Altius Health Plans
www. altiushealthplans. com 2002
A Health Maintenance
Organization
For changes in benefits,
see page 8
Serving: Parts of Utah along the Wasatch Front and St. George
Enrollment in this Plan is limited; see page 7 for requirements.
Enrollment codes for this Plan:
9K1 Self Only
9K2 Self and Family
RI 73-564 1
1 Page
2 3
2002 Altius Health Plans 2
Table of Contents
Table of Contents
Introduction………………………………………………………………….
........................................................ 4
Plain
Language………………………………………………………………........................................................
4
Inspector General advisory: Stop health care
fraud!...............................................................................................
5
Section 1. Facts about this HMO plan
...................................................................................................................
6
How we pay providers
..........................................................................................................................
6
Your
Rights...........................................................................................................................................
6
Service
Area..........................................................................................................................................
7
Section 2. How we change for
2002………………………………………........................................................... 8
Program-wide
changes..........................................................................................................................
8
Changes to this
Plan..............................................................................................................................
8
Section 3. How you get care …………...
..............................................................................................................
9
Identification cards
...............................................................................................................................
9
Where you get covered
care..................................................................................................................
9
Plan
providers.................................................................................................................................
9
Plan facilities
..................................................................................................................................
9
What you must do to get covered
care..................................................................................................
9
Primary care
...................................................................................................................................
9
Specialty care
.................................................................................................................................
9
Hospital
care.................................................................................................................................
10
Circumstances beyond our
control......................................................................................................
11
Services requiring our prior approval
.................................................................................................
11
Section 4. Your costs for covered services
..........................................................................................................
13
Copayments
..................................................................................................................................
13
Deductible
....................................................................................................................................
13
Coinsurance
..................................................................................................................................
13
Your out-of-pocket maximum
............................................................................................................
13
Section 5.
Benefits…………………………………………………………........................................................
14
Overview.............................................................................................................................................
14
(a) Medical services and supplies provided by physicians and other health
care professionals........ 15
(b) Surgical and anesthesia services provided
by physicians and other health care professionals.... 23
(c) Services
provided by a hospital or other facility, and ambulance
services.................................. 27
(d) Emergency services/
accidents
.....................................................................................................
30
(e) Mental health and substance abuse benefits
................................................................................
32
(f) Prescription drug benefits
............................................................................................................
34
(g) Special
features............................................................................................................................
37
Flexible benefits option 2
2 Page 3 4
2002 Altius Health
Plans 3 Table of Contents
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............................................................................................................................
38
(i) Non-FEHB benefits available to Plan members
.......................................................................... 41
Section 6. General exclusions --things we don't
cover.......................................................................................
42
Section 7. Filing a claim for covered services
....................................................................................................
43
Section 8. The disputed claims process
..............................................................................................................
45
Section 9. Coordinating benefits with other coverage
........................................................................................
47
When you have…
Other health
coverage...................................................................................................................
47
Original
Medicare.........................................................................................................................
47
Medicare managed care
................................................................................................................
50
TRICARE/ Workers' Compensation/
Medicaid...................................................................................
51
Other Government
agencies...............................................................................................................
51
When others are responsible for
injuries............................................................................................
51
Section 10. Definitions of terms we use in this
brochure....................................................................................
52
Section 11. FEHB
facts.......................................................................................................................................
54
Coverage information
........................................................................................................................
54
No pre-existing condition
limitation............................................................................................
54
Where you get information about enrolling in the FEHB
Program............................................. 54
Types of coverage
available for you and your family
................................................................. 54
When
benefits and premiums start
..............................................................................................
54
Your medical and claims records are
confidential.......................................................................
55
When you retire
..........................................................................................................................
55
When you lose
benefits........................................................................................................................
55
When FEHB coverage
ends.........................................................................................................
55
Spouse equity coverage
..............................................................................................................
55
Temporary Continuation of Coverage
(TCC).............................................................................
55
Converting to individual
coverage..............................................................................................
56
Getting a Certificate of Group Health Plan
Coverage................................................................. 56
Long Term Care insurance is coming later in 2002
............................................................................................
57
Index
...............................................................................................................................................................
58
Summary of benefits
............................................................................................................................................
59
Rates
.................................................................................................................................................
Back Cover 3
3 Page
4 5
2002 Altius Health Plans 4 Introduction
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, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates
with each plan annually. Benefit changes are effective January 1, 2002, and are
summarized on page 8. Rates are shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and understandable to
the public. For instance,
Except for necessary technical terms, we use common words. For instance,
"you" means the enrollee or
family member; "we" means Altius Health
Plans.
