Altius Health Plans
www. altiushealthplans. com
A Health Maintenance Organization
For changes in benefits,
see page 7.
Serving: Parts of Utah along the Wasatch Front
Enrollment in this Plan is limited; see page 6 for requirements.
Enrollment codes for this Plan:
9K1 Self Only
9K2 Self and Family
RI 73-564 1
1 Page
2 3
2001 Altius Health Plans 2
Table of Contents
Table of Contents
Introduction………………………………………………………………….
........................................................ 4
Plain
Language………………………………………………………………........................................................
4
Section 1. Facts about this HMO plan
...................................................................................................................
5
How we pay providers
.................................................................................................................................
5
Patients' Bill of Rights
.................................................................................................................................
5
Service
Area.................................................................................................................................................
6
Section 2. How we change for
2001………………………………………...........................................................
7
Program-wide
changes.................................................................................................................................
7
Changes to this
Plan.....................................................................................................................................
7
Section 3. How you get care …………...
..............................................................................................................
8
Identification
cards.......................................................................................................................................
8
Where you get covered
care.........................................................................................................................
8
Plan
providers........................................................................................................................................
8
Plan facilities
.........................................................................................................................................
8
What you must do to get covered care
.........................................................................................................
8
Primary
care...........................................................................................................................................
8
Specialty
care.........................................................................................................................................
8
Hospital care
..........................................................................................................................................
9
Circumstances beyond our
control.............................................................................................................
10
Services requiring our prior approval
........................................................................................................
10
Section 4. Your costs for covered services
..........................................................................................................
12
Copayments
.........................................................................................................................................
12
Deductible............................................................................................................................................
12
Coinsurance
.........................................................................................................................................
12
Your out-of-pocket
maximum....................................................................................................................
12
Section 5.
Benefits…………………………………………………………........................................................
13
Overview....................................................................................................................................................
13
(a) Medical services and supplies provided by physicians and other health
care professionals........ 14
(b) Surgical and anesthesia services provided
by physicians and other health care professionals.... 21
(c) Services
provided by a hospital or other facility, and ambulance
services.................................. 24
(d) Emergency services/
accidents
.....................................................................................................
27
(e) Mental health and substance abuse benefits
................................................................................
29
(f) Prescription drug benefits
............................................................................................................
31
(g) Special
features............................................................................................................................
34
(h) Dental
benefits.............................................................................................................................
35
(i) Non-FEHB benefits available to Plan
members..........................................................................
38
Section 6. General exclusions --things we don't cover
......................................................................................
39 2
2 Page 3 4
2001 Altius Health Plans 3 Table of Contents
Section 7. Filing a claim for covered services
....................................................................................................
40
Section 8. The disputed claims process
..............................................................................................................
42
Section 9. Coordinating benefits with other coverage
........................................................................................
44
When you have…
Other health coverage
........................................................................................................................
44
Original Medicare
..............................................................................................................................
44
Medicare managed care
.....................................................................................................................
46
TRICARE/ Workers' Compensation/ Medicaid
..........................................................................................
46
Other Government agencies
......................................................................................................................
47
When others are responsible for
injuries...................................................................................................
47
Section 10. Definitions of terms we use in this
brochure....................................................................................
48
Section 11. FEHB
facts.......................................................................................................................................
50
Coverage
information................................................................................................................................
50
No pre-existing condition limitation
.................................................................................................
50
Where you get information about enrolling in the FEHB Program
.................................................. 50
Types of coverage
available for you and your
family....................................................................... 50
When benefits and premiums
start....................................................................................................
50
Your medical and claims records are confidential
............................................................................ 50
When you
retire................................................................................................................................
51
When you lose benefits
.............................................................................................................................
51
When FEHB coverage ends
..............................................................................................................
51
Spouse equity
coverage....................................................................................................................
51
Temporary Continuation of Coverage (TCC)
..................................................................................
51
Converting to individual coverage
...................................................................................................
51
Getting a Certificate of Group Health Plan Coverage
...................................................................... 52
Inspector General advisory: Stop health care fraud!
.................................................................................
52
Index
...............................................................................................................................................................
53
Summary of benefits
............................................................................................................................................
55
Rates……………………………………………………………………………………………………..
Back cover 3
3 Page
4 5
2001 Altius Health Plans 4 Introduction/ Plain Language
Introduction
Altius Health Plans 10421 South Jordan Gateway,
Suite 400
South Jordan, Utah 84095
This brochure describes the benefits
of Altius Health Plans under our contract (CS2839) with the Office of Personnel
Management (OPM), as authorized by the Federal Employees Health Benefits law.
This brochure is
the official statement of benefits. No oral statement can
modify or otherwise affect the benefits, limitations, and exclusions of this
brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for 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, 2001, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates
with each plan annually. Benefit changes are effective January 1, 2001, and are
summarized on page 7. Rates are shown at the end of this brochure.
Plain Language
The President and Vice President are making the
Government's communication more responsive, accessible, and understandable to
the public by requiring agencies to use plain language. In response, a team of
health plan
representatives and OPM staff worked cooperatively to make this
brochure clearer. Except for necessary technical terms, we use common words.
"You" means the enrollee or family member; "we" means Altius
Health
Plans.
The plain language team reorganized the brochure and the
way we describe our benefits. When you compare this Plan with other FEHB plans,
you will find that the brochures have the same format and similar information to
make comparisons easier.
If you have comments or suggestions about how
to improve this brochure, let us know. Visit OPM's "Rate Us" feedback
area at www. opm. gov/ insure or e-mail
us at fehbwebcomments@ opm. gov or
write to OPM at Insurance
Planning and Evaluation Division, P. O. Box 436, Washington, DC 20044-0436. 4
4 Page 5 6
2001 Altius Health Plans 5 Section 1
Section 1.
Facts about this HMO plan
This Plan is a health maintenance organization
(HMO). We require you to see specific physicians, hospitals, and other providers
that contract with us. These Plan providers coordinate your health care
services.
HMOs emphasize 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.
When you receive services from Plan
providers, you will not have to submit claim forms or pay bills. You only pay
the copayments, and coinsurance, as described in this brochure. When you receive
emergency services from
non-Plan providers, you may have to submit claim
forms.
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.
How we pay providers
We contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept a negotiated payment from us, and you will only be
responsible for your copayments
or coinsurance. We compensate contracted
providers by either discount fee-for-service fee schedules or capitation
agreements.
Altius Health Plans is a Mixed Model Plan (MMP). This means the doctors
provide care in contracted medical centers or in their own offices.
Approximately 950 Primary Care Physicians and 2,050 specialists participate in
this Plan.
All members must select a Primary Care Physician, or PCP,
from the Plan's Participating Provider Directory. Your PCP should practice one
of the following disciplines: General Practice, Family Medicine, Internal
Medicine, Obstetrics/ Gynecology (OB/ GYN), or Pediatrics. Choosing a PCP is
very important to Plan members because the PCP provides the coordination of all
medical care, including referrals and authorizations for surgery,
visits to
specialists, hospitalization, durable medical equipment and other services. Each
of your family members may choose a different Primary Care Physician. You can
find locations and telephone numbers of Plan providers
in the Altius
Provider Directory, or call our Customer
Service Department at 801-323-6200 or 1-800-377-4161. You may also visit our
website at www. altiushealthplans. com to see the most current listing of
Plan providers.
Patients' Bill of Rights
OPM requires that all FEHB Plans comply
with the Patients' Bill of Rights, recommended by the President's Advisory
Commission on Consumer Protection and Quality in the Health Care Industry. You may get
information about us, our
networks, providers, and facilities. 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.
Altius Health
Plans is a State of Utah licensed and Federally Qualified Health Maintenance
Organization. Altius Health Plans (formerly PacifiCare of Utah) has been in
existence for over 24 years.
Altius Health Plans is a private for-profit
corporation.
If you want more information about us, call 801-323-6200 or
1-800-377-4161, or write to Altius Health Plans, Attn: Customer Service
department, 10421 South Jordan Gateway, Suite 400, South Jordan, UT 84095.
You
may also contact us by fax at 801-933-3639 or visit our website at www.
altiushealthplans. com. 5
5 Page
6 7
2001 Altius Health Plans 6
Section 1
Section 1. Facts about this HMO plan (continued)
Service Area
To enroll in this Plan you must live or work in our
service area. This is where our providers practice. Our service area is:
The counties of Box Elder, Davis, Morgan, Salt Lake, Summit, Tooele, Utah,
Wasatch, Weber and portions of the following counties as defined by zip codes:
Jaub -84628, 84639, 84640, 84645, 84648
Sanpete -84629, 84632
You
must get you care from providers who contract with us. If you receive care
outside our service area, we will pay only for emergency or urgently needed
care. We will not pay for any other health care service.
