
  • Enhancements to standard equipment and devices that are not medically necessary
  • Supplies, equipment and appliances that include comfort, luxury, or convenience items
  • Disposable supplies for use in the home such as bandages, antiseptics and dressings
  • Consumer wearable/personal mobile devices (such as a smart phone, smart watch, or other personal tracking devices), including any software or applications.

All charges

 

Benefit Description : Home health servicesHigh Option (You pay )

Up to 100 visits combined per calendar year including but not limited to:

  • Intermittent Skilled Nursing Services (by an R.N. or L.P.N.)
  • Private-Duty Nursing
  • Medical/Social Services
  • Diagnostic Services
  • Nutritional Guidance
  • Home Health Aide Services - The Member must be receiving skilled nursing or therapy. Services must be furnished by appropriately trained personnel employed by the Home Health Care Provider. Other organizations may provide services only when approved by us, and their duties must be assigned and supervised by a professional nurse on the staff of the Home Healthcare Provider.
  • Therapy Services
  • Medical/Surgical Supplies
  • Durable Medical Equipment

Note: To be eligible for benefits, you must essentially be confined to the home, as an alternative to a hospital stay, and be physically unable to get needed medical services on an outpatient basis. Services must be prescribed by a doctor and the services must be so inherently complex that they can be safely and effectively performed only by qualified, technical, or professional health staff.

Note: In-home intensive behavioral health visits are covered if available in your area. See Section 5(e).

Network:  Nothing

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Not covered:

  • Food, housing, homemaker services and home delivered meals
  • Services provided by Registered Nurses and other health workers who are not acting as employees or under approved arrangements with a contracting Home Health Care Provider
  • Manipulation therapy
All charges
Benefit Description : Chiropractic High Option (You pay )

Up to 26 visits per calendar year, through American Specialty Health Providers, including:

  • Diagnostic testing
  • Manipulations
  • Treatment

Network:  $20 per office visit to your PCP or $40 per office visit to a Specialist

POS Non-Network: After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Not covered:

  • Maintenance therapy
  • Nutritional or dietary supplements, including vitamins
  • Cervical pillows
  • Spinal decompressions devices such as: Vertebral Axial Decompression (Vax-D) and DRX9000
All charges
Benefit Description : Alternative treatmentsHigh Option (You pay )

No benefit. 

All charges
Benefit Description : Educational classes and programsHigh Option (You pay )
  • Tobacco cessation programs include:
    • individual, group, and phone counseling
    • coverage for physician prescribed over-the-counter (OTC) and prescription drugs approved by the FDA to treat nicotine dependence

Note: See Section 5(f) Prescription Drug Benefits for information on physician prescribed OTC and prescription drugs approved by the FDA to treat tobacco dependence. See Section 5(e) for information on individual and group psychotherapy.

Nothing
  • Nutritional counseling for treatment of obesity
  • Diabetes

Note: Diabetes self management training is covered for an individual with insulin dependent diabetes, noninsulin dependent diabetes, or elevated blood glucose levels induced by pregnancy or another medical condition.

Network:  $20 per office visit to your PCP or $40 per office visit to a Specialist

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

  • Applied Behavior Analysis (ABA) Therapy for Autism Spectrum Disorder through age six

Note: Applied Behavior Analysis (ABA) Therapy is limited to services for members through age six.

Network: $20 per visit to your PCP or $40 per visit to a Specialist

POS Non-Network: After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Not covered:

  • Any educational service not listed above as covered
All charges



Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Plan physicians must provide or arrange your care within the network.
  • There is a calendar year deductible for covered out-of-network services. The deductible is $2,000 for Self Only, $2,000 per person for Self Plus One and $6,000 for Self and Family enrollment.
  • Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost-sharing works. Also, read Section 9 Coordinating Benefits with Medicare and Other Coverage.
  • The services listed below are for the charges billed by a physician or other healthcare professional for your surgical care. See Section 5(c) for charges associated with a facility (i.e. hospital, surgical center, etc.).
  • YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.



Benefit Description : Surgical proceduresHigh Option (You pay )

A comprehensive range of services, such as:

  • Operative and cutting procedures
  • Treatment of fractures and dislocations, including casting
  • Normal pre- and post-operative care by the surgeon
  • Endoscopy procedures
  • Correction of congenital anomalies (see Reconstructive surgery)
  • Insertion of internal prosthetic devices. See 5(a) – Orthopedic and prosthetic devices for device coverage information 

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.

Network:  Nothing

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

  • Surgical treatment of morbid obesity (bariatric surgery)

Network:  Nothing

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Not covered:

  • Reversal of voluntary sterilization
  • Routine treatment of conditions of the foot; see Foot care
All charges
Benefit Description : Reconstructive surgery High Option (You pay )
  • Surgery performed to correct significant deformities caused by congenital or developmental abnormalities, illness, injury, or an earlier treatment in order to create a more normal appearance.
  • All stages of breast reconstruction surgery following a mastectomy, such as:
    • Surgery to produce a symmetrical appearance of breasts;
    • Treatment of any physical complications, such as lymphedemas;
    • Breast prostheses and surgical bras and replacements (see Prosthetic devices).

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

Note: Prior authorization is required. See Section 3. How You Get Care, for more information.

Network:  Nothing

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Gender reassignment surgeries consisting of any combination of the following:

  • hysterectomy, salpingo-oophorectomy; ovariectomy, orchiectomy, metoidioplasty, phalloplasty, vaginoplasty, penectomy, clitoroplasty, labiaplasty, vaginectomy, scrotoplasty, urethroplasty, placement of testicular prostheses or bilateral mastectomy. 

Note: Prior authorization is required. See Section 3. How You Get Care, for more information.

Network: Nothing
POS Non-Network: After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

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.
  • Enhancements related to gender reassignment, including:
    abdominoplasty, blepharoplasty, breast augmentation, brow lift, calf implants, electrolysis, face lift, facial bone reconstruction, facial implants, gluteal augmentation, jaw reduction (jaw contouring), lip reduction/enhancement, lipofilling/collagen injections, liposuction, nose implants, pectoral implants, rhinoplasty, thyroid cartilage reduction (chondroplasty), voice modification surgery, or voice therapy
  • Reversal of voluntary sterilization

All charges

Benefit Description : Oral and maxillofacial surgery High Option (You pay )

Oral surgical procedures include:

  • Orthognathic surgery for a physical abnormality that prevents normal function of the upper and/or lower jaw and is Medically Necessary to attain functional capacity of the affected part.
  • Oral/surgical correction of accidental injuries.
  • Treatment of non-dental lesions, such as removal of tumors and biopsies.
  • Incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses.
  • Surgical correction of anatomical abnormalities for treatment of temporomandibular (TMJ) disease when approved in advance.
  • Other surgical procedures that do not involve the teeth or their supporting structures.

Note: We will cover general anesthesia in conjunction with covered oral surgical procedures only for patients as indicated below:

  • Member is under the age of 7;
  • Member has a chronic disability that is attributable to a mental and/ or physical impairment which results in substantial functional limitation in an area of the Member’s major life activity, and the disability is likely to continue indefinitely; or
  • Member has a medical condition that requires hospitalization or general anesthesia for dental care.

Network:  Nothing

POS Non-network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Not covered:

  • Oral implants and transplants
  • Extraction of teeth, surgery for impacted teeth and other oral surgeries to treat the teeth or bones and gums directly supporting the teeth, except as otherwise listed
All charges
Benefit Description : Organ/tissue transplantsHigh Option (You pay )

These solid organ transplants are covered. Solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. See Other services under You need prior Plan approval for certain services on page 17. Solid organ transplants are limited to:

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

Network:  Nothing

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Blood or Marrow Stem Cell Transplants: 

Allogeneic transplants for:

  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin's lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic leukemia (CLL/SLL)
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e., Fanconi's, PNH, Pure Red Cell Aplasia)
  • Myelodysplasia/Myelodysplastic Syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell
  • X-linked lymphoproliferative syndrome

Autologous transplant for:

  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Amyloidosis
  • Advanced Hodgkin's lymphoma relapsed or refractory
  • Advanced Non-Hodgkin's lymphoma relapsed or refractory
  • Breast Cancer
  • Epithelial ovarian cancer
  • Neuroblastoma

Network:  Nothing

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Mini-transplants performed in a Clinical Trial Setting as shown below (non-myeloablative, reduced intensity conditioning) for members with a diagnosis listed below: Subject to Medical Necessity.