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is
the Office of Personnel Management. If we use
others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar
descriptions to help you
compare plans.
If you have comments or suggestions about
how to improve the structure of
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. You may
also write to OPM at the Office of Personnel Management, Office of Insurance
Planning and Evaluation Division, 1900 E Street, NW Washington, DC 20415-3650. 4
4 Page 5 6
2002 Altius Health Plans 5 Inspector General
Advisory
Inspector General Advisory
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 or
write
THE HEALTH CARE FRAUD HOTLINE 202-418-3300
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 someone who is not an eligible family member, or is no longer
enrolled
in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you.
Stop health care fraud! 5
5 Page 6 7
2002 Altius Health Plans 6 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.
Your Rights
OPM requires that all FEHB Plans provide certain
information to their FEHB members. 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. 6
6 Page
7 8
2002 Altius Health Plans 7
Section 1
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, Cache, Carbon, Davis, Morgan, Salt Lake, Summit,
Tooele, Unita, Utah, Wasatch, Washington, Weber and portions of the following
counties as defined by zip codes:
Jaub -84628, 84639, 84640, 84645, 84648
Sanpete -84629, 84632
Ordinarily, 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 care benefits. We will not pay for any other health care
services out of our
service area unless the services have received prior
plan approval.
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. 7
7 Page
8 9
2002 Altius Health Plans 8
Section 2
Section 2. How we change for 2002
Do not rely on
these change descriptions; this page is not an official statement of benefits.
For that, go to Section 5 Benefits. Also, we edited and clarified language
throughout the brochure; any language change not shown here
is a
clarification that does not change benefits.
Program-wide changes
We changed the address for sending disputed claims to OPM. (Section 8)
Changes to this Plan
We now cover routine screening for
chlamydial infection. (Section 5( a))
We clarified the brochure to show why
we think you should use generic drugs whenever possible. We moved other language
around within the Prescription drugs section but didn't change its meaning.
(Section
5( f)
We clarified the Medicare Primary Payer Chart to explain how we
coordinated benefits for former spouses. (Section 9)
We clarified other language about coordinating benefits with Medicare.
(Section 9)
Your share of the non-Postal premium will increase by 7. 1% for
Self Only or 4. 5% for Self and Family.
We have changed our Prior
Authorization List. (Section 3)
Your copay for after-hours and urgent care
visits in a provider's office or urgent care facility has increased to $20 each
visit.
Your cost share for services provided by physicians and other health care
professionals in an outpatient hospital or surgical center has increased to 10%
of Plan Allowance.
We now cover chiropractic services, up to 20 visits per
member per calendar year. Prior authorization is required after your initial
consultation. (Sections 3 and 5( a))
We no longer cover clomiphene for
treatment of infertility. (Section 5( f))
We clarified the Preventive care,
adult benefits by removing the entry for blood lead level testing for adults
because it is a test more typically done for children. (Section 5( a))
We clarified the Family planning and Infertility benefits by providing more
examples of covered and not covered benefits. (Section 5( a))
We clarified Surgical procedures to show that we cover a comprehensive ranges
of services, such as operative procedures. (Section 5( b))
We now cover
certain intestinal transplants. (Section 5( b))
We no longer limit total
blood cholesterol tests to certain age groups. (Section 5( a))
We changed
speech therapy benefits by removing the requirement that services must be
required to restore functional speech. (Section 5( a)) 8
8 Page 9 10
2002 Altius Health Plans 9 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.
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. When you receive a referral from your primary care
physician, you must
return to the primary care physician after the
consultation, unless your primary care physician authorized a certain number of
visits without
additional referrals.
What you must do to get covered care 9
9
Page 10 11
2002
Altius Health Plans 10 Section 3
The primary care physician must
provide or authorize all follow-up care. Do not go to the specialist for return
visits unless your primary care
physician gives you a referral. However,
female members may self-refer to an Altius contract OB/ GYN Physician for one
outpatient examination
per year. You may see a contracted optometrist
without a referral. Your optometrist will refer you to a contracted
ophthalmologist when
medically necessary.