If you or a covered family member move outside of 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 for
information. 6
6 Page
7 8
2001 Altius Health Plans 7
Section 2
Section 2. How we change for 2001
Program-wide
changes
The plain language team reorganized the brochure and the way we
describe our benefits. We hope this will make it easier for you to compare
plans.
This year, the Federal Employees Health Benefits Program is implementing
network mental health and substance abuse parity. This means that your coverage
for mental health, substance abuse, medical, surgical,
and hospital services
from providers in our plan network will be the same with regard to coinsurance
and copays, and day and visit limitations when you follow a treatment plan that
we approve. Previously, we
placed different day and visit limitations on
mental health and substance abuse services than we did on services to treat
physical illness, injury, or disease.
Many healthcare organizations have turned their attention this past year to
improving healthcare quality and patient safety. OPM asked all FEHB plans to
join them in this effort. You can find specific information on
our patient
safety activities by calling 1-800-377-4161 or 801-323-6200, or checking
our website www. altiushealthplans. com. You can find out more about patient
safety on the OPM website,
www. opm. gov/ insure. To improve your
healthcare, take these five steps:
Speak up if you have questions or
concerns.
Keep a list of all the medicines you take.
Make sure you get
the results of any test or procedure.
Talk with your doctor and health care
team about your options if you need hospital care.
Make sure you understand
what will happen if you need surgery.
We clarified the language to show that anyone who needs a mastectomy may
choose to have the procedure performed on an inpatient basis and remain in the
hospital up to 48 hours after the procedure. Previously, the
language
referenced only women.
Changes to this Plan Your share of the non-Postal premium will
increase by 19. 5% for Self Only or 16. 7% for Self and Family.
Inpatient
Hospital/ Room and Board, (including Maternity Care). You pay nothing. Inpatient
Hospital/ Physician, Surgeon and Anesthesia (including Maternity Care). You pay
10%.
Major Diagnostic Lab/ X-ray services provided in an outpatient setting.
You pay 10%. Inpatient Mental Health and Substance Abuse Care/ Room and Board.
You pay nothing .
Inpatient Mental Health and Substance Abuse Care/
Physicians, Psychologists, Psychiatrists. You pay 10%. Outpatient Mental Health
and Substance Abuse Care. You pay a $10 copay each office visit.
A separate
Out-Of-Pocket Maximum for Mental Health and Substance Abuse Care is included in
the plan: one family member for $2,000 and $4,000 for two or more family
members.
Prescription Drug Mail Service -90 Day Supply. You pay a $20 copay
for generic/ formulary medications, a $30 copay for preferred/ name brand
medications, and a $60 copay for non-formulary medications. 7
7 Page 8 9
2001 Altius Health Plans 8 Section 3
Section 3. How you get care
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 (for annuitants), or your 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 1-800-
377-4161 or 801-323-6200.
Where you get covered care You get care from "Plan
providers" and "Plan facilities." You will only pay copayments,
and/ or coinsurance, and you will not have to file claims.
Plan providers Plan providers are physicians and other health care
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
periodically. The list is also on our website. If you have questions about
plan providers, call us at 1-800-377-4161 or 801-323-6200 or visit our
website at www. altiushealthplans. com.
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
periodically. The list is also on our website. If you have questions about plan
providers, call us at 1-
800-377-4161 or 801-323-6200 or visit our website at
www. altiushealthplans. com.
What you must do It depends on the type of care you need. First, you
and each family member must choose a primary care physician. This decision is
important since your primary care physician provides or arranges for most of
your health care. If you have been seeing a primary care
physician or you
need to choose a primary care physician, make sure he/ she is listed in the
provider directory. If you need help choosing a
primary care physician, call
us at 1-800-377-4161 or 801-323-6200.
Primary care Your primary care physician can be a Family Practitioner,
Internist, Pediatrician or an OB/ GYN. Some OB/ GYN's do not provide primary
care, so you need to ask that provider if he/ she is willing to provide
primary care services. Your primary care physician will provide most of
your
health care, or give you a referral to see a specialist.
If you want to
change primary care physicians or if your primary care physician leaves the
Plan, call us. We will help you select a new one.
When you change your
primary care physician, the change will be effective the first of the month
following the date of the change.
Specialty care Your primary care physician will refer you to a
specialist for needed care. However, female members may self-refer to an Altius
contract OB/ GYN
Physician for one outpatient examination per year. 8
8 Page 9 10
2001 Altius Health Plans 9 Section 3
Here are other things you should know about specialty care:
If you
need to see a specialist frequently because of a chronic, complex, or serious
medical condition, your primary care physician
will develop a treatment plan
that allows you to see your specialist for a certain number of visits without
additional referrals. Your primary
care physician will use our criteria when
creating your treatment plan (the physician may have to get an authorization or
approval
beforehand).
If you are seeing a specialist when you enroll in
our Plan, talk to your primary care physician. Your primary care physician will
decide
what treatment you need. If he or she decides to refer you to a
specialist, ask if you can see your current specialist. If your current
specialist does not participate with us, you must receive treatment from a
specialist who does. Generally, we will not pay for you to see
a specialist
who does not participate with our Plan.
If you are seeing a specialist and
your specialist leaves the Plan, call your primary care physician, who will
arrange for you to see another
specialist. You may receive services from
your current specialist until we can make arrangements for you to see someone
else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
terminate our contract with your specialist for other
than cause; or
drop out of the Federal Employees Health Benefits (FEHB)
Program and you enroll in another FEHB 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 at 1-800-377-4161
or 801-323-6200 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 in the
hospital when your enrollment in our Plan begins, call our customer service
department immediately at 1-800-377-4161 or 801-
323-6200.
If you are new
to the FEHB Program, we will arrange for you to receive care.
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; or 9
9 Page 10 11
2001 Altius
Health Plans 10 Section 3
The day your benefits from your former
plan run out; or
The 92 nd day after you become a member of this Plan,
whichever happens first.
These provisions apply only to the benefits of the hospitalized person.
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.
Services requiring our Your primary care physician has authority to
refer you for most services. prior approval For certain services,
however, your physician must obtain approval from
us. Before giving
approval, we consider if the service is covered, medically necessary, and
follows generally accepted medical practice.
We call this review and approval process Prior Authorization. Your primary
care physician must obtain prior authorization for the following
services:
Abortion Services All Out-of-Network Services (applicable to all Altius HMO
plans)
Behavioral Health Services (inpatient and outpatient) –
including neuro-psychological testing and treatment, alcohol and substance
abuse treatments Cardiac-Pulmonary Rehabilitation (outpatient)
Durable
Medical Equipment Genetic Counseling – evaluation and treatment
Health
Education Services Home Health Care
Infertility evaluations and treatment
Injectable Medications (excluding Imitrex, insulin, glucagon kits and
bee
sting kits) Inpatient Facility Admissions (including maternity)
Inpatient
Rehabilitation Admissions Osteopathic Manipulative Treatment
Outpatient
Surgeries Outpatient Therapy – occupational, physical and speech therapy
services Pain Management Services – evaluation and treatment
PET
and SPECT Scans Photodynamic Therapy of the Retina
Plastic Surgery and
related procedures (cosmetic procedures are not covered)
Radiation Oncology
Services Skilled Nursing Facility Admissions
Transportation (non-urgent)
If you are under the care of a specialist for treatment that requires prior
authorization and you change your primary care physician, your new
primary
care physician must approve the care and treatment of the specialist.
Your primary care or specialty care physician must request prior
authorization for you by calling or faxing us directly. We will
authorize or
deny services as soon as possible, but within 24 hours for emergent services and
within two to five business days for routine 10
10
Page 11 12
2001
Altius Health Plans 11 Section 3
services. If we deny the request
for prior authorization, we will notify your provider by telephone. We will also
send a letter to you and to
your provider with an explanation of the denial.
Emergent hospital admissions do not require prior authorization, but we must
be notified as soon as reasonably possible. If you, a friend, or
family
member does not let us know, it could result in no coverage for all services
received after your condition is stabilized. 11
11
Page 12 13
2001
Altius Health Plans 12 Section 4
Section 4. Your costs for
covered services
You must share the cost of some services. You are
responsible for:
Copayments A copayment is a fixed amount of money
you pay to the provider when you receive services.
Example: When you see your primary care physician you pay a copayment of $10
per office visit.
Deductible We do not have a deductible.
Coinsurance Coinsurance is the percentage of our negotiated fee that
you must pay for your care.
Example: In our Plan, you pay 50% of our allowance for infertility services
and durable medical equipment.
Your out-of-pocket maximum After your copayments and/ or coinsurance
total $2,000 per person or $4,000 per family enrollment in any calendar year,
you do not have to
pay any more for covered services for the remainder of
the calendar year. However, copayments and/ or coinsurance for the following
services do
not count toward your out-of-pocket maximum, and you must
continue to pay copayments and/ or coinsurance for these services:
Durable Medical Equipment (DME) Prescription Drugs
Dental Services
Non-Covered Services
Under you plan you have a separate out-of-pocket maximum for Mental Health
and Substance Abuse Services. After your copayments and/ or
coinsurance
reach $2,000 per person or $4,000 per family during a calendar year, you do not
have to pay any more for covered mental health
services.