  • Allogeneic transplants for:
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Acute myeloid leukemia
    • Chronic lymphocytic leukemia/small lymphocytic leukemia (CLL/SLL)
    • Hemoglobinopathy
    • Hodgkin’s lymphoma – relapsed
    • Marrow Failure and Related Disorders (i.e., Fanconi’s, PNH, Pure Red Cell Aplasia)
    • Myelodysplasia/Myelodysplastic Syndromes
    • Myeloproliferative Disorders (MPDs)
    • Non-Hodgkin’s lymphoma – relapsed
    • Paroxysmal Nocturnal Hemoglobinuria
    • Severe combined immunodeficiency
    • Severe or very severe aplastic anemia
  • Autologous transplants for:
    • Amyloidosis
    • Hodgkin's lymphoma – relapsed
    • Neuroblastoma
    • Non-Hodgkin's lymphoma – relapsed

Network:  Nothing

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Tandem transplants for covered transplants: subject to medical necessity review by the Plan

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

Network:  Nothing

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Blood or Marrow Stem Cell Transplants: Not subject to medical necessity:

Allogeneic transplant for:

  • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)

Autologous transplants for:

  • Multiple myeloma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

Network: Nothing

POS Non-Network: After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Blood or Marrow Stem Cell Transplants: Not subject to Medical Necessity.

Autologous transplants for:

  • Advanced childhood kidney cancers
  • Advanced Ewing sarcoma
  • Aggressive non-Hodgkin’s lymphomas (Mantle Cell lymphoma, adult T-cell leukemia/lymphoma, peripheral T-cell lymphomas and aggressive Dendritic Cell neoplasms)
  • Breast cancer
  • Childhood rhabdomyosarcoma
  • Epithelial ovarian cancer
  • Mantle Cell (Non-Hodgkin lymphoma)

Network:  Nothing

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Blood or Marrow Stem Cell Transplants under clinical trials.

Allogeneic transplants for:

  • Beta Thalassemia Major 
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma  
  • Multiple myeloma (after a previous autologous stem cell transplant or due to primary graft failure, failure to engraft or rejection)
  • Multiple sclerosis*
  • Sickle cell

*Procedure requires review for medical necessity and benefit determination by an external medical director.

 Non-myeloablative allogeneic transplants for:

  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin's lymphoma
  • Advanced Non-Hodgkin's lymphoma - relapsed or refractory
  • Chronic lymphocytic leukemia
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL) relapsed/refractory disease
  • Myelodysplasia/Myelodysplastic Syndromes
  • Chronic myelogenous leukemia
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma (after a previous autologous stem cell transplant or due to primary graft failure, failure to engraft or rejection) 
  • Multiple sclerosis*
  • Myeloproliferative Disorders
  • Myeloproliferative/Myelodysplastic Syndromes
  • Sickle Cell disease

*Procedure requires review for medical necessity and benefit determination by an external medical director.

Autologous transplants for the following autoimmune diseases*:

  • Multiple sclerosis
  • Scleroderma
  • Scleroderma-SSc (severe, progressive)
  • Systemic lupus erythematosus
  • Systemic sclerosis

*Procedures require review for medical necessity and benefit determination by an external medical director.

Autologous transplants for*:

  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL) (after allogeneic transplant)
  • Chronic myelogenous Leukemia (after allogeneic transplant)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma (after allogeneic transplant)

*Procedures require review for medical necessity and benefit determination by an external medical director.

Network:  Nothing

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Blood or Marrow Stem Cell Transplants

Allogeneic transplants for: 

  • Infantile malignant osteopetrosis
  • Kostmann’s syndrome
  • Leukocyte adhesion deficiencies
  • Mucolipidosis (e.g., Gaucher's disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  • Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler's syndrome, Sanfilippo’s syndrome, Maroteaux-Lamy syndrome variants)
  • Myeloproliferative disorders
  • Sickle cell
  • X-linked lymphoproliferative syndrome

Autologous transplants for:

  • Ependymoblastoma
  • Ewing’s sarcoma
  • Medulloblastoma
  • Pineoblastoma
  • Waldenstrom’s macroglobulinemia

All care for transplants must be coordinated through Blue Open Access POS’s transplant department.

Transportation and lodging, covered, as approved by us, up to a $10,000 benefit limit per transplant. Benefits are based upon current limits set forth in the Internal Revenue Code. This must be approved in advance by us.

Network: Nothing

POS Non-Network: After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Donor testing for up to four bone marrow transplant donors from individuals unrelated to the patient in addition to testing of family members per year.

Network:   Nothing

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Not covered:

  • Implants of artificial organs
  • Transplants not listed as covered 
  • Donor screening tests and donor search expenses, except as shown above
All charges
Benefit Description : AnesthesiaHigh Option (You pay )

Professional services provided in:

  • Hospital (inpatient)
  • Hospital outpatient department 
  • Skilled nursing facility
  • Ambulatory surgical center

Network:  Nothing

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

  • Office

Note: We will cover general anesthesia in conjunction with covered oral surgical procedures only for patients as indicated below:

  • Member is under the age of 7;
  • Member has a chronic disability that is attributable to a mental and/ or physical impairment which results in substantial functional limitation in an area of the member’s major life activity, and the disability is likely to continue indefinitely; or
  • Member has a medical condition that requires hospitalization or general anesthesia for dental care.

The general anesthesia must be provided in a hospital, freestanding surgery center or dentist’s office. The dental procedures themselves are not covered.

Network:  $20 per office visit to your PCP or $40 per office visit to a Specialist

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge




Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Plan physicians must arrange your care
  • There is a calendar year deductible for covered out-of-network services. The deductible is $2,000 for Self Only, $2,000 per person for Self Plus One and $6,000 for Self and Family enrollment.
  • Be sure to read Section 4, Your Costs for Covered Services for valuable information about how cost- sharing works. Also, read Section 9 Coordinating Benefits with Medicare and Other Coverage.
  • The amounts listed below are for the charges billed by the facility. Any costs associated with the professional services (i.e., physician, anesthesiologist, etc.) are in Sections 5(a) or (b).
  • YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification. 

 




Benefit Description : Inpatient hospitalHigh Option (You pay)

Covered services include acute care in a hospital setting.

Benefits for room, board and nursing services include:

  • A room with two or more beds
  • A private room. The private room allowance is the hospital’s average semi-private room rate unless it is medically necessary that you use a private room for isolation and no isolation facilities are available.
  • A room in a special care unit approved by us. The unit must have facilities, equipment and supportive services for intensive care of critically ill patients.
  • Routine nursery care for newborns during the mother’s normal hospital stay.
  • General nursing care
  • Meals and special diets

Network: $500 copay per day for a maximum of 3 days per inpatient admission

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

 

Other hospital services and supplies, such as:

  • Operating, childbirth, and treatment rooms and equipment
  • Prescribed drugs
  • Anesthesia, anesthesia supplies and services given by the hospital or other provider
  • Medical and surgical dressings, supplies, casts and splints
  • Diagnostic services
  • Therapy services, including infusion therapy services

Nothing

POS Non-Network: After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Not covered:

  • Custodial care
  • Non-covered facilities, such as schools
  • Personal comfort items, such as phone, television, barber services, guest meals and beds
  • Private-Duty nursing care
All charges
Benefit Description : Outpatient hospital or ambulatory surgical centerHigh Option (You pay)
  • Surgical rooms and equipment
  • Prescribed drugs including specialty drugs
  • Diagnostic services
  • Medical and surgical dressings and supplies, casts, and splints
  • Anesthesia and anesthesia supplies and services given by the hospital or other facility

Network: $350 Facility charge copay

Note: This copay only applies when a surgical procedure is performed.

POS Non-Network: After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Other non-surgical care    

Network: 20% of our allowance

POS Non-Network: After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge.
  • CT Scans (including CTA), MRI, MRA, PET, MRS, nuclear cardiology imaging studies and non-maternity related ultrasounds

Note: Prior approval is required. See Section 3.