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. 10
10 Page 11 12
2002 Altius Health Plans 11 Section 3
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
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 physician
must obtain prior authorization for the following services:
Abortion
Services All Services from Non-Plan Providers (except urgent and
emergency
care) Behavioral Health Services (inpatient and outpatient) – including
neuro-psychological testing and treatment, alcohol and substance abuse
treatments
Cardiac-Pulmonary Rehabilitation (outpatient) Chiropractic
Services (after initial consultation)
Durable Medical Equipment Genetic
Counseling – evaluation and testing
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 Medical
Coverage of Dental Services
Osteopathic Manipulative Treatment Outpatient
Surgeries
Outpatient Therapy – occupational, physical, speech, biofeedback,
and hyperbaric oxygen therapy services
Pain Management Services 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 11
11
Page 12 13
2002
Altius Health Plans 12 Section 3
Transportation (non-urgent) We
require prior authorization for certain prescription drugs. See
section 5(
f) for a list of these drugs.
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
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.
You must verify that your physician has obtained prior authorization from us
before you receive the services on our prior authorization list.
If you do
not verify that we have authorized your service, we may deny your claim and your
physician may bill you. To verify prior
authorization, you may call your
physician and ask for the prior authorization number we provided, or you may
call us directly at 801-
323-6200 or 1-800-377-4161.
Prior authorization
of a service does not guarantee payment. We will not pay if on the date you
receive services:
you are not eligible for benefits, you have used up a limited benefit, or
your plan has changed (January 1, new plan year) and we no longer cover the
service. 12
12 Page
13 14
2002 Altius Health Plans 13
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, facility,
pharmacy, etc., when you receive services.
Example: When you see your primary care physician you pay a copayment of $10
per office visit and $20 for an after-hours or urgent
care 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.
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 your 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.
Your catastrophic protection out-of-pocket maximum for
coinsurance and
copayments 13
13 Page
14 15
2002 Altius Health Plans Section 5 14
Section 5. Benefits –
OVERVIEW (See page 8 for how our benefits changed this year and page
59 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............................. 15-22
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 Physical and
occupational therapies
Speech therapy 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
Chiropractic
Alternative treatments Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ....................... 23-26
Surgical procedures
Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and
ambulance services..................................................... 27-29
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance
(d) Emergency services/ accidents
........................................................................................................................
30-31
Medical emergency Ambulance
(e) Mental health and substance abuse
benefits
..................................................................................................
32-33
(f) Prescription drug benefits
...............................................................................................................................
34-36
(g) Special
features.....................................................................................................................................................
37
Flexible Benefits Option
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................................................................................................................................................
38-40
(i) Non-FEHB benefits available to Plan members
...................................................................................................
41
Summary of
benefits....................................................................................................................................................
59 14
14 Page 15
16
2002 Altius Health Plans Section 5( a) 15
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
Office medical consultations
Second
surgical opinion
$10peroffice visit;$20forafter-hours orurgentcare
Professional services of physicians
In an urgent care center
$20pervisit
Professional services of physicians
During a hospital stay
In a
skilled nursing facility
10%ofPlanAllowance
Lab, X-ray and other diagnostic tests
Minor diagnostic tests, such
as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Ultrasound
Electrocardiogram and
EEG
$10 per office visit; $20 for after-hours or urgent care (waived if
performed in conjunction with an office visit)
10% of Plan Allowance in a hospital or other facility
Major diagnostic labs and x-rays, such as,
Cat Scans and MRIs
PET and
SPECT Scans
Angiography
10% of Plan Allowance 15
15 Page 16 17
2002 Altius
Health Plans Section 5( a) 16
Preventive care, adult You pay
Routine screenings, such as:
Total Blood Cholesterol – once every
three years
Colorectal Cancer Screening, including
– Fecal occult blood
test
– Sigmoidoscopy, screening – every five years starting at age 50
Prostate Specific Antigen (PSA test) – one annually for 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; $20 for after-hours visit
10% of Plan Allowance in
a hospital or other facility
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, ages 19 and over (except as provided for under Childhood
immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
$10 per office visit; $20 for after-hours visit
Not covered: Immunizations exclusively for travel All charges
Preventive care, children
Childhood immunizations recommended
by the American Academy of Pediatrics
Well-child care charges for routine examinations, immunizations and care (to
age 22)
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 (toage 22)
$10 per office visit; $20 for after-hours visit
10% of Plan Allowance in
a hospital or other facility
Not covered: Immunizations exclusively for travel. All charges 16
16 Page 17 18
2002 Altius Health Plans Section 5( a) 17
Maternity care You pay
Complete maternity (obstetrical) care,
such as:
Prenatal care
Delivery
Postnatal care
Obstetrical care
in an observation setting
10% of Plan Allowance
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
A broad range of voluntary family planning
services, such as:
Voluntary sterilization (in a physician's office)
Surgically implanted contraceptives (such as Norplant)
Injectable
contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Note: We cover oral contraceptives and diaphragms under the prescription
drug benefit; see section 5( f).