Be sure to keep
accurate records of your copayments and/ or coinsurance since you are
responsible for informing us when you reach the maximum. 12
12 Page 13 14
2001 Altius Health Plans Section 5 13
Section 5. Benefits
--OVERVIEW (See page 7 for how our benefits changed this year and page
55 for a benefits summary.)
NOTE: This benefits section is
divided into subsections. Please read the important things you should keep in
mind at the beginning of each subsection. Also read the General Exclusions in
Section 6; they apply to the benefits in the
following subsections. To
obtain claims forms, claims filing advice, or more information about our
benefits, contact us at 1-801-323-6200 or 1-800-377-4161 or at our website at www. altiushealthplans. com
(a) Medical services and supplies provided by physicians and other health
care professionals............................. 14-20
Diagnostic and
treatment services
Lab, X-ray, and other diagnostic tests
Preventive
care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Rehabilitative therapies
Hearing services (testing, treatment, and supplies)
Vision services
(testing, treatment, and supplies)
Foot care
Orthopedic and prosthetic
devices
Durable medical equipment (DME)
Home health services
Alternative treatments
Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ....................... 21-23
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery
Organ/ tissue
transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance
services..................................................... 24-26
Inpatient hospital
Outpatient hospital or ambulatory surgical center
Extended care benefits/ skilled nursing care facility benefits
Hospice care
Ambulance
(d) Emergency services/ accidents
........................................................................................................................
27-28
Medical emergency Ambulance
(e) Mental health and substance abuse
benefits...................................................................................................
29-30
(f) Prescription drug benefits
...............................................................................................................................
31-33
(g) Special features
....................................................................................................................................................
34
Services for deaf, hard of hearing, and non-English speaking members
High risk pregnancies
Centers of excellence for transplants/ heart
surgery/ etc.
Travel benefit/ services overseas
(h) Dental benefits
................................................................................................................................................
35-37
(i) Non-FEHB benefits available to Plan members
..................................................................................................
38
Summary of benefits
...................................................................................................................................................
55 13
13 Page 14
15
2001 Altius Health Plans Section 5( a) 14
Section 5 (a) Medical services and supplies provided by physicians and
other health care professionals
I M
P O
R T
A N
T
Here are some important things to 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.
We have no calendar
year deductible.
Be sure to read Section 4, Your costs for covered
services for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In a primary care physician's
office
In a specialist's office
Second surgical opinion
In an urgent
care center
$10perofficevisit
Lab, X-ray and other diagnostic tests
Minor diagnostic tests, such
as:
Blood tests
Urinalysis
Non-routine and Routine pap tests
Pathology
X-rays
Non-routine Mammograms
Ultrasound
Electrocardiogram and EEG
$10 per office visit (waived if performed in conjunction with an
office
visit)
Major diagnostic labs and x-rays, such as,
Cat Scans and MRI's
PET
and SPECT Scans
Angiography
10% of Plan Allowance 14
14 Page 15 16
2001 Altius
Health Plans Section 5( a) 15
Preventive care, adult You pay
Routine screenings, such as:
Blood lead level – One annually
Total Blood Cholesterol – once every three years, ages 19 through 64
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening – everyfive years starting at age 50
Prostate Specific Antigen (PSA test) – one annuallyfor men age 40 and
older
Routine pap test
Note: The office visit is covered if pap test is
received on the same day; see Diagnosis and Treatment, above.
Routine mammogram –covered for women age 35 and older, as follows:
From age 35 through 39, one during this five year period
From age 40
through 64, one every calendar year
At age 65 and older, one every two
consecutive calendar years
$10 per office visit
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel. All charges
Routine Immunizations, limited to:
Tetanus-diphtheria (Td) booster
– once every 10 years, ages19 and over (except as provided for under
Childhood immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
$10 per office visit
Not covered: Immunizations exclusively for travel All charges
Preventive care, children
Childhood immunizations recommended
by the American Academy of Pediatrics $10 per office visit
Examinations, such as:
Eye exams through age 17 to determine the need for
vision correction.
Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations ( through age 22)
Well-child care charges for routine examinations, immunizations and care
(through age 22)
$10 per office visit
Not covered: Immunizations exclusively for travel. All charges 15
15 Page 16 17
2001 Altius Health Plans Section 5( a) 16
Maternity care You pay
Complete maternity (obstetrical) care,
such as:
Hospital care requires prior authorization
Prenatal care,
postnatal care and delivery (physician, surgeon and anesthesia)
10% of Plan Allowance
Delivery (room and board) Nothing
Obstetrical care in an observation
setting $10 per office visit
Note: Here are some things to keep in mind:
You may remain in the hospital up to 48 hours after a regular 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 and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits
(Section 5b).
Not covered:
Routine sonograms to determine
fetal age, size or sex.
Home delivery
All charges
Family planning
Voluntary sterilization (in a physician's office)
Surgically implanted contraceptives
Injectable contraceptive drugs
Intrauterine devices (IUDs)
$10 per office visit
Not covered:
Reversal of voluntary surgical sterilization
Predictive genetic testing and/ or counseling
Elective
abortions, except when the life of the mother would be endangered if the fetus
were carried to term, in cases where the
pregnancy is the result of rape or incest, or to prevent the birth of a
child that would be born with grave defects.
All charges 16
16 Page 17 18
2001 Altius
Health Plans Section 5( a) 17
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial
insemination:
Intravaginal insemination (IVI)
Intracervical insemination
(ICI)
Intrauterine insemination (IUI)
50% of Plan Allowance
Not covered:
Assisted reproductive technology (ART) procedures,
such as:
invitro fertilization
embryo transfer and GIFT
Services and supplies related to excluded ART procedures
Cost of donor sperm
Fertility Medications, other than
Clomiphene
All charges
Allergy care
Testing and treatment $10 per office visit
Allergy serum
Allergy Injections Nothing
Not covered:
Provocative food testing
Sublingual
allergy desensitization
All charges
Treatment therapies
Chemotherapy and radiation therapy
Note:
High dose chemotherapy in association with autologous bone marrow transplants
are limited to those transplants listed under
Organ/ Tissue Transplants on page 23.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous (IV)/
Infusion Therapy – Home IV and antibiotic therapy
Injectable Medications such as Growth hormone therapy (GHT) when obtained in
a physician's office.
$10 per office visit
Not covered: Injectables for treatment of infertility All charges 17
17 Page 18 19
2001 Altius Health Plans Section 5( a) 18
Rehabilitative therapies
Physical therapy, occupational therapy
and speech therapy –
60 visits per condition for the services of each
of the following:
qualified physical therapists;
speech therapists; and
occupational therapists.
Note: We only cover therapy to restore bodily
function or speech when there has been a total or partial loss of bodily
function or functional
speech due to illness or injury.
Outpatient Cardiac rehabilitation
following a heart transplant, bypass surgery or a myocardial infarction, is
provided at a Plan
facility for up to 12 weeks for Phase II and Phase III combined.
$10 per office visit
Not covered:
long-term rehabilitative therapy
exercise programs
All charges
Hearing services (testing, treatment, and supplies)
Hearing
testing for children and adults $10 per office visit
Not covered:
hearing aids, testing and examinations for them
All charges
Vision services (testing, treatment, and supplies)
One pair of
eyeglasses or contact lenses to correct an impairment directly caused by
accidental ocular injury or intraocular surgery
(such as for cataracts)
50% of Plan Allowance
Eye exam to determine the need for vision correction
Annual eye
refractions $10 per office visit
Not covered:
Eyeglasses or contact lenses for refractive
purposes
Eye exercises and orthoptics
Routine eye exams
performed by an Ophthalmologist
Radial keratotomy and other
refractive surgery
All charges
Foot care
Routine foot care when you are under active treatment
for a metabolic or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$10 per office visit
Foot care continued on next page 18
18
Page 19 20
2001
Altius Health Plans Section 5( a) 19
Foot care (Continued)
You pay
Not covered:
Cutting, trimming or removal
of corns, calluses, or the free edge of toenails, and similar routine treatment
of conditions of the foot,
except as stated above
Treatment of weak, strained or flat feet
or bunions or spurs; and of any instability, imbalance or subluxation of the
foot (unless the
treatment is by open cutting surgery)
Foot orthotics
All charges
Orthopedic and prosthetic devices
Artificial limbs and 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.
50% of Plan Allowance
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear
implants, and surgically implanted breast implant
following mastectomy.
See Sections 5( b) and 5( c) for coverage of the surgery to insert the
device.