Note: Central supply (IV tubing) and pharmacy (dye) necessary to perform tests are covered as part of the test.

Network:  20% of our allowance per test

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Benefit Description : Extended care benefits/Skilled nursing care facility benefitsHigh Option (You pay)

Extended care/skilled nursing facility benefits - Up to 60 days per calendar year when full-time skilled nursing care and/or confinement in a skilled nursing facility is medically necessary.

Network: $500 copay per day for a maximum of 3 days 

POS Non-Network: After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Not covered:

  • Custodial care, domiciliary or convalescent care
  • Private-Duty nursing care
All charges
Benefit Description : Hospice careHigh Option (You pay)

When a terminally ill member’s life expectancy has reached 12 months or less. Your Doctor must agree to care by the Hospice and must be consulted in the development of the treatment plan. The Hospice must keep a written care plan on file and give it to us upon request. Covered services include:

  • Care from an interdisciplinary team with the development and maintenance of an appropriate plan of care
  • Short-term Inpatient Hospital care when needed in periods of crisis or as respite care
  • Skilled nursing services, home health aide services, and homemaker services given by or under the supervision of a registered nurse
  • Social services and counseling services from a licensed social worker
  • Nutritional support such as intravenous feeding and feeding tubes
  • Physical therapy, occupational therapy, speech therapy, and respiratory therapy given by a licensed therapist
  • Pharmaceuticals, medical equipment, and supplies needed for the palliative care of your condition, including oxygen and related respiratory therapy supplies
  • Bereavement (grief) services, including a review of the needs of the bereaved family and the development of a care plan to meet those needs, both before and after the Member’s death. Bereavement services are available to surviving Members of the immediate family for one year after the Member’s death. Immediate family means your spouse, children, stepchildren, parents, brothers and sisters.

Network:  Nothing

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Not covered:

  • Independent nursing
  • Homemaker services
All charges
Benefit Description : AmbulanceHigh Option (You pay)

Medically necessary ambulance services when one or more of the following criteria are met:

  • You are transported by a state licensed vehicle that is designed, equipped, and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionals. This includes ground, water, fixed wing, and rotary wing air transportation.
  • For ground ambulance, you are taken:
    • From your home, the scene of an accident or medical emergency to a hospital;
    • Between hospitals, including when we require you to move from a non-network hospital to a network hospital; or
    • Between a hospital and a skilled nursing facility or other approved facility.

Note: All scheduled ground ambulance services for non-emergency transfers, except transfers from one acute facility to another, must be approved through precertification. Benefits will be limited to $50,000 per occurrence if a non-network provider is used.

  • For air and water ambulance, you are taken:
    • From the scene of an accident or medical emergency to a hospital;
    • Between hospitals, including when we require you to move from a non-network hospital to a network hospital; or
    • Between a hospital and an approved facility.

Note: Air ambulance services for non-emergency hospital to hospital transfers must be approved through precertification. Benefits will be limited to $50,000 per occurrence if a non-network provider is used.

Note: Non-network providers may also bill you for any charges that exceed the maximum amount.

Nothing

Not Covered:

  • Ambulance services for your convenience or the convenience of your family.

All charges




Section 5(d). Emergency Services

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost- sharing works. Also, read Section 9 Coordinating Benefits with Medicare and Other Coverage.
  • When you need emergency medical care outside of the U.S., go to the nearest hospital. Call the Placard Worldwide Service Center at 800-810-BLUE (2583), or call collect at 804-673-1177, if you are admitted.




What is a medical emergency?

An accidental bodily injury or other medical condition that arises suddenly and unexpectedly and manifests itself by acute symptoms of such severity that the absence of immediate medical attention could be reasonably expected to: place the person’s health in significant jeopardy; result in serious impairment to a bodily function; result in serious dysfunction of any bodily organ or part; result in inadequately controlled pain; or with respect to a pregnant woman who is having contractions: 1) believe that there is inadequate time to effect a safe transfer to another hospital; or 2) believe that transfer to another hospital may pose a threat to the health or safety of the woman or unborn child.




What to do in case of emergency:

When you need care right away but it is not an emergency, always call your physician first. Your physician may have you come into the office for an urgent appointment. An urgent appointment is one scheduled with a physician for the same day or during hours not normally used for appointments.

Emergencies at network hospitals within our service area

If possible, when an unexpected condition arises, call your physician – unless you believe any delay would be harmful. This applies even if it’s after office hours. Your physician will tell you whether to go to the emergency room.

If you need additional care after an emergency condition is stabilized, precertification is required.

Emergencies at non-network hospitals (inside or outside our service area)

If possible, when an unexpected condition arises, call your network physician unless you believe any delay would be harmful. This applies even if it’s after office hours. Your network physician will tell you whether to go to the emergency room.

If you are admitted as an inpatient in a non-network hospital as a result of an emergency, you, your doctor or a family member should call Blue Open Access POS as soon as possible for precertification of the case

If you need additional care after an emergency condition is stabilized, precertification is required.

After Hours Care

If you need care after normal business hours, your Doctor may have several options for you. You should call your Doctor’s office for instructions if you need care in the evenings, on weekends, or during the holidays and cannot wait until the office reopens. If you have an Emergency, call 911 or go to the nearest Emergency Room.




Benefit Description : Emergency within our service areaHigh Option (You pay )
  • Emergency care at a doctor’s office

$20 per primary care visit

$40 per specialty care visit

  • Emergency care at an urgent care center
$40 per visit
  • Emergency care as an outpatient or inpatient at a hospital, including doctors’ services
  • Hospital observation

Note:  If you need follow-up care after emergency treatment, call your physician.

Note:  We will only apply the emergency room copay as long as you are not admitted as inpatient to the hospital.

$200 per visit; if visit results in an inpatient admission, you pay a $500 per day copay for a maximum of 3 days per admission

 

Not covered:

  • Elective or non-emergency care
  • Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
All charges
Benefit Description : Emergency outside our service areaHigh Option (You pay )
  • Emergency care at a doctor’s office

$20 per primary care visit

$40 per specialty care visit

  • Emergency care at an urgent care center
$40 per visit
  • Emergency care as an outpatient or inpatient at a hospital, including doctors’ services
  • Hospital observation

Note:  If you need follow-up care after emergency treatment, call network physician.

Note:  We will only apply the emergency room copay as long as you are not admitted as inpatient to the hospital.

$200 per visit; if visit results in an inpatient admission, you pay a $500 per day copay for a maximum of 3 days per admission

Not covered:

  • Elective care or non-emergency care
  • Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
All charges
Benefit Description : AmbulanceHigh Option (You pay )

Medically necessary ambulance services when one or more of the following criteria are met:

  • You are transported by a state licensed vehicle that is designed, equipped, and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionals. This includes ground, water, fixed wing, and rotary wing air transportation.
  • For ground ambulance, you are taken:
    • From your home, the scene of an accident or medical emergency to a hospital;
    • Between hospitals, including when we require you to move from a non-network hospital to a network hospital; or
    • Between a hospital and a skilled nursing facility or other approved facility.

Note: All scheduled ground ambulance services for non-emergency transfers, except transfers from one acute facility to another, must be approved through precertification. Benefits will be limited to $50,000 per occurrence if a non-network provider is used

  • For air and water ambulance, you are taken:
    • From the scene of an accident or medical emergency to a hospital;
    • Between hospitals, including when we require you to move from a non-network hospital to a network hospital; or
    • Between a hospital and an approved facility.

Note: Air ambulance services for non-emergency hospital to hospital transfers must be approved through precertification. Benefits will be limited to $50,000 per occurrence if a non-network provider is used.

Note: Non-network providers may also bill you for any charges that exceed the Plan’s maximum allowed amount.