$10 per office visit; $20 for after-hours visit
Not covered:
Reversal of voluntary surgical sterilization
Predictive genetic testing and/ or counseling
All charges
Infertility services
Diagnosis and treatment of infertility, such
as:
Artificial insemination:
– Intravaginal insemination (IVI)
–
Intracervical insemination (ICI)
– Intrauterine insemination (IUI)
50% of Plan Allowance
Infertility services -continued on next page 17
17 Page 18 19
2002 Altius Health Plans Section 5( a) 18
Infertility services (continued) You pay
Not
covered:
Assisted reproductive technology (ART) procedures, such as:
– invitro fertilization
– embryo transfer, gamete GIFT and
zygote zift
– zygote transfer
Services and supplies
related to excluded ART procedures
Cost of donor sperm
Cost of donor egg
Fertility Medications
Infertility services after voluntary sterilization
All charges
Allergy care
Testing and treatment $10 per office visit; $20 for
after-hours 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
Note: We cover home IV infusion therapy under the under the
home health services benefit.
Growth hormone therapy (GHT)
Note: Growth hormone is covered under the
prescription drug benefit. We require prior authorization for growth hormone and
other injectable
medicatons. You must verify that your physician has received prior
authorization from us for growth hormone. See Services requiring our
prior approval in Section 3.
$10 per office visit; $20 for after-hours or urgent care
10% of Plan
Allowance in a surgical center, hospital, or other
facility
Not covered: Injectables for treatment of infertility All charges 18
18 Page 19 20
2002 Altius Health Plans Section 5( a) 19
Physical and occupational therapies You pay
60 visits per
condition for the services of each of the following:
– qualified physical
therapists
– occupational therapists
Note: We only cover these therapies
to restore bodily function when there has been a total or partial loss of bodily
function due to illness or
injury. We cover physical and occupational therapy under the home health
services benefit when provided by a home health agency as part
of an
authorized home treatment plan.
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; $20 for after-hours visit
10% of Plan Allowance in
a surgical center, hospital, or other
facility
Not covered:
long-term rehabilitative therapy
therapy that we determine will not significantly improve your
condition
exercise programs
All charges
Speech therapy
60 visits per condition
Note: We cover speech
therapy under the home health services benefit when provided by a home health
agency as part of an authorized home
treatment plan.
$10 per office visit; $20 for after-hours visit
Hearing services (testing, treatment, and supplies)
Hearing
testing for children and adults in a provider's office $10 per office visit; $20
for after-hours visit
Inpatient hearing examination of a newborn child covered under a family
enrollment 10% of Plan Allowance in a surgical center, hospital, or other
facility
Not covered:
Hearing aids, including testing,
examinations, and fittings 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
Annual eye refractions
Note: See Preventive care, children for eye exams
for children
$10 per office visit; $20 for after-hours 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 19
19 Page 20 21
2002 Altius
Health Plans Section 5( a) 20
Foot care You pay
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; $20 for after-hours visit
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
Note: 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 20
20 Page 21 22
2002 Altius
Health Plans Section 5( a) 21
Durable medical equipment (DME) You pay
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
oxygen concentrators Nothing
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
Home rehabilitative therapy, including
physical therapy, occupational therapy, and speech therapy when significant
improvement can be expected.
Home visits by a medical social worker.
Nothing
Home health services -continued on next page 21
21 Page 22 23
2002 Altius Health Plans Section 5( a) 22
Home health services (continued) You pay
Not
covered:
nursing care requested by, or for the convenience of, the
patient or the patient's family
services primarily for hygiene, feeding, exercising, moving the patient,
homemaking, companionship or giving oral medication
home care
primarily for personal assistance that does not include a medical component and
is not diagnostic, therapeutic, or
rehabilitative.
All charges
Chiropractic
Coverage is limited to 20 visits per calendar year.