Nothing
Not covered:
orthopedic and corrective shoes
arch
supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings,
support hose, and other supportive devices unless medically necessary
Replacement of prosthetic devices and corrective appliances unless it is
needed because of a change in the member's condition,
Replacement due
to malicious damage, neglect or wrongful disposition
All charges
Durable medical equipment (DME)
Rental or purchase, at our option,
including repair and adjustment, of durable medical equipment prescribed by your
Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds
wheelchairs
crutches
walkers
blood glucose
monitors
insulin pumps
50% of Plan Allowance
Durable medical equipment (DME) continued on next page 19
19 Page 20 21
2001 Altius Health Plans Section 5( a) 20
Durable medical equipment (DME) (Continued) You pay
Medically necessary accessories and supplies such as hoses, tubes,
oxygen and ostomy supplies.
Note: Call us at 1-800-377-4161 or 801-323-6200 as soon as your Plan
physician prescribes this equipment. We will arrange with a health care
provider to rent or sell you durable medical equipment at discounted rates
and will tell you more about this service when you call.
Nothing
Not covered:
Durable medical equipment, corrective appliances,
prostheses and artificial aids, including supplies and accessories, are excluded
when primarily used for convenience, comfort, or in the absence of an
illness or injury. Routine periodic servicing, such as cleaning
and
regulating is not covered.
Replacement of prosthetic devices and
corrective appliances unless it is needed because of a change in the member's
condition,
Replacement due to malicious damage, neglect or wrongful disposition
All charges
Home health services
Home health care ordered by a Plan physician
and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.),
licensed
vocational nurse (L. V. N.), or home health aide
Services include oxygen
therapy, intravenous therapy and medications
Home visits made by a physician
Nothing
Not covered:
nursing care requested by, or for the convenience
of, the patient or the patient's family
nursing care primarily for hygiene, feeding, exercising, moving the
patient, homemaking, companionship or giving oral medication
All charges
Alternative treatments
No Benefit
Educational classes and programs
Coverage is limited to:
Diabetes self-management
Asthma Management $10 per office visit
Not covered: Health education services that are not related to the care
and treatment of an illness or injury. All charges 20
20 Page 21 22
2001 Altius Health Plans 21 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by
physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things to 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.
We have no calendar
year deductible
Be sure to read Section 4, Your costs for covered
services for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other coverage, including with
Medicare.
The amounts listed below are for the charges billed by a
physician or other health care professional for your surgical care. Look in
Section 5( c) for charges associated with the facility (i. e. hospital,
surgical center, etc.).
YOU MUST GET PRIOR AUTHORIZATION OF SOME SURGICAL
PROCEDURES. Please refer to the prior authorization information shown in Section
3 to be sure which services require prior
authorization and identify which surgeries require prior authorization.
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures
Treatment of
fractures, including casting
Removal of tumors and cysts
Normal
pre-operative care by the surgeon
Endoscopy procedure
Biopsy procedure
Voluntary sterilization
Norplant (a surgically implanted contraceptive)
and intrauterine devices (IUDs)
Correction of congenital anomalies (see reconstructive surgery)
Treatment
of burns
Insertion of internal prosthetic devices. See Section 5( a) –
Orthopedic braces and prosthetic devices for device coverage
information
Surgical treatment of morbid obesity – a condition in
which an individual weighs 100 pounds or 100% over his or her normal
weight according to current underwriting standards; eligible members must be
age 18 or over.
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.
$10 per office visit
Nothing in an outpatient hospital or surgical center
10% of Plan Allowance in an inpatient hospital or other
facility
Surgical procedures continued on next page 21
21 Page 22 23
2001 Altius Health Plans 22 Section 5( b)
Surgical procedures (Continued) You pay
Not
covered:
Reversal of voluntary sterilization
Routine
treatment of conditions of the foot; see Foot care.
All charges
Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the
condition produced a major effect on the member's appearance and
the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital
anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks;
webbed fingers; and webbed toes.
All stages of breast reconstruction surgery following a mastectomy, such as:
Surgery to produce a symmetrical appearance on the other breast;
Treatment of any physical complications;
breast prostheses, lymphedema
pumps, 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.
$10 per office visit in a physician's office
Nothing in an outpatient
hospital or surgical center
10% of Plan Allowance in an inpatient hospital
or other
facility
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
Surgeries related to sex transformation
All charges
Oral and maxillofacial surgery
Oral surgical procedures, limited
to:
Reduction of fractures of the jaws or facial bones;
Surgical
correction of cleft lip, cleft palate or severe functional malocclusion;
Removal of stones from salivary ducts;
Excision of leukoplakia or
malignancies;
Excision of cysts and incision of abscesses when done as
independent procedures; and
Other surgical procedures that do not involve the teeth or their supporting
structures.
Nothing in an outpatient hospital or surgical center
10% of Plan
Allowance in an inpatient hospital or other
facility
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures
(such as the periodontal membrane, gingiva, and alveolar bone)
All charges 22
22 Page 23 24
2001 Altius
Health Plans 23 Section 5( b)
Organ/ tissue transplants You
pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single – Double
Pancreas
Allogenic (donor) bone marrow transplants
Autologous bone marrow
transplants (autologous stem cell and peripheral stem cell support) for the
following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and ovarian
germ cell tumors
National Transplant Program
(NTP) -We provide over 48 contracted Centers of Excellence throughout the United
States,
when determined medically necessary and prior authorized by the plan.
Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical
trial at a Plan-designated center of excellence and if approved by the Plan's
medical director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.
Nothing in an outpatient hospital or surgical center
10% of Plan
Allowance in an inpatient hospital or other
facility
Not covered:
Donor screening tests and donor search expenses,
except those performed for the actual donor
Implants of artificial organs
Transplants not listed as covered
Travel expenses, lodging, and meals
All charges
Anesthesia
Professional services provided in –
Hospital
(inpatient)
10% of Plan Allowance
Professional services provided in –
Hospital outpatient department
Ambulatory surgical center
Skilled Nursing Facility
Nothing
Professional services provided in –
Office
$10 per office visit
23
23 Page 24 25
2001 Altius Health Plans 24 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and
ambulance services
I M
P O
R T
A N
T
Here are some important things to remember 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
and you must be hospitalized in a Plan facility.
We have no calendar year deductible.
Be sure to read Section 4, Your
costs for covered services for valuable information about how cost sharing
works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The
amounts listed below are for the charges billed by the facility (i. e., hospital
or surgical center) or ambulance service for your surgery or care. Any costs
associated with the professional charge (i. e., physicians, etc.) are covered
in Section 5( a) or (b).
YOU MUST GET PRIOR AUTHORIZATION OF HOSPITAL STAYS. Please refer to
Section 3 to be sure which services require prior authorization.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as
ward, semiprivate, or intensive care accommodations
general
nursing care
meals and special diets
NOTE: If you want a private room when it is not medically necessary, you pay
the additional charge above the semiprivate room rate.
Nothing
Other hospital services and supplies, such as:
Operating, recovery,
maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood
products
Blood or blood plasma, if donated or replaced
Dressings,
splints, casts, and sterile tray services
Medical supplies and equipment,
including oxygen
Take-home items
Medical supplies, appliances, medical
equipment, and any covered items billed by a hospital for use at home
Nothing
Inpatient hospital continued on next page 24
24 Page 25 26
2001 Altius Health Plans 25 Section 5( c)
Inpatient hospital (Continued) You pay
Not
covered:
Custodial care
Non-covered facilities, such as
nursing homes, long-term care facilities, schools
Personal comfort items, such as telephone, television, barber services,
guest meals and beds
Private nursing care
All charges
Outpatient hospital or ambulatory surgical center
Operating,
recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and
blood plasma, if donated or replaced
Pre-surgical testing
Dressings,
casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesiologist services
NOTE: – We cover
hospital services and supplies related to dental procedures when necessitated by
a non-dental physical impairment. We
do not cover the dental procedures.
Nothing
Not covered:
Blood and blood derivatives not replaced by the
member
Personal comfort items
All charges
Extended care benefits/ skilled nursing care facility benefits
Skilled nursing facility (SNF)/ Extended care benefits: 30 days per
member per calendar year
Professional services – physicians and general nursing care
Medical
supplies and medications
Medical equipment ordinarily provided by a skilled
nursing facility
Room and board
Nothing
Not covered: custodial care, personal, comfort or convenience items All
charges
Hospice care
Services for pain and symptom management
Short-term inpatient care and procedures necessary for pain control
Respite care may be provided only on an occasional basis and may not be
provided longer than five days
Home visits made by a physician, nurse, home health aide, social worker or
therapist with no limit on number of visits
General medical equipment and
supplies related to the terminal illness
Nothing
Hospice care continued on next page 25
25
Page 26 27
2001
Altius Health Plans 26 Section 5( c)
Hospice care
(Continued) You pay
Not covered:
Independent
nursing
Homemaker services
Specialized, customized
equipment
All charges
Ambulance
Local professional ambulance service when medically
appropriate $50 copayment per incident
Not covered: Medical transportation for the convenience of the member or
family All charges 26
26 Page 27 28
2001 Altius
Health Plans 27 Section 5( d)
Section 5 (d). Emergency
services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
We have no calendar year deductible Be sure to read Section 4, Your Costs,
for valuable information about how cost sharing
works. Also read Section 9
about coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe endangers your life or could result in serious injury
or disability, and requires immediate medical or
surgical care. Some problems are emergencies because, if not treated
promptly, they might become more serious; examples include deep cuts and broken
bones. Others are emergencies because they are
potentially life-threatening,
such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability
to breathe. There are many other acute conditions that we may determine are
medical emergencies – what
they all have in common is the need for
quick action.