Nothing

Not Covered:

  • Ambulance services for your convenience or the convenience of your family

All charges




Section 5(e). Mental Health and Substance Use Disorder Benefits

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Plan physicians must provide or arrange your care. 
  • There is a calendar year deductible for covered out-of-network services. The deductible is $2,000 for Self Only, $2,000 per person for Self Plus One and $6,000 for Self and Family enrollment.
  • Pre-approval or precertification must be obtained if Non-Network providers are used. Also read Section 5(d) about emergency services.
  • Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost- sharing works. Also, read Section 9 Coordinating Benefits with Medicare and Other Coverage.
  • CERTAIN SERVICES REQUIRE PREAUTHORIZATION. Please refer to the precertification information shown in Section 3 to be sure which services require preauthorization. 
  • We will provide medical review criteria or reasons for treatment plan denials to enrollees, members or providers upon request or as otherwise required.
  • OPM will base its review of disputes about treatment plans on the treatment plan’s clinical appropriateness.  OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.



Benefit Description : Professional servicesHigh Option (You pay )

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

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

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

  • Diagnostic evaluation
  • Medication evaluation and management (pharmacotherapy)
  • Treatment and counseling
  • Diagnosis and treatment of substance use disorders including detoxification, treatment and counseling
  • Intensive In-home Behavioral Health Services when available in the member's area.  These services do not require confinement to the home.

Network:  $20 per office visit

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge 

  • Inpatient hospital physician visit

Nothing

POS Non-Network: After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

  • Individual and group psychotherapy for the treatment of smoking cessation
Nothing
Benefit Description : DiagnosticsHigh Option (You pay )
  • Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment 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 facility

Network:  Nothing

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Benefit Description : Inpatient hospital or other covered facilityHigh Option (You pay )

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
  • Residential treatment centers

Network:  $500 copay per day up to a maximum of 3 days per admission

POS Non-Network: After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge

Benefit Description : Outpatient hospital or other covered facilityHigh Option (You pay )

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

  • Services in approved treatment programs, such as partial hospitalization program (PHP) or facility-based intensive outpatient treatment (IOP)

Network:   Nothing

POS Non-Network:  After satisfying the annual deductible, 30% coinsurance and any difference between our payment and the billed charge




Section 5(f). Prescription Drug Benefits

Important things you should keep in mind about these benefits:

  • We cover prescribed drugs and medications, as described in the chart beginning on page 56.
  • Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Members must make sure their prescribers obtain prior approval/authorizations for certain prescription drugs and supplies before coverage applies. Prior approval/authorizations must be renewed periodically.
  • Federal law prevents the pharmacy from accepting unused medications.
  • Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost- sharing works. Also, read Section 9 Coordinating Benefits with Medicare and Other Coverage.



There are important features you should be aware of. These include:

  • Who can write your prescription? A licensed physician or dentist, and in states allowing it, licensed certified providers with prescriptive authority prescribing within their scope of practice must prescribe your medication.
  • Where you can obtain them. You may fill the prescription at a Plan pharmacy, by mail or from our Specialty Pharmacy. When using a plan pharmacy you have two levels to choose from. Level 1 pharmacies will have lower copayments and Level 2 pharmacies will have higher copayments. Call us at 844-423-9988 or visit our website at www.anthem.com/federal-employees/health-plans-ga/ for information on how to obtain a listing of the Level 1 and Level 2 pharmacies.
  • We use a four-tier formulary. Drugs are prescribed by Plan doctors and dispensed in accordance with Blue Open Access POS’s drug formulary. The Essential prescription drug list is a list of pharmaceutical products, developed in consultation with physicians and pharmacists, approved for their quality and cost effectiveness. The covered prescription drug list is subject to periodic review and amendment. Except as otherwise stated, certain drugs may not be covered if they are not on the Essential prescription drug list. To obtain our formulary, you may check the Blue Open Access POS's website at www.anthem.com/federal-employees/health-plans-ga/ or call Client Services at 844-423-9988. The Plan may require authorization for certain drugs before they are dispensed. It is the prescribing doctor’s responsibility to obtain the Plan's authorization.
  • A generic equivalent will be dispensed if it is available. Prescription drugs will always be dispensed as ordered by your physician. When you request Tier 2 or Tier 3 drugs while Tier 1 drugs are available, you will be responsible for the difference in cost between Tier 1 and the applicable Tier copayment, in addition to the Tier one copayment. If a Tier 1 drug is not available, or your physician writes "Dispense as Written" or "Do not Substitute" on your prescription, you will only be required to pay the applicable Tier 2 or Tier 3 copayment.
  • These are the dispensing limitations. Prescription drugs prescribed by Plan doctors and obtained at Plan pharmacies will be dispensed for up to a 30-day supply for retail pharmacies; 90-day supply from the mail order program or 30-day supply for the Specialty Pharmacy. If a member is called to active military duty, or in times of national or other emergency, call us to arrange for a medium-term supply of covered medications.
  • Why use generic drugs? Generic drugs normally cost considerably less than brand name drugs. So, the copayment you pay for generic drugs is also lower. The generic name of a drug is its chemical name. The brand name is the trade name under which the drug is advertised and sold. By law, generic and brand name drugs must meet the same standards for safety, purity, strength and effectiveness. They are dispensed in the same dosage and taken in the same way.
  • The Specialty Pharmacy Program. The Specialty Pharmacy network is available to members who use specialty drugs. "Specialty drugs" are prescription legend drugs that typically need close supervision and checking of their effect on the patient by a medical professional. They often need special handling, such as temperature-controlled packaging and overnight delivery, and are often not available at retail pharmacies. They may be administered in many forms including, but not limited to, injectable, infused, oral and inhaled.  

Specialty pharmacies have dedicated patient care coordinators to help you manage your condition and offer toll-free twenty-four hour access to nurses and registered pharmacists to answer questions regarding your medications.

You or your physician can order your specialty drugs directly from the Specialty Pharmacy. Simply call the Pharmacy Member Services number on the back of your Plan Identification Card. If you or your physician orders your specialty drugs from the Specialty Pharmacy, you will be assigned a patient care coordinator who will work with you and your physician to obtain prior authorization and to coordinate the shipping of your specialty drugs directly to you or your physician's office. Your patient care coordinator will also contact you directly when it is time to refill your specialty drug prescription.

  • When you do have to file a claim. See instructions for filing claims in Section 7.



Benefit Description : Covered medications and suppliesHigh Option (You pay )

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

  • Prescription legend drugs
  • Specialty drugs
  • Injectable insulin and syringes used for administration of insulin
  • Certain supplies and equipment obtained by Mail Order or from a Network Pharmacy (such as those for diabetes and asthma)
  • Injectables
  • Compound drugs when a commercially available dosage form is not available
  • Drugs to treat gender dysphoria (Certain hormone therapies may require prior authorization, contact the pharmacy member services phone number on your ID card)

Note: Specialty drugs must be obtained through the Specialty Pharmacy. You cannot obtain specialty drugs from a retail pharmacy unless we have granted an exception.

Note: When a 90-day supply of drugs is obtained from a retail pharmacy the mail order copayments will apply.

Level 1 Retail Pharmacy (up to a 30-day supply)
Tier 1 - $5
Tier 2 - $70
Tier 3 - $110

Level 2 Retail Pharmacy (up to a 30-day supply)
Tier 1 - $20
Tier 2 - $80
Tier 3 - $120

Tier 4 - 35% of our allowance up to a maximum out-of-pocket of $350 per prescription order for a 30-day supply

Mail order (up to a 90-day supply)
Tier 1 - $10
Tier 2 - $175
Tier 3 - $275

  • FDA approved drugs for the treatment of tobacco use.  

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco and nicotine dependence are covered under the Tobacco cessation programs.  (see page 37 Section 5(a))

Nothing
  • Women's contraceptive drugs and devices

Note: The morning after pill when prescribed by a physician and purchased at a Plan pharmacy

Nothing

Preventive care medications

Medications to promote better health as recommended by ACA.