Services include:
Manipulation of the spine and extremities
Adjunctive
procedures such as ultrasound, electrical muscle stimulation, vibratory therapy,
and cold pack application
$10 per office visit; $20 for after-hours visit
Alternative treatments
No Benefit All charges
Educational classes and programs
Coverage is limited to:
Diabetes self-management
Asthma Management
$10 per office visit 22
22 Page 23 24
2002 Altius
Health Plans 23 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
A
comprehensive range of services, such as:
Operative procedures
Treatment
of fractures, including casting
Removal of tumors and cysts
Normal
pre-operative care by the surgeon
Endoscopy procedures
Biopsy procedures
Voluntary sterilization
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; $20 for after-hours or urgent care
10% of Plan
Allowance in a surgical center, hospital, or other
facility
Surgical procedures -continued on next page 23
23 Page 24 25
2002 Altius Health Plans 24 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; $20 for after-hours or urgent care
10% of Plan
Allowance in a surgical center, 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;
Other surgical procedures that do not involve the teeth or their supporting
structures;
$10 per office visit; $20 for after-hours or urgent care
10% of Plan
Allowance in a surgeical center, 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 24
24 Page 25 26
2002 Altius
Health Plans 25 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
Intestinal transplants
(small intestine) and the small intestine with the liver or small intestine with
multiple organs such as the liver,
stomach, and pancreas
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.
10% of Plan Allowance in a surgical center, 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 25
25 Page 26 27
2002 Altius
Health Plans 26 Section 5( b)
Anesthesia
Professional
services provided in –
Hospital (inpatient)
10% of Plan Allowance
Professional services provided in –
Hospital outpatient department
Ambulatory surgical center
Skilled Nursing Facility
10% of Plan Allowance
Professional services provided in –
Office
$10 per office visit; $20
for after-hours or urgent care 26
26 Page 27 28
2002 Altius
Health Plans 27 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 Sections 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 27
27 Page 28 29
2002 Altius Health Plans 28 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
Minor
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
Major diagnostic labs and x-rays, such as,
Cat Scans and MRIs
PET and
SPECT Scans
Angiography
10% of Plan Allowance
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 28
28 Page
29 30
2002 Altius Health Plans 29
Section 5( c)
Hospice care You pay
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
You pay nothing
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 29
29 Page 30 31
2002 Altius
Health Plans 30 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 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
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 30
30 Page 31 32
2002 Altius Health Plans 31 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
$20 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
$20 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 31
31 Page 32 33
2002 Altius
Health Plans 32 Section 5( e)
Section 5 (e). Mental health and
substance abuse benefits
I M
P O
R T
A N
T
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 visit
Diagnostic tests
Intensive outpatient treatment $10 per 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 32
32 Page 33 34
2002 Altius Health Plans 33 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
obtain a treatment plan and follow 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. 33
33 Page 34 35
2002 Altius Health Plans 34 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.
YOUR PHYSICIAN MUST
GET PRIOR AUTHORIZATION FOR CERTAIN DRUGS.
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. 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
35 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. The Altius
formulary is a list of "preferred" prescription drugs that are identified by our
team of physicians and pharmacists (Pharmacy and Therapeutics Committee) to be
the best overall value based on quality, safety, effectiveness, and cost. Our
formulary includes all covered generic drugs, and specific brand-name drugs
selected by the Committee. We list the most
commonly requested formulary
drugs on our Preferred Drug List. To order a Preferred Drug List, call our
Customer Service Department at 1-800-377-4161 or 801-323-6200. The Preferred
Drug List
is subject to review and modification on a quarterly basis.
We
also cover non-preferred drugs prescribed by your Plan doctor. However, we
encourage you to use preferred drugs, especially generics, whenever possible
because they will cost you less. Refer to
your Preferred Drug List, and check with your doctor or pharmacist to find
out if a generic is available, or if a lower-cost alternative might work for
you.
These are the dispensing limitations.
– Your pharmacist will fill
up to 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 size. You will pay one copayment for each prescription
filled, even if your prescription provides less than a 30-day supply.
– 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 34
34 Page 35 36
2002 Altius
Health Plans 35 Section 5( f)
& Drug Administration (FDA) or
us to be taken on a daily basis. Examples include, but are not limited to,
medications for blood pressure, asthma, antidepressants, diabetes, hormone
replacement and birth control. With the exception of insulin (in vials
only), injectable medications are not available through mail order.
Non-maintenance medications are not
available through mail order. 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.
You must use
at least 75% of your current prescription before you can get a refill, either at
a pharmacy or, when applicable, through the mail.
You may ask your pharmacist for a generic equivalent if it is available,
unless your physician specifically requires a name brand and indicates "Dispense
as Written" on your prescription. If
a generic equivalent is not available,
or if your physician specifically requires a name brand, you will pay the name
brand copayment.