What to do in case of emergency:
Emergencies within our service
area:
If you have a life-threatening or serious condition, immediately
call 911 or other emergency services, or go to the nearest medical facility. It
is important to call your Primary Care Provider (PCP) in an
emergency so
that he or she can be involved in your care. Please contact your PCP as soon as
reasonably possible. We will cover emergency care provided by non-plan providers
as long as the
condition continues to be an emergency. Once your condition
is stable, your PCP will work together with us to transfer you to a plan
facility.
If your life is not in danger and you have a condition that is not serious
but still requires prompt medical attention, contact your PCP and follow his or
her instructions. If you are not able to contact
your PCP, you may go to any
Plan urgent care facility. Please refer to your Altius Participating Provider
Listing. After you receive urgent care, contact your PCP as soon as you can.
Your PCP
will coordinate any follow-up care you need.
Emergencies
outside our service area:
If you have an emergency while outside of the
service, please seek the appropriate medical treatment. You may be asked to pay
the bill at the time of service. Keep your receipts so we can reimburse you
for those costs. We will cover emergency care provided by non-plan providers
as long as the condition continues to be an emergency. Once your condition is
stable, your PCP will work with us to transfer
you to a plan facility.
Please contact us as soon as reasonably possible at 1-800-377-4161 or
801-323-6200.
Emergency service/ accidents benefits – Continued on next page
27
27 Page 28
29
2001 Altius Health Plans 28 Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office
Emergency care at an urgent care
center
$10 copayment per office
visit
Emergency care as an outpatient at a hospital, including doctors' services
(copayment is waived if you are admitted to the hospital) $50 copayment per
visit
Not covered: Elective care or non-emergency care All charges
Emergency outside our service area
Emergency care at a
doctor's office
Emergency care at an urgent care center $10 copayment per
office visit
Emergency care as an outpatient at a hospital, including doctors' services
(copayment is waived if you are admitted to the hospital) $100 copayment per
visit
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
Medical and hospital costs resulting from a normal full-term delivery of a
baby outside the service area
All charges
Ambulance
Professional ground ambulance, air ambulance, and/ or
paramedic services when medically appropriate.
See 5( c) for non-emergency service.
$50 copayment per incident
Not covered:
Medical transportation for the convenience of you
or your family
Death-related transportation
All charges 28
28 Page 29 30
2001 Altius
Health Plans 29 Section 5( e)
Section 5 (e). Mental health and
substance abuse benefits
I M
P O
R T
A N
T
Parity
Beginning in 2001, all FEHB plans' mental health and
substance abuse benefits will achieve "parity" with other benefits.
This means that we will provide mental health and substance abuse
benefits differently than in the past.
When you get our approval for
services and follow a treatment plan we approve, cost-sharing and limitations
for Plan mental health and substance abuse benefits will be no greater than for
similar benefits for other illnesses and conditions.
Here are some
important things to keep in mind about these benefits:
All benefits are
subject to the definitions, limitations, and exclusions in this brochure.
We
have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other
coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF
THESE SERVICES. See the instructions after the benefits description below.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and
contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.
Note: Plan benefits are payable only when we determine the care is clinically
appropriate to treat your condition and only when you receive
the care as
part of a treatment plan that we approve.
Your cost sharing responsibilities are no
greater than for any other
illness or conditions.
Professional services, including individual or group therapy by providers
such as psychiatrists, psychologists, or clinical social
workers on an
outpatient basis.
Medication management
$10 per office visit
Diagnostic tests
Intensive outpatient treatment $10 per office visit
Services provided by a hospital or other facility on an inpatient basis (room
and board), including partial hospitalization. Nothing
Professional services by providers such as psychiatrists, psychologists, or
clinical social workers provided on an inpatient
basis
10% of Plan
Allowance
Mental health and substance abuse benefits -Continued on next page 29
29 Page 30 31
2001 Altius Health Plans 30 Section 5( e)
Mental health and substance abuse benefits (Continued)
You Pay
Not covered: Services we have not approved.
Note:
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.
All charges
Preauthorization To be eligible to receive these benefits you must
follow your treatment plan and all the following authorization processes:
You must contact Horizon Behavioral Services at 1-800-701-8663 for prior
authorization of all inpatient and outpatient mental health/ substance abuse
services, information about contracted mental health providers and/ or
immediate access to care. You may call 24 hours a day, seven days a week.
Mental Health and Substance Abuse Out-Of-Pocket
Maximums
After your copayments and/ or coinsurance total $2,000 per person or $4,000
per family in any calendar year, you do not have to pay any
more for covered
mental health services for the remainder of the calendar year.
Special transitional benefit If a mental health or substance abuse
professional provider is treating you under our plan as of January 1, 2001, you
will be eligible for continued
coverage with your provider for up to 90 days
under the following conditions:
If your mental health or substance abuse professional provider with
whom
you are currently in treatment leaves the plan at our request for other than
cause.
If this condition applies to you, we will allow you reasonable time to
transfer your care to a Plan mental health or substance abuse professional
provider. During the transitional period, you may continue to see your
treating provider and will not pay any more out-of-pocket than you did in
the year 2000 for services. This transitional period will begin with our
notice to you of the change in coverage and will end 90 days after you
receive our notice. If we write to you before October 1, 2000, the 90-day
period ends before January 1 and this transitional benefit does not apply.
For information regarding this benefit contact Horizon Behavioral Services
at 1-800-701-8663.
Limitation We may limit your benefits if you do not follow your
treatment plan. 30
30 Page
31 32
2001 Altius Health Plans 31
Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
We have no calendar year deductible.
Be sure to read Section
4, Your costs for covered services for valuable information about how
cost sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
There are important features you should be aware of. These include:
Who can write your prescription. A Plan physician or licensed dentist
must write the prescription.
Where you can obtain them. You must fill
the prescription at a Plan pharmacy, or by mail for a maintenance medication.
At a pharmacy: To get your prescription filled, present your Altius
membership card to any Plan pharmacy. You will pay the prescription drug
copayment listed on your Altius membership card or
on page 32 of this
booklet. If you need prescription medications while outside of the service area,
contact Express Scripts, Inc (ESI) for the nearest Plan pharmacy, or you may pay
for your
prescription and ESI will reimburse you according to your benefits.
To find out about Plan pharmacies, or get reimbursement for a covered drug,
contact: Express Scripts, Inc, Customer
Service Department at
1-800-698-0149.
By mail: 1) Get a prescription for your maintenance
medication with the maximum refills allowed from your Plan provider (see
"Prescription Mail Services" below for a definition of a maintenance
medication). 2) Contact ESI's Customer Service Department at 1-800-698-0149
to get an order form. 3) Mail your prescription with the completed order form to
Express Scripts, Inc. Prescriptions
are mailed within fourteen days,
directly to your house or office in a labeled envelope to ensure privacy and
safety. ESI has a pharmacist available to you 24 hours a day to answer your
questions.
We use a formulary. A team of physicians, health care professionals
and pharmacists have developed the preferred prescription drug list. It allows
you to receive the most effective
medications, while ensuring positive
health outcomes at an affordable cost. The preferred prescription drug list is
subject to review and modification on a quarterly basis.
These are the dispensing limitations.
Your pharmacist will fill a
maximum 30-day supply of medications prescribed by a plan provider, unless
otherwise stated by us, State law, Federal law, or as determined by the
manufacturer's package.
Prescription Mail Services: You can get a 90-day
supply of maintenance medications through the mail service. A maintenance
medication is a prescription that is recommended by the Food &
Drug Administration (FDA) or us to be taken on a daily basis. Examples
include, but are not limited to, medication for blood pressure, asthma,
antidepressants, diabetes, hormone replacement
and birth control. Examples
of non-maintenance medications include, but are not limited to: antihistamines,
antibiotics, pain management, muscle relaxants, anti-migraine, medications for
sleep or anxiety, acne preparations, creams and ointments.
When you
have to file a claim. If you are outside of the service care and need a
prescription, contact Express Scripts for Plan pharmacies outside of the service
area. If one is not available, then Express
Scripts will reimburse you. Keep your receipts and mail them along with a
reimbursement form. Call Express Scripts at 1-800-698-0149 for the reimbursement
form and instructions.