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

  • Aspirin (81 mg) for men age 45-79 and women age 55-79 and women of childbearing age
  • Folic acid supplements for women of childbearing age 400 & 800 mcg
  • Pre-natal vitamins for pregnant women
  • Fluoride tablets, solution (not toothpaste, rinses) for children age 0-6

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

Preventive Generic drugs for the following conditions: 

  • Asthma
  • Blood clots
  • Diabetes
  • Heart health and high blood pressure
  • High cholesterol
  • Osteoporosis
  • Stroke

Note: You may obtain a copy of the drug list by calling the customer service number on the back of your identification card or visit the web site at www.anthem.com/federal/ga

Nothing

Not covered:

  • Charges for the administration of any drug
  • Any drug that is primarily for weight loss (except when authorized by the Plan doctor through the prior approval process for treatment of morbid obesity)
  • Drugs in quantities that exceed the limits established by the Plan, or which exceed any age limits established by us
  • Treatment of Onychomycosis (toenail fungus)
  • Refills of lost or stolen medications
  • Over-the-counter drugs not shown as covered
  • Drugs and supplies for cosmetic purposes
  • Drugs to enhance athletic performance
  • Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
  • Nonprescription medications not shown as covered

All charges




Section 5(g). Dental Benefits

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • There is a calendar year deductible for covered out-of-network services. The deductible is $2,000 for Self Only, $2,000 per person for Self Plus One and $6,000 for Self and Family enrollment.
  • If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your FEHB Plan will be First/Primary payor of any Benefit payments and your FEDVIP Plan is secondary to your FEHB Plan. See Section 9 Coordinating benefits with Medicare and other coverage.
  • Pre-approval or precertification must be obtained if Non-Network providers are used. Also read Section 5(d) about emergency services.
  • We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. See Section 5(c) for inpatient hospital benefits. We do not cover the dental procedure unless it is described below.
  • Be sure to read Section 4, Your Costs for Covered Services, for valuable information about how cost- sharing works. Also, read Section 9 Coordinating Benefits with Medicare and Other Coverage.



Benefit Description : Accidental injury benefitHigh Option (You Pay)

We cover work needed to treat injuries to the jaw, sound natural teeth, mouth or face as a result of an accident. An injury that results from chewing or biting is not considered an injury under this Plan, unless the chewing or biting results from a medical or mental condition.

Treatment must begin within 12 months of the injury, or as soon after that as possible to be a covered service under this Plan.

Network:  Cost-share is based upon place of service.  See specific benefit descriptions in Sections 5(a), 5(b) and 5(c). 

Benefit Description : Dental benefitsHigh Option (You Pay)
We have no other dental benefits.All charges



Section 5(h). Wellness and Other Special Features

Feature : FeatureHigh Option (Description)

Flexible Benefits Option      

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

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

Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8).

Reciprocity benefit

BlueCard® Program

We participate in the BlueCard®Program which provides services to you when you are outside our service area. Blue Cross and Blue Shield has Host Plans throughout the county, when you receive covered services within a Host Blue geographic area we will fulfill our contractual obligations if the criteria's below apply. When this occurs the Host Blue is responsible for: (a) contracting with its providers; and (b) handling its interactions with those providers.

Emergency/Urgent Care Out-of-Area Services

You have access to benefits when traveling outside the Plan's service area for urgent care and emergency room services.

Non-Emergent Out-of-Area Services

You have access to benefits when traveling for more than 90 days outside our service area. Some examples for 90 days of travel include out-of-town business, children away at school, dependent children in another state, or a winter "snowbird" residency in the South.

When covered services are provided outside a Host Blue's service area by non-participating providers, we may determine benefits and make payment based on pricing from either the Host Blue or the pricing arrangements required by applicable state or federal law. In these situations, the amount you pay for such services as deductible, copayment or coinsurance will be based on that allowed amount. Also, you may be responsible for the difference between the amount that the non-participating provider bills and the payment we will make for the covered services as set forth in this paragraph.

To find a nearby health care provider call BlueCard Access at 800-810-BLUE (2583) or through the "Find a Provider" option online at www.anthem.com/.

Centers of excellence

We use the Blue Distinction Center for Transplants as our transplant network. The network consists of leading medical facilities throughout the nation. For a list of transplant hospitals near you, call 800-824-0581.

Blue Distinction Centers for Cardiac Care provide a full range of cardiac care services, including inpatient cardiac care, cardiac rehabilitation, cardiac catheterization and cardiac surgery (including coronary artery bypass graft surgery). To date, we have designated more than 410 Blue Distinction Centers for Cardiac Care across the country.

24-hour Nurse line

This is a free 24-hour phone service link to non-emergency health information. Simply call the toll-free number of 888-220-3891 day or night to speak to a registered nurse. You also have access, through the internet www.anthem.com, to receive customized health information.

Disease management

Blue Open Access POS is committed to helping you and your family stay well. We created a Health Promotion and Disease Management Program to encourage awareness, healthy habits and regular doctor visits. To obtain information about these programs please visit our website at www.anthem.com/. Our programs include but are not limited to: Asthma Care; Cardiac Care; Chronic Kidney Disease Program; Chronic Obstructive Pulmonary Disease (COPD) Program; Diabetes Care Program; and Maternity Care Program.




Section 5(i) Point of Service Benefits

Facts about this Plan’s POS option

Services which are not obtained from network providers or approved by us, will be considered a non-network services under Blue Open Access POS. Under this option, you may choose to obtain covered health services from non-network providers. When you obtain covered medical services from a non-network provider, you will be responsible for the deductible, copayment, coinsurance, and any difference between the actual charge and the Plan's payment. This option applies to all covered services except the following:

  • Prescription drugs
  • Emergency services
  • Services when authorized by the Plan 

Deductible

When you utilize this option you must meet the calendar year deductible of $2,000 for Self Only or $2,000 per person for Self Plus One or $6,000 for Self and Family before we begin paying for covered services.

Coinsurance

Once you have met the calendar year deductible, you owe 30% coinsurance for all covered services plus any difference between our payment and the billed charges. You are also responsible up to the billed charge for all non-covered services. We base our payment and your 30% coinsurance for covered services upon the maximum allowable amount for the covered services.

Out-of-pocket Maximum

The out-of-pocket maximum applies to covered services. After your deductible and coinsurance total $12,000 for Self Only or $20,000 for Self Plus One or $20,000 for Self and Family enrollment for covered services, we will reimburse 100% of our maximum allowable charge and will no longer apply coinsurance for the remainder of the year. Please note that you will still be responsible for the difference between the actual charge and our payment.

What is covered

  • Diagnostic and treatment service
  • Preventive care, adult and child
  • Family planning
  • Allergy care
  • Physical, occupational and speech therapies
  • Foot care
  • Durable medical equipment (DME)
  • Educational classes and programs
  • Surgical procedures
  • Oral and maxillofacial surgery
  • Inpatient hospital
  • Extended care/Skilled nursing care facility
  • Emergency care in the office or urgent care center
  • Lab, X-ray and other diagnostic tests
  • Maternity care
  • Infertility services
  • Treatment therapies
  • Hearing and vision services
  • Orthopedic and prosthetic devices
  • Home health services
  • Organ/tissue transplants
  • Reconstructive surgery
  • Anesthesia
  • Outpatient hospital or ambulatory surgical center
  • Hospice care
  • Mental health and substance use care

Emergency services

When you experience a sudden or an unexpected onset of a condition or injury you should call 911 or go to the nearest emergency facility.  In this instance your out-of-pocket expense will be the same as in-network benefits.  See Section 5(d) Emergency services for more details.

Prior approval and precertification

See Section 3 How You Get Care for details on prior approval and precertification.




Non-FEHB Benefits Available to Plan Members

The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them.  Fees you pay for these services do not count toward the FEHB out-of-pocket maximum.  Your medical program copay does not apply to these services.  You must pay for the services or supplies when you receive them.

Discount programs

You can receive negotiated savings on selected health and wellness services and programs simply by being an eligible Blue Open Access POS member. To obtain information about these programs please call us at 844-423-9988 or visit our website at www.anthem.com. Services available through the discount program include but are not limited to:

  • Puritan’s Pride – discounts on various vitamins, minerals and supplements
  • LivingFree – discount on smoking cessation classes
  • LivingEasy – discounts on stress management programs
  • LivingLean – discounts on weight-loss programs
  • LifeMart – deals on beauty/skin care, diet plans, fitness clubs, spas and more
  • Safebeginnings – discounts on baby-proofing products
  • HelpCare Plus – Senior Care Services with access to a pharmacy discount card
  • EyeMed – discounts on glasses and accessories
  • HearPO – discounts on hearing aids
  • TruVision – preferred pricing on LASIK eye surgery
  • Global Fit – discounts on gym memberships, fitness equipment, coaching and more

Questions? Please contact the number listed on your ID card or visit www.anthem.com/federal-employees/health-plans-ga/ to sign up today.