Why use generic drugs? Generic drugs are therapeutically equivalent to
brand-name drugs, but they cost less. They have the same active ingredients, and
are required by the U. S. Food and Drug
Administration to meet the same
quality standards for safety, strength, and effectiveness. You pay your lowest
copay when you use generic drugs.
When you have to file a claim. If you are outside of the service area
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.
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 purchase, except those
listed as Not Covered
Contraceptive drugs
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
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
Aerochamber, limited to one per calendar year $15 copayment
Diaphragms,
limited to one every three months $15 copayment
Covered medications and
supplies -continued on next page 35
35 Page 36 37
2002 Altius
Health Plans 36 Section 5( f)
Covered medications and supplies
(continued) You pay
Prior Authorization Requirements
Your plan provider must get prior authorization for the following
specific medications:
Accutane Nexium Aggrenox Prilosec
Celebrex Prozac Clarinex Regranex
Clozaril Relenza DDAVP Retin-A
Differin Sarafem Diflucan Sporanox
Lamisil Tamiflu
Your plan provider must also get prior authorization for
the following categories of medications:
Drugs to treat sexual dysfunction when medically necessary Injectable
medications
Note: For authorization, physicians must fax the request form to
us. Each request will be answered by a return fax.
Not covered:
Nonprescription medications
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
Disposable needles and
syringes not required for injecting covered prescribed medication
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 36
36 Page 37 38
2002 Altius
Health Plans 37 Section 5( g)
Section 5 (g). Special features
Feature Description
Flexible benefits option Under the flexible benefits option, we
determine the most effective way to provide services.
We may identify
medically appropriate alternatives to traditional care and coordinate other
benefits as a less costly alternative
benefit.
Alternative benefits are subject to our ongoing review.
By
approving an alternative benefit, we cannot guarantee you will get it in the
future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
Our decision
to offer or withdraw alternative benefits is not subject to OPM review under the
disputed claims process.
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. 37
37 Page
38 39
2002 Altius Health Plans 38
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 onlywhen we
determine theyare medicallynecessary.
We have no calendar year deductible.
Plan dentists must provide or
arrange your care.
We cover hospitalization for dental procedures onlywhen a
non-dental physical impairment exists which makes hospitalization necessaryto
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 howcost 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; $20 for after-hours or urgent care
10% of Plan Allowance in a surgical center, hospital or other facility
Not covered
Implants
All charges
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 38
38 Page 39 40
2002 Altius Health Plans 39 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 39
39 Page 40 41
2002 Altius Health Plans 40 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
$47
$50
$90
The following services are limited:
Replacement of prosthetic
appliances less than five years old is covered only when good dental care
dictates and such replacement is prescribed by a Plan dentist
Single unit gold restorations and crowns are covered only when the tooth
cannot be adequately
restored with other restorative materials
Not
Covered
Implants
surgical grafting
procedures
treatment for developmental malformations such as
enamel hypoplasia and fluorosis (brown and
white stains on teeth)
maxillary and mandibular
malformations and anodontia
general anesthetic
composite resin on posterior teeth
cosmetic or orthodontic treatment
full mouth
rehabilitation, periodontal splints, restoration of tooth structure lost from
attrition
and restoration for misalignment of the teeth
dental
treatment for temporomandibular (jaw) joint disorders and related dieases
replacement of lost or stolen denture, bridges or other dental
appliances
services not specified as covered
2002 Altius Health Plans 41 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:
Our "AltiusExtra" web site is
continually updated with the latest providers, pricing and special offers for
Altius members. There is no cost to this program but you can bank on the
savings! Just visit www.
altiushealthplans. com
and click on "AltiusExtra", then select the
programs you are interested in.
No Computer? No Problem! Just complete and mail the brochure that you
will receive with your Altius I. D. card, or contact customer service and
we
will send you a copy of all the information from our website. The computer is
the quickest way to view the most updated information, but isn't required to
participate in the AltiusExtra program.
Overview of the "AltiusExtra" Services:
Optical Discounts:
10-30% discounts on prescription and non-prescription eyewear and other
products from participating Altius Optical providers.
Lasik Vision Eye Surgery: AltiusExtra has contracted with multiple
LASIK centers to provide more choice and greater convenience at competitive
prices.
Vitamins, Minerals and Nutritional Supplements: A complete line of quality vitamins
and minerals at significantly discounted prices delivered right to your door!
Hearing Aids: 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: 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".
Cosmetic Dentistry: Advances in
teeth whitening technology along with the cost savings available