. 31
31 Page 32 33
2001 Altius
Health Plans 32 Section 5( f)
Benefit Description You Pay
Covered medications and supplies
We cover the following medications
and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or
our mail order
program:
Drugs and medicines that by Federal law of the United States
require a physician's prescription for their purpose, except as
excluded below.
Contraceptive drugs and devices
Insulin, insulin
syringes, needles, glucose test strips and lancets
Injectable medications
obtained through a plan pharmacy need prior authorization. For authorization,
physicians must fax the
request to us. Each request will be answered by a return fax.
Clomiphene
for infertility
Disposable needles and syringes needed for injecting covered
prescribed medication
Generic:
$10 copayment $20 for mail order
Preferred name brand
$15 copayment $30 for mail order
Non-formulary
$30 copayment $60 for mail order
Note: If there is no generic equivalent available, you will still
have to
pay the name brand copay.
Drugs to treat sexual dysfunction, limited to 6 pills per month (see Prior
Authorization below). 50% of Plan Allowance
Here are some things to keep in mind about our prescription drug program:
We have an open formulary. If your physician believes a name brand product
is necessary or there is no generic available, your
physician may prescribe
a name brand drug from a formulary list. This list of name brand drugs is a
preferred list of drugs that we
selected to meet patient needs at a lower
cost. To order a Preferred Drug List, call our Customer Service Department at
1-800-377-
4161 or 801-323-6200.
Covered medications and supplies continued on next page 32
32 Page 33 34
2001 Altius Health Plans 33 Section 5( f)
Covered medications and supplies (Continued) You pay
Prior Authorization Requirements
Your plan provider must get prior
authorization for the following medications:
Accutane Prevacid Celebrex Prozac
Clozaril Regranex DDAVP Retin-A
Differin Sporanox Diflucan Tritec
Helidac Ultram Lamisil Wellbutrin SR
Prepac Vioxx Drugs to treat sexual dysfunction when medically necessary.
Note: For authorization, physicians must fax the request form to us. Each
request will be answered by a return fax.
Not covered:
Drugs
available without a prescription or for which there is no nonprescription
equivalent
Drugs obtained at a non-Plan pharmacy, except for out-of-the-area
emergencies
Medical supplies, such as dressing and antiseptics
Experimental medications
Fertility medications, other than
Clomiphene
Hypodermic needles
Natural progesterone
(including suppositories and creams)
Smoking cessation products and
medications prescribed for smoking cessation
Skin patches for motion sickness
Medications or nutritional
supplements for weight loss or weight gain for non-medical indications
Immunizations and medications required exclusively for foreign travel
Hair growth products
Medications for cosmetic indications
Insulin pens
Medications to enhance athletic performance
All Charges 33
33 Page 34 35
2001 Altius
Health Plans 34 Section 5( g)
Section 5 (g). Special Features
Feature Description
Services for deaf, hard of hearing, and non-English
speaking members
If you need interpreter services for an appointment with a Customer
Service Representative, you must arrange for these services by calling
801-323-6200 or 1-800-377-4161.
When interpreter services are needed in
the provider's office, contact the provider's office directly.
High risk pregnancies If you or your Plan provider feel that your
pregnancy may be a difficult one, or that you may be at risk for complications,
you or your PCP may ask us to assign you an ABC prenatal case manager. A
prenatal care
manager is a Registered Nurse with special training in
maternity care. Your case manager will ask you questions about your medical
history
and then tell you what you can do to keep yourself and your baby
healthy. Your case manager will also work with your provider to plan
a
course of treatment for you and will check with you from time to time to see how
you are doing.
Centers of excellence for transplants/ heart
surgery/ etc.
We
provide over 48 contracted Centers of Excellence throughout the United States,
when determined medically necessary and prior
authorized by the plan.
Travel benefit/ services overseas Services outside of our service area
are limited to emergency and urgent care only. See Section 5( d) for Emergency
services/ accidents. 34
34 Page
35 36
2001 Altius Health Plans 35
Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R
T
A N
T
Here are some important things to 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.
We have no calendar year deductible.
Plan dentists must provide or
arrange your care.
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; 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 about
coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You pay
We cover restorative services
and supplies necessary to promptly repair (but not replace) sound natural teeth.
The need for these services must result from an accidental injury.
$10
per office visit in a physician's office
Nothing in an outpatient hospital
or surgical center
10% of Plan Allowance in an inpatient hospital or other facility
Dental benefits
Service You Pay
Preventive & diagnostic
Initial examination, including full series x-rays
Recall
examinations, including bite wing x-rays
Single films
Prophylaxis and
fluoride treatment (child)
Prophylaxis (adult)
Preventive education
Nothing
Emergency treatment
Palliative during office hours
After hours
or as provided by the Altius dentist on call
Emergency services required
when a member is over 100 miles from home and a Plan dentist is not available.
$14
$53
All charges in excess of $50
Dental benefits continued on next page 35
35
Page 36 37
2001
Altius Health Plans 36 Section 5( h)
Dental benefits
(Continued) You Pay
Restorative
Routine fillings
– Amalgam posterior or Composite anterior for permanent or primary teeth.
For each filling:
1 surface Amalgam
Anterior composite
2 surfaces
Amalgam
2 Anterior composite
3 surfaces Amalgam
Anterior composite
4 surfaces Amalgam
Stainless steel crown
$13
$19
$19
$33
$25
$51
$39
$58
Periodontics
Deep scaling, root planing and curettage per quadrant
Periodontal consultation
Gingevectomy per quadrant
Muco-osseous
surgery per quadrant
Gingivectomy per tooth (to three teeth)
$77
$41
$120
$270
$20
Oral surgery
Extractions (routine) 1 st tooth
Each additional
tooth
Impacted teeth – soft tissue
Impacted teeth – partial
bony
Impacted teeth – full bony
$32
$26
$59
$88
$122
Endodontics
Pulp cap
Vital pulpotomy
Root Canal, Single
canal
Two canals
Three canals
$18
$27
$108
$131
$161
Crowns & Bridges
Crown build up with pins
Preformed post
and build up
Porcelain fused to metal crown per unit
Porcelain fused to
precious metal per unit
$30
$51
$266
$336
Dental benefits continued on next page 36
36
Page 37 38
2001
Altius Health Plans 37 Section 5( h)
Dental benefits
(Continued) You Pay
Removable dentures
Complete
denture (upper or lower)
Partial denture – cast frame
Teeth &
clasp, extra per unit
Stayplates
Repairs, full or partial dentures,
simple or involved
teeth (each)
Relines, per denture
$375
$419
$36
$150
$34
$126
Preventive appliances
Space maintainer – unilateral
Lingual holding arch
Habit-breaking appliance
2001 Altius Health Plans 38 Section 5( i)
Section 5 (i).
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 out-of-pocket maximums.
Value-Added Benefits:
Optical Discounts
Members
can receive discounts from 10-30% on prescription and non-prescription eyewear
and other products from participating Altius Optical providers. Participating
providers can be found in the Altius Participating Provider
Listing.
Lasik Vision Eye Surgery Permanent solutions to vision problems are
now available at a 10% discount to all Altius members through the Moran
Eye
Institute at the University of Utah. For more information, call the University
of Utah physician referral line at 1-800-662-0052.
Vitamins, Minerals and Nutritional Supplements Thanks to an exclusive
agreement with Earth's Pharmacy, Altius members can now get quality vitamins and
minerals
at significantly discounted prices. The Earth's Pharmacy Physician
Formula product line includes formulations for stress management, antioxidants,
insomnia, energy, immunity and many others. For a complete catalogue and price
list call 1-888-562-9891, or you can order from the web site at http:// www. epphysicansformula. com.
Orders are shipped on or before the following business day by priority mail.
Hearing Aids If you're ready to hear what you've been missing,
consider a high-quality hearing aid from Beltone. These state-of-the-
art
hearing aids are smaller and less noticeable than ever before and available at
significant discounts for Altius members. For more information call Beltone at
1-800-BEL-TONE.
Smoking Cessation The decision to quit smoking is one of the best
– and also the toughest – decisions many people make. Yet thanks to
recent advances in technology and programs, more people than ever are
successfully breaking this deadly habit. Altius members have two ways to quit.
Express Scripts/ Value Rx offers an 18% discount on CQ Nicoderm patches.
You
can also participate in a personalized stop smoking program called
"Committed Quitters". To receive an order form for patches and
information on the personalized program, call the Altius Customer Service
Department at 1-800-
377-4161 or 801-323-6200.
Altius continually expands
our value-added benefit program throughout the year. Visit our website at www.
altiushealthplans. com, for details on the most up-to-date value-added programs.
Other Value-Added Discounts to look forward to in 2001:
Expanded list of providers who will offer discounts for Lasik
Corrective Vision Eye Surgery Discounts on Cosmetic dental services-such
as teeth whitening and veneers
Discounts for Health Club Memberships
Massage clinic discounts
Discounts for Cosmetic Dermatology
and Plastic Surgery services Monthly Web-based member specials 38
38 Page 39 40
2001 Altius Health Plans Section 6 39
Section 6. General exclusions --things we don't cover
The
exclusions in this section apply to all benefits. Although we may list a
specific service as a benefit, we will not cover it unless your Plan doctor
determines it is medically necessary to prevent, diagnose, or
treat your
illness, disease, injury or condition.