Section 6. General Exclusions - Services, Drugs and Supplies We Do Not Cover

The exclusions  in this section apply to all benefits.  There may be other exclusions and limitations listed in Section 5 of this brochure.  Although we may list a specific service as a benefit, we will not cover it unless it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition.  For information on obtaining prior approval for specific services, such as transplants, see Section 3 When you need prior Plan approval for certain services.

We do not cover the following:

  • Services, drugs, or supplies you receive while you are not enrolled in this Plan.
  • Services, drugs, or supplies not medically necessary.
  • Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice.
  • Experimental or investigational procedures, treatments, drugs or devices (see specifics regarding transplants).
  • Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest.
  • Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.
  • Services, drugs, or supplies you receive without charge while in active military service.
  • Services or supplies furnished by yourself, immediate relatives or household members, such as spouse, parents, children, brothers or sisters by blood, marriage or adoption.
  • Services or supplies we are prohibited from covering under the law.
  • Autopsies and post-mortem testing.
  • Services and supplies specifically for education or academic services.



Section 7. Filing a Claim for Covered Services

This Section primarily deals with post-service claims (claims for services, drugs or supplies you have already received).  See Section 3 for information on pre-service claims procedures (services, drugs or supplies requiring prior Plan approval), including urgent care claims procedures. When you see Plan providers, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims.  Just present your identification card and pay your copayment, coinsurance, or deductible.

You will only need to file a claim when you receive emergency services from non-Plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:




TermDefinition

Medical and hospital benefits

In most cases, providers and facilities file claims for you. Providers 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 844-423-9988.

How to file a claim:

  • You can obtain claim forms by calling Client Services at 844-423-9988. The back of the claim form has complete filing instructions.
  • You can use the same claim form to file a claim for all your health care benefits, except for prescription drugs.
  • You may submit claims for more than one person in the same envelope. However, you must submit a separate claim form for each person. Attach each person’s bill to the correct form.
  • Complete the claim form fully and accurately. You must check “yes” or “no” for each question. If you do not answer a question, we may have to return your claim to you. This is also true if you do not provide additional information required.
  • When you write in your identification number on the claim form, be sure to include the first three digits.
  • We can only accept itemized bills. Each bill must show: the name of the patient, the name and address of the provider of care, a description of each service and the date provided, a diagnosis and the charge for each service.
  • Canceled checks and nonitemized bills that show only “balance due” or “for professional services rendered” are not sufficient.
  • Include all bills for covered services not previously submitted.
  • If you have paid the provider, mark each bill “paid.”
  • In some cases, we will pay you directly for covered services. In other cases, we will pay the provider.
  • Please keep copies of the completed claim form and itemized bills.

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

Send your claims to the address shown below:

Blue Open Access POS
P. O. Box 105370
Atlanta, GA  30348-5370

Prescription drugs    

Major chains and independent pharmacies belong to your pharmacy network. At these pharmacies, if you show your Blue Open Access POS ID card, you should only be responsible for paying your share of the cost. The pharmacy should file your claim, and we will pay the pharmacy directly.

Non-Network Pharmacy: If you go to a non-network pharmacy in an urgent or emergency situation outside the Blue Open Access POS service area, you are responsible for paying for your prescription at the time of service and then filing a claim. Your program will not provide benefits if you use a non-network pharmacy within the Blue Open Access POS service area.

You can obtain a Prescription Drug Claim Form by calling Client Services at 844-423-9988.

You can file up to three prescriptions on each form. Please do not use a regular health benefits claim form to file your prescription drug claim. If you do, your claim may be denied.

  • Please fill out a separate claim form for each person and pharmacy.
  • Be sure to provide all the information requested for each prescription. You may need to have the pharmacy complete the form or get the information from the pharmacy.
  • Then you or the pharmacist should fill out the pharmacy’s name, address and National Association of Board of Pharmacy (NABP) number.
  • On the completed form, tape your original itemized prescription drug receipt(s). Please do not send cash register receipts, canceled checks, bottle labels, copies of the original prescription drug receipts, or your own itemization of charges.
  • The receipt(s) must show: the prescription number, the patient’s name, the name of the drug, the quantity and unit dose, and the strength of the drug.

Sign the claim form and mail it along with your receipt(s) to the address shown below:

Claims Department
P.O. Box 52065
Phoenix, AZ 85072-2065

Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.
Post-service claims procedures

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.

When we need more informationPlease reply promptly when we ask for additional information. We may delay processing or deny benefits for your claim if you do not respond.  Our deadline for responding to your claim is stayed while we await all of the additional information needed to process your claim.
Authorized RepresentativeYou 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, a health care professional with knowledge of your medical condition will be permitted to act as your authorized representative without your express consent.  For the purposes of this section, we are also referring to your authorized representative when we refer to you.

Notice Requirements

If you live in a county where at least 10 percent 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 phone 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.




Section 8. The Disputed Claims Process

You may appeal directly to the Office of Personnel Management (OPM) if we do not follow required claims processes.  For more information or to make an inquire about situations in which you are entitled to immediately appeal to OPM, including additional requirements not listed in Sections 3, 7 and 8 of this brochure, please call your plan’s customer service representative at the phone number found on your enrollment card, plan brochure, or plan website.

Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your post-service claim (a claim where services, drugs or supplies have already been provided).  In Section 3 If you disagree with our pre-service claim decision, we describe the process you need to follow if you have a claim for services, referrals, drugs or supplies that must have prior Plan approval, such as inpatient hospital admissions.

To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan documents under our control relating to your claim, including those that involve any expert review(s) of your claim.  To make your request, please contact our Customer Service Department by writing Blue Open Access POS Appeals, Mail Location: OH3402-B014, 3075 Vandercar Way, Cincinnati, OH 45209 or calling 844-423-9988.

Our reconsideration will take into account all comments, documents, records, and other information submitted by you relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.

When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical necessity, experimental/investigational), we will consult with a healthcare professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who was not involved in making the initial decision.

Our reconsideration will not take in account the initial decision.  The review will not be conducted by the same person, or their subordinate, who made the initial decision.

We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support the denial of benefits.

Should you have a complaint, problem or question about your health plan or any services received, a Customer Service representative will assist you. Contact Customer Service by calling the number on the back of your member identification card.




StepDescription

1

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: Blue Open Access POS, Attention:  Appeals, Mail No. OH3402-B014, 3075 Vandercar Way, Cincinnati, OH  45209; 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 your 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.

2

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.

3

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

You must write to OPM within:

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

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 2, 1900 E Street, NW, Washington, DC 20415-3620.

Send OPM the following information:

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

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

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

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

4

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

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

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




Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 844-423-9988.  We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal.  You may call OPM’s FEHB 2 at 202-606-3818 between 8 a.m. and 5 p.m. Eastern Time. 

Please remember that we do not  make decisions about plan eligibility issues.  For example, we do not determine whether you or a dependent is covered under this plan.  You must raise eligibility issues with your Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant or the Office of Workers’ Compensation Programs if you are receiving Workers’ Compensation benefits.




Section 9. Coordinating Benefits with Medicare and Other Coverage

TermDefinition

When you have other health coverage

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

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

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

When we are the secondary payor, we will determine our allowance. After the primary Plan pays, we will pay what is left of our allowance, up to our regular benefit. All programs together will not pay more than 100% of allowable expenses. The allowable expense is the maximum amount that a Plan will pay for covered services. We will not pay more than our allowance.

Please see Section 4, Your Cost for Covered Services, for more information about how we pay claims.

TRICARE and CHAMPVA

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

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

Workers’ Compensation

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.

Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care.

Medicaid

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.

When other Government agencies are responsible for your care

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

When others are responsible for injuries

If another person or entity, through an act or omission, causes you to suffer an injury or illness, and if we pay benefits for that injury or illness, you must agree to the provisions listed below. In addition, if you are injured and no other person or entity is responsible but you receive (or are entitled to) a recovery from another source, and if we provide benefits for that injury, you must agree to the following provisions:

  • All recoveries you obtain (whether by lawsuit, settlement, or otherwise), no matter how described or designated, must be used to reimburse us in full for benefits we paid. Our share of any recovery extends only to the amount of benefits we have paid or will pay to you or, if applicable, to your heirs, administrators, successors, or assignees.
  • Reimbursement to us out of your recoveries shall take first priority (before any of the rights of any other parties are honored).  Our right of reimbursement is not subject to reduction based on attorney fees or costs under the “common fund” doctrine.  Our right of reimbursement is fully enforceable regardless of whether you are “made whole” (you are fully compensated for the full amount of damages claimed).  We will not reduce our share of any recovery unless we agree in writing to a reduction, because (1) you do not receive the full amount of damages that you claimed, or (2) you had to pay attorneys’ fees.  This is our right of recovery. 
  • If you do not seek damages for your illness or injury, you must permit us to initiate recovery on your behalf (including the right to bring suit in your name). This is called subrogation.
  • If we pursue a recovery of the benefits we have paid, you must cooperate in doing what is reasonably necessary to assist us. You must not take any action that may prejudice our rights to recover.

You must tell us promptly if you have a claim against another party for a condition that we have paid or may pay benefits for, and you must tell us about any recoveries you obtain, whether in or out of court. We may seek a lien on the proceeds of your claim in order to reimburse ourselves to the full amount of benefits we have paid or will pay.

We may request that you assign to us (1) your right to bring an action or (2) your right to the proceeds of a claim for your illness or injury. We may delay processing of your claims until you provide the assignment.

Note:  We will pay the costs of any covered services you receive that are in excess of any recoveries made.

The following are examples of circumstances in which we may subrogate or assert a right of recovery:

  • When you or your dependent are injured on premises owned by a third party; or
  • When you or your dependent are injured and benefits are available to you or your dependent, under any law or under any type of insurance, including, but not limited to:
    • Personal injury protection benefits
    • Uninsured and underinsured motorist coverage (does not include no-fault automobile insurance)
    • Workers’ compensation benefits
    • Medical reimbursement coverage

Contact us if you need more information about subrogation.

When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) coverage

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 www.BENEFEDS.com, or by phone 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.

Clinical Trials

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.  These costs are covered by this plan.
  • 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.  This plan does not cover these costs.
  • 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.



TermDefinition

When you have Medicare

For more detailed information on “What is Medicare?” and “Should I Enroll in Medicare?” Please contact Medicare at 800-MEDICARE (800-633-4227), (TTY 877-486-2048) or at www.medicare.gov.

The Original Medicare Plan (Part A or Part B)

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

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

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

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

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

When Original Medicare is the primary payor, Medicare processes your claim first.  In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges.  To find out if you need to do something to file your claim, call us at 844-423-9988 or see our website at www.anthem.com.

We do not waive any costs if the Original Medicare Plan is your primary payor.

Please review the following list of benefits, it illustrates your cost share if you are enrolled in Medicare Part B.

Blue Open Access POS

Benefit Description: Deductible for Out-of-Network services
You Pay without Medicare: 
$2,000 Self only/$2,000 per person for Self Plus One/$6,000 Self and Family
You Pay with Medicare Part B: 
$2,000 Self only/$2,000 per person for Self Plus One/$6,000 Self and Family

Benefit Description: Out of Pocket Maximum for In-Network Services
You Pay without Medicare: 
$6,000 Self Only/$10,000 for Self Plus One and $10,000 Self and Family In Network
You Pay with Medicare Part B: 
$6,000 Self Only/$10,000 for Self Plus One/$10,000 Self and Family In Network

Benefit Description: Part B Premium Reimbursement Offered
You Pay without Medicare:
 NA
You Pay with Medicare Part B:
 NA

Benefit Description: Primary Care Physician
You Pay without Medicare:
 $20
You Pay with Medicare Part B:
 $20

Benefit Description: Specialist
You Pay without Medicare: 
$40
You Pay with Medicare Part B: 
$40

Benefit Description: Inpatient Hospital
You Pay without Medicare:
 $500 per day x 3 days
You Pay with Medicare Part B:
 $500 per day x 3 days

Benefit Description: Outpatient Hospital
You Pay without Medicare: 
$350 per surgical admission or 20% of our allowance per non-surgical admission
You Pay with Medicare Part B: 
$350 per surgical admission or 20% of our allowance per non-surgical admission

Benefit Description: Incentives Offered
You Pay without Medicare:
NA
You Pay with Medicare Part B:
NA

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

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

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 800-MEDICARE (800-633-4227), TTY: 877-486-2048 or at www.medicare.gov.

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

This Plan and our Medicare Advantage plan: You may enroll in an Anthem Medicare Advantage Plan and also remain enrolled in our FEHB plan. In this case, we do not waive any of our copayments or coinsurance for your FEHB coverage.

In the Anthem Medicare Advantage Plan we offer benefits, such as wellness programs like SilverSneakers®.

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. 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. 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.

  • Medicare prescription drug coverage            (Part D)

When we are the primary payor, we process the claim first. If you enroll in Medicare        Part D, and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB Plan.




Primary Payor Chart

A. When you – or your covered spouse are age 65 or over and have Medicare and you...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have FEHB coverage on your own as an active employee
2) Have FEHB coverage on your own as an annuitant or through your spouse who is an annuitant
3) Have FEHB through your spouse who is an active employee
4) Are a reemployed annuitant with the Federal government and your position is excluded from the FEHB (your employing office will know if this is the case) and you are not covered under FEHB through your spouse under #3 above
5) Are a reemployed annuitant with the Federal government and your position is not excluded from the FEHB (your employing office will know if this is the case) and...
  • 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
6) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge) and you are not covered under FEHB through your spouse under #3 above
7) Are enrolled in Part B only, regardless of your employment status ✓ for Part B services ✓ for other services
8) Are a Federal employee receiving Workers' Compensation ✓ *
9) Are a Federal employee receiving disability benefits for six months or more


B. When you or a covered family member...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have Medicare solely based on end stage renal disease (ESRD) and..
  • 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
2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and...
  • 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
3) Have Temporary Continuation of Coverage(TCC) and...
  • 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)


C. When either you or a covered family member are eligible for Medicare solely due to disability and you...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have FEHB coverage on your own as an active employee or through a family member who is an active employee
2) Have FEHB coverage on your own as an annuitant or through a family member who is an annuitant
D. When you are covered under the FEHB Spouse Equity provision as a former spouse

*Workers' Compensation is primary for claims related to your condition under Workers’ Compensation.




Section 10. Definitions of Terms We Use in This Brochure

TermDefinition
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.

Clinical Trials 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 (FDA); or is a drug trial that is exempt from the requirement of an investigational new drug application.

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

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

Coinsurance

See Section 4, page 22.

Copayment

See Section 4, page 22.

Cost-sharing

See Section 4, page 22.

Covered services Care we provide benefits for, as described in this brochure.

Custodial care

Services that do not seek to cure, but are provided primarily for the convenience of the patient or his or her family, the maintenance of the patient, or to assist the patient in meeting his or her activities of daily living, rather than primarily for therapeutic value in the treatment of a condition. Custodial care includes, but is not limited to, help in walking, bathing, dressing, eating, preparation of special diets, supervision over self-administration of medications not requiring constant attention of trained medical personnel, or acting as a companion or sitter. Custodial care that lasts 90 days or more is sometimes known as Long term care.

Deductible

See Section 4, page 22.

Experimental or
investigational service

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

An FDA-approved drug, device or biological product (for use other than its intended purpose and labeled indications), or medical treatment or procedure is experimental or investigational if

1) Reliable evidence shows that it is the subject of ongoing phase I, II or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, or

2) Reliable evidence shows that the consensus of opinion among experts regarding the drug, device, or biological product or medical treatment or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis.

Reliable evidence shall mean only published reports and articles in the authorized medical and scientific literature; the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device or medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device or medical treatment or procedure.