We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies
(see Emergency Benefits);
Services, drugs, or supplies you receive while you
are not enrolled in this Plan;
Services, drugs, or supplies that are 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;
Procedures, services, drugs, and 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, or
to prevent the birth of a child that would be born with grave defects;
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred
from the FEHB Program. 39
39 Page 40 41
2001 Altius
Health Plans 40 Section 7
Section 7. Filing a claim for
covered services
When you see Plan physicians, 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 and/ or
coinsurance.
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:
Medical and hospital benefits In most cases, providers and facilities
file claims for you. Physicians must file on the form HCFA-1500, Health
Insurance Claim Form.
Facilities will file on the UB-92 form. For claims
questions and assistance, call us at 801-323-6200 or 1-800-377-4161.
When you must file a claim --such as for out-of-area care --submit it on the
HCFA-1500 or a claim form that includes the information shown
below. Bills
and receipts should be itemized and show:
Covered member's name and ID
number;
Name and address of physician or facility that provided the service
or supply;
Dates you received the services or supplies;
Diagnosis;
Type of each
service or supply;
The charge for each service or supply;
A copy of the
explanation of benefits, payments, or denial from any primary payer --such as
the Medicare Summary Notice
(MSN); and
Receipts, if you paid for your
services.
Submit your claims to:
Altius Health Plans Claims
Department
P. O. Box 95950 South Jordan, UT 84095-0950
Prescription drugs Call Express Scripts, Inc. (ESI) Customer Service
Department at 1-800-698-0149 to get forms and instructions for reimbursement.
Submit your claims to:
Express Scripts, Inc. Attn: Claims
P.
O. Box 52123 Phoenix, AZ 85072-2123 40
40 Page 41 42
2001 Altius
Health Plans 41 Section 7
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.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 41
41 Page
42 43
2001 Altius Health Plans 42
Section 8
Section 8. The disputed claims process
Follow
this Federal Employees Health Benefits Program disputed claims process if you
disagree with our decision on your claim or request for services, drugs, or
supplies – including a request for prior authorization:
Step Description
1 Ask us in writing to reconsider our initial
decision. You must: (a) Write to us within six months from the date of our
decision; and
(b) Send your request to us at: Altius Health Plans Appeals Department, 10421
South Jordan Gateway, Suite 400, South Jordan, UT 84095; 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.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of our request— go to step 3.
3 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.
4 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: Office of Personnel Management, Office of Insurance
Programs, Contracts Division II, P. O. Box 436, Washington, D. C. 20044-0436. 42
42 Page 43 44
2001 Altius Health Plans 43 Section 8
The Disputed Claims process (Continued)
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.
Note: If you want OPM to review different claims, 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
provide a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable
to meet the deadline because of reasons beyond your control.
5 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.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received the
disputed services, drugs, or supplies. 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 sue 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
(a) We haven't responded yet to your initial request for care
or prior authorization, then call us at 1-800-377-4161 or 801-323-6200 and we
will expedite our review; or
(b) We denied your initial request for care or
prior authorization/ prior approval, then:
If we expedite our review and
maintain our denial, we will inform OPM so that they can give your claim
expedited treatment too, or
You can call OPM's Health Benefits Contracts Division II at 202-606-3818
between 8 a. m. and 5 p. m. eastern time. 43
43
Page 44 45
2001
Altius Health Plans 44 Section 9
Section 9. Coordinating
benefits with other coverage
When you have other health coverage You
must tell us if you are covered or a family member is covered under another
group health plan or have automobile insurance that pays care
expenses
without regard to fault. This is called "double coverage."
When
you have double coverage, one plan normally pays its benefits in full as the
primary payer and the other plan pays a reduced benefit as the
secondary
payer. We, like other insurers, determine which coverage is primary according to
the National Association of Insurance
Commissioners' guidelines.
When we
are the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will determine our allowance. After the
primary plan pays, we will pay what is left of our allowance, up
to our
regular benefit. We will not pay more than our allowance. We will waive any
copayments, coinsurance, and deductibles you have under
this Plan.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under
65 years of age.
People with End-Stage Renal Disease (permanent kidney
failure requiring dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A.
Part B (Medical Insurance). Most people pay monthly
for Part B.
If you are eligible for Medicare, you may have choices in how you get your
health care. Medicare + Choice is the term used to describe the various health
plan
choices available to Medicare beneficiaries. The information in the
next few pages shows how we coordinate benefits with Medicare, depending on the
type of
Medicare managed care plan you have.
The Original Medicare Plan The Original Medicare Plan is available
everywhere in the United States. It is the way most people get their Medicare
Part A and Part B benefits.
You may go to any doctor, specialist, or
hospital that accepts Medicare. Medicare pays its share and you pay your share.
Some things are not
covered under Original Medicare, like prescription
drugs.
When you are enrolled in this Plan and Original Medicare, you still need to
follow the rules in this brochure for us to cover your care. Your care
must
continue to be authorized by your Plan provider, or prior authorized by us as
required. When we pay as secondary, we will waive any
copayments or
coinsurance, you have under this Plan.
(Primary payer chart begins on
next page.) 44
44 Page
45 46
2001 Altius Health Plans 45
Section 9
The following chart illustrates whether Original Medicare
or this Plan should be the primary payer for you according to your employment
status and other factors determined by Medicare. It is critical that you tell us
if you or a covered
family member has Medicare coverage so we can administer
these requirements correctly.
Primary Payer Chart
Then the primary
payer is… A. When either you --or your covered spouse --are age 65 or
over and …
Original Medicare This Plan
1) Areanactiveemployee
withtheFederalgovernment (includingwhenyouor afamilymemberare
eligibleforMedicaresolely becauseofadisability),
2) Are an annuitant,
3) Are a re-employed annuitant with the Federal
government when…
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
Ask your employing office which
of these applies to you.
4) 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),
5) Are enrolled in Part B only,
regardless of your employment status, (for Part B
services)
(for other services)
6) Are a former Federal employee receiving Workers' Compensation and the
Office of Workers' Compensation Programs has determined
that you are unable
to return to duty,
(except for claims related to Workers'
Compensation.)
B. When you --or a covered family member --have
Medicare based on end stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD,
2) Have completed the 30-month ESRD coordination
period and are still eligible for Medicare due to ESRD,
3) Become eligible
for Medicare due to ESRD after Medicare became primary for you under another
provision,
C. When you or a covered family member have FEHB and…
1) Are eligible for Medicare based on disability, and
a) Are an
annuitant, or
b) Are an active employee
Please note, if your Plan provider does not participate in Medicare, you will
have to file a claim with Medicare 45
45 Page 46 47
2001 Altius Health Plans 46 Section 9
Claims process
--You probably will never have to file a claim form when you have both our
Plan and Medicare.
When we are the primary payer, we process the claim
first.
When Original Medicare is the primary payer, Medicare processes
your claim first. In most cases, your claims will be coordinated
automatically and we will pay the balance of covered charges. You
will not need to do anything. To find out if you need to do something about
filing your claims, call us at 801-323-6200 or 1-800-377-4161.
We waive some costs when you have Medicare --When Medicare is the
primary payer, we will waive some out-of-pocket costs, as follows:
Medical
services and supplies provided by physicians and other
health care
professionals. If you are enrolled in Medicare Part B, and we pay as secondary,
we will waive any copayments, coinsurance,
and deductibles you have under this Plan. However, if Medicare denies
coverage for a service or supply, we will not waive your out-of-
pocket costs
for that service or supply.
Medicare managed care plan If you are eligible for Medicare, you may
choose to enroll in and get your Medicare benefits from a Medicare managed care
plan. These are health
care choices (like HMOs) in some areas of the
country. In most Medicare managed care plans, you can only go to doctors,
specialists, or
hospitals that are part of the plan. Medicare managed care
plans cover all Medicare Part A and B benefits. Some cover extras, like
prescription
drugs. To learn more about enrolling in a Medicare managed care
plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at
www. medicare. gov. If you enroll in a
Medicare managed care plan, the following options are available to you:
This Plan and another Plan's Medicare managed care plan: You may
enroll in another plan's Medicare managed care plan and also remain
enrolled
in our FEHB plan. We will still provide benefits when your Medicare managed care
plan is primary. You still need to follow the
rules in this brochure for us
to cover your care. Your care must continue to be authorized by your Plan
provider, or prior authorized by us as
required. When we pay as secondary,
we will waive any copayments, coinsurance, and deductibles you have under this
Plan. However, if the
Medicare managed care plan denies coverage for a
service or supply, we will not waive your out-of-pocket expenses for that
service or supply.
Suspended FEHB coverage and a Medicare managed care plan: If you are
an annuitant or former spouse, you can suspend your FEHB
coverage and enroll
in a Medicare managed care plan. 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 managed care
plan service area.
Enrollment in Note: If you choose not to enroll in
Medicare Part B, you can still be Medicare Part B covered under the FEHB
Program. We cannot require you to enroll in
Medicare.
TRICARE TRICARE is the health care program for members, eligible
dependents of military persons, and retirees of the military. TRICARE includes
the 46
46 Page 47
48
2001 Altius Health Plans 47 Section 9
CHAMPUS program. If both TRICARE and this Plan cover you, we pay first.
See your TRICARE Health Benefits Advisor if you have questions
about TRICARE
coverage.
Workers' Compensation We do not cover services that:
you need
because of a workplace-related disease 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 benefits. You must use
our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State, are responsible for your care or Federal Government
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for for injuries medical or hospital care for injuries or illnesses
caused by another
person, you must reimburse us for any expenses we paid.
However, we will cover the cost of treatment that exceeds the amount you
received in
the settlement.
If you do not seek damages you must agree to
let us try. This is called subrogation. If you need more information, contact us
for our
subrogation procedures. 47
47 Page 48 49
2001 Altius
Health Plans 48 Section 10
Section 10. Definitions of terms we
use in this brochure
Calendar year January1 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.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 12.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 12.
Covered services Care we provide
benefits for, as described in this brochure.
Elective Surgery Surgery
that can be scheduled for two or more days in advance without any anticipated
detriment to the health of the patient.
Experimental or Treatments, procedures, devices, or drugs that are
experimental, investigational services investigational, unproven, not
generally accepted, or part of research
study.
Hospital A facility that is licensed by the State of Utah as a general
hospital or a specialty hospital.
Medical necessity Services that are
(1) appropriate and necessary for the symptoms, diagnosis or treatment of a
medical condition and (2) within recognized
standards of medical practice
and (3) not primarily for the convenience of a Member or his or her family,
physician or other Non-Contracted
Provider.
Member Any Subscriber or Eligible Dependent who is enrolled for
coverage.
Plan allowance Plan allowance is the amount we use to determine our
payment and your coinsurance for covered services. We determine our allowance as
follows: The total dollar amount allowed by the Plan for Covered Services,
including the amounts payable by the Plan and payable by the
Member.
With respect to Participating Providers and Facilities, this amount is based
on the applicable contractual payment schedule (fee schedule)
negotiated
with the Provider or facility.
Provider Any person, organization, health facility or institution
licensed by the State of Utah to deliver or furnish health care services.
Skilled nursing facility A qualified, licensed facility designated by
us that has the staff and equipment to provide skilled nursing care as well as
other related health
services.
Urgent medical problems Those problems resulting from an unforeseen
illness or injury that do not place life in jeopardy, but require prompt
treatment. 48
48 Page
49 50
2001 Altius Health Plans 49
Section 10
Us/ We Us and we refer to Altius Health Plans.
You You refers to the enrollee and each covered family member. 49
49 Page 50 51
2001 Altius Health Plans 50 Section 11
Section 11. FEHB facts
No pre-existing condition We will not
refuse to cover the treatment of a condition that you had limitation
before you enrolled in this Plan solely because you had the condition
before you enrolled.
Where you can get information See www. opm.
gov/ insure. Also, your employing or retirement about enrolling in the FEHB
office can answer your questions, and give you a Guide to Federal
program Employees Health Benefits Plans, brochures for other
plans, and other materials you need to make an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for enrollment
begins.
We don't determine who is eligible for coverage and, in most cases,
cannot change your enrollment status without information from your
employing or retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for for you and your family you, your spouse, and
your unmarried dependent children under age 22,
including any foster
children or stepchildren your employing or retirement office authorizes coverage
for. Under certain circumstances,
you may also continue coverage for a
disabled child 22 years of age or older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You
may
change your enrollment 31 days before to 60 days after that event. The Self and
Family 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 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 marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we.
Please
tell us immediately when you add or remove family members from your coverage for
any reason, including divorce, or when your child
under age 22 marries or
turns 22.
If you or one of your family members is enrolled in one FEHB plan,
that person may not be enrolled in or covered as a family member by another
FEHB plan.
When benefits and The benefits in this brochure are effective on
January 1, 2001. If you are new premiums start to this Plan, your
coverage and premiums begin on the first day of your first pay
period that
starts on or after January 1, 2001. Annuitants' premiums begin on January 1,
2001. 50
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2001 Altius Health Plans 51
Section 11
Your medical and claims We will keep your medical
and claims information confidential. Only records are confidential the
following will have access to it:
OPM, this Plan, and subcontractors when
they administer this contract;
This Plan, and appropriate third parties,
such as other insurance plans and the Office of Workers' Compensation Programs
(OWCP), when
coordinating benefit payments and subrogating claims;
Law enforcement
officials when investigating and/ or prosecuting alleged civil or criminal
actions;
OPM and the General Accounting Office when conducting audits;
Individuals
involved in bona fide medical research or education that does not disclose your
identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
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
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.
You may be eligible for
spouse equity coverage or Temporary Continuation of Coverage.
Spouse equity If you are divorced from a Federal employee or
annuitant, you may not coverage continue to get benefits under your
former spouse's enrollment. But, you
may be eligible for your own FEHB
coverage under the spouse equity law. If you are recently divorced or are
anticipating a divorce, contact
your ex-spouse's employing or retirement
office to get RI 70-5, the Guide to Federal Employees Health Benefits Plans
for Temporary
Continuation of Coverage and Former Spouse Enrollees, or
other information about your coverage choices.
TCC If you leave Federal service, or if you lose coverage because you
no longer qualify as a family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if you are
not able to continue your FEHB enrollment after you retire.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
Get the RI 79-27, which describes TCC, and the RI 70-5, the
Guide to Federal Employees Health Benefits Plans for Temporary Continuation of
Coverage and Former Spouse Enrollees, from your employing or retirement
office or from www. opm. gov/ insure.
Converting to You may convert to a non-FEHB individual policy if:
individual coverage Your coverage under TCC or the spouse equity law
ends. If you
canceled your coverage or did not pay your premium, you cannot
convert; 51
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2001 Altius Health Plans 52
Section 11
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 service, your employing office will
notify you of your right to convert. You must apply in writing to us within 31
days
after you receive this notice. However, if you are a family member who is
losing coverage, the employing or retirement office will not notify
you. You must apply in writing to us within 31 days after you are no longer
eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and
we
will not impose a waiting period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of If you leave the FEHB Program, we will give
you a Certificate of Group Group Health Plan Coverage Health Plan
Coverage that indicates how long you have been enrolled with us. You
can use
this certificate when getting health insurance or other health care coverage.
Your new plan must reduce or eliminate waiting periods, limitations, or
exclusions
for health related conditions based on the information in the
certificate, as long as you enroll within 63 days of losing coverage under this
Plan.
If you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a
certificate
from those plans.
Inspector General Advisory Stop health care fraud! Fraud increases the
cost of health care for everyone. If you suspect that a physician, pharmacy, or
hospital 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 1-800-377-4161
or
801-323-6200 and explain the situation. If we do not resolve the issue, call
THE HEALTH CARE FRAUD
HOTLINE— 202-418-3300 or write to: The
United States Office of Personnel Management, Office of the Inspector General
Fraud
Hotline, 1900 E Street, NW, Room 6400, Washington, DC 20415.
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate
anyone who uses an ID card if the person tries to obtain
services for a person who is not an eligible family member, or are no longer
enrolled in
the Plan and tries to obtain benefits. Your agency may also take
administrative action against you. 52
52 Page 53 54
2001 Altius
Health Plans 53 Index
Index
Do not rely on this page;
it is for your convenience and does not explain your benefit coverage.
Allergy tests 17 Alternative treatment 20
Ambulance 26 Anesthesia
23
Autologous bone marrow transplant 23
Biopsies 21 Blood and
blood plasma 24
Casts 24, 25 Changes for 2001 7
Chemotherapy 17
Cholesterol tests 15
Claims 40-41 Coinsurance (definition) 48
Colorectal
cancer screening 15 Congenital anomalies 21, 22
Contraceptive devices and
drugs 16, 32 Coordination of benefits 44-47
Covered services (definition) 48
Definitions 48
Dental care 35-37, 39 Diagnostic services 14
Disputed claims review 42-43 Durable medical equipment
(DME) 19-20
Educational classes and programs 20
Effective date of enrollment 50
Emergency 27-28
Eyeglasses/ Eyeware 18, 38 Family planning 16
Fecal occult blood test 15 Foot care 18-19
General Exclusions 39 Hearing services 15, 18, 38
Home
health services 20 Hospice care 25-26
Immunizations 15, 33
Infertility 17, 32
Injectable medication 16, 17