FDA-approved drugs, devices, or biological products used for their intended purpose and labeled indication and those that have received FDA approval subject to postmarketing approval clinical trials, and devices classified by the FDA as “Category B Non-experimental/Investigational Devices” are not considered experimental or investigational.

New Treatments and Procedures – Helping our members get care that is safe and effective

When it comes to the latest information about medical care, we want you to know that we strive to review it quickly. We have teams of healthcare professionals that review our medical, behavioral (mental) health and drug policies on a regular basis. The resources we look to when making our decisions include:

  • Professional medical publications and journals
  • Policies and procedures from government agencies
  • Study results showing the impact of new technology on long-term health
  • Doctors, specialists and other health care consultants

We update our health policies and even create new ones to address many new treatments.  Because helping you get and stay healthy is our number one goal. 

Group health coverageA health benefit Plan that is offered to employees through their place of employment or to the membership of a sponsoring organization such as a union or association.

Healthcare professional

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

Maximum allowable amount

The amount that we determine is the maximum payable for covered services you receive. Generally, to determine the maximum allowable amount for a covered service, we use, in addition to other information, internally developed criteria and industry accepted methodologies and fee schedules which are based on estimates of resources and costs required to provide a drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service or supply.

For a network provider, the maximum allowable amount is equal to the amount that constitutes payment in full under the network provider’s participation agreement for this Plan. If a network provider accepts as full payment an amount less than the negotiated rate under the participation agreement for this Plan, the lesser amount will be the maximum allowable amount.

For a non-network provider who is a physician or other non-facility provider, even if the provider has a participation agreement with us for another plan, the maximum allowable amount is the lesser of the actual charge or the standard rate under the participation agreement used with network providers for this Plan.

For a non-network provider that is a facility, the maximum allowable amount is equal to an amount negotiated with that non-network provider facility for covered services under this Plan or any other plan. In the absence of a negotiated amount, we shall have discretionary authority to establish, as we deem appropriate, the maximum allowable amount. The maximum allowable amount is the lesser of the non-network provider facility’s charge, or an amount determined by us, after consideration of one or more of the following: industry cost, peer reimbursement, utilization data, previously negotiated rates, outstanding offers that we may have made, or other factors we deem appropriate. It is your obligation to pay any deductibles, coinsurance and/or copayments. (Refer to Reciprocity for other out of area services, Section 5(h).)

Medical necessity

We only cover care that is medically necessary. But we do not cover all medically necessary care. Even if the type of care is covered in general, the care is not covered if we determine it was not medically necessary in a specific case. Blue Open Access POS must agree that care was medically necessary.

However, in some cases, you will not have to pay for care that was not medically necessary. In these cases, the provider is responsible. You do not need to pay if all of the following are true:

Blue Open Access POS did not notify you in advance that the care was not medically necessary.

The services would have been covered if they were medically necessary.

To be medically necessary, care must be provided to diagnose or treat a condition. Also, the type and level of care must be necessary and appropriate. We use current standards of medical practice to decide necessity and appropriateness. The type and level of care must not be more than what is necessary.

For example, surgery may not be medically necessary for your condition if your provider has not tried more conservative treatment. Also, inpatient care is not medically necessary if appropriate care is available on an outpatient basis.

Network Provider

A provider who has entered into a contractual agreement or is being used by us, or another organization, which has an agreement with us, to provide covered services and certain administrative functions for the Blue Open Access POS network. 

Non-network Provider

A provider who has not entered into a contractual agreement with us for Blue Open Access POS.  Providers who have not contracted or affiliated with our designated subcontractor(s) for the services they perform are also considered non-network providers. 

Plan allowance

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

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.

Post-service claimsAny 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.
Pre-service claimsThose 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.
Reimbursement 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.
SpecialistFor purposes of this Plan, a specialist is any provider other than your Primary Care Physician (PCP).  The term specialist would include licensed or certified physical, occupational or speech therapists in addition to medical doctors, psychologists, etc.  A $40 office visit copay applies to the services of specialists.
SubrogationA 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.

Urgent care claims

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

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

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

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

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at 844-423-9988.  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.

Us/We

Us and We refer to Blue Open Access POS.

You You refers to the enrollee and each covered family member.



Index

Do not rely on this page; it is for your convenience and may not show all pages where the terms appear. 



Index Entry
(Page numbers solely appear in the printed brochure)



Notes

Summary of Benefits for Blue Open Access POS - 2022

  • Do not rely on this chart alone. This is a summary.  All benefits are subject to the definitions, limitations, and exclusions in this brochure. Before making a decision, please read this FEHB brochure.  You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.anthem.com/federal-employees/health-plans-ga/
  • Under the Blue Open Access POS the deductible is $2,000 for Self Only, $2,000 per person for Self Plus One and $6,000 for Self and Family enrollment.

 




BenefitsYou pay Page

Medical services provided by physicians: Diagnostic and treatment services provided in the office

Network: $20 per office visit to your primary care physician or $40 per office visit to a specialist

POS Non-network: After satisfying the annual deductible, 30% coinsurance

28

Medical services provided by physicians: Lab, X-ray and other diagnostic tests

Network: Nothing

POS Non-network: After satisfying the annual deductible, 30% coinsurance

29

Medical services provided by physicians: CT Scans, MRI, MRA, PET, nuclear cardiology imaging studies, and non-maternity related ultrasounds

Network: 20% of our allowance per test

POS Non-network: After satisfying the annual deductible, 30% coinsurance 

29

Services provided by a hospital: Inpatient

Network:  $500 copay per day for a maximum of 3 days

POS Non-network: After satisfying the annual deductible, 30% coinsurance

47

Services provided by a hospital: Outpatient

Network:  $350 per visit (Facility copay only applies when surgical procedure is performed.)  20% of our allowance for non-surgical visits

POS Non-network: After satisfying the annual deductible, 30% coinsurance

48

Emergency Benefits: In-area or out-of-area

$200 per emergency room visit

51

Mental health and substance use disorder treatment:

Regular cost-sharing

53

Prescription drugs: Retail pharmacy
Up to a 30-day supply from a participating retail pharmacy
Note: You must obtain Tier 4 specialty medication from our Specialty Pharmacy Program.

Tier 1: Level 1 - $5, Level 2 - $20
Tier 2: Level 1 - $70, Level 2 - $80
Tier 3: Level 1 - $110, Level 2 - $120
Tier 4: 35% of our allowance up to a maximum of $350

56

Prescription drugs: Mail order
Up to a 90-day supply of maintenance medication
Note: Tier 4 medication is not available through the mail-order pharmacy.

Tier 1: $10
Tier 2: $175
Tier 3: $275

 56

Dental care:  Accidental injury only

Copay or coinsurance is based on place of service

58

Vision care: Routine eye exam or refraction (one per calendar year)

Network: $20 per visit to your PCP or $40 per visit to a Specialist

POS Non-network: After satisfying the annual deductible, 30% coinsurance

34

Wellness and Other Special features: 

Flexible benefits option; Reciprocity; Centers of Excellence; Disease Management

 59

Protection against catastrophic costs (out-of-pocket maximum):

Network:  $6,000 Self Only or $10,00 for Self Plus One or $10,000 Self and Family per year.

POS Non-network:  $12,000 Self only or $20,000 for Self Plus One or $20,000 Self and Family per year.   

22




2022 Rate Information for Blue Open Access POS

To compare your FEHB health plan options please go to www.opm.gov/fehbcompare.

To review premium rates for all FEHB health plan options please go to www.opm.gov/FEHBpremiums or www.opm.gov/Tribalpremium.

Premiums for Tribal employees are shown under the Monthly Premium Rate column. The amount shown under employee contribution is the maximum you will pay. Your Tribal employer may choose to contribute a higher portion of your premium. Please contact your Tribal Benefits Officer for exact rates.




Georgia
Type of EnrollmentEnrollment CodePremium Rate
BiWeekly
Gov't Share
Premium Rate
BiWeekly
Your Share
Premium Rate
Monthly
Gov't Share
Premium Rate
Monthly
Your Share
High Option Self OnlyQM1$242.90$80.97$526.29$175.43
High Option Self Plus OneQM3$524.63$207.13$1,136.70$448.78
High Option Self and FamilyQM2$574.13$276.69$1,243.95$599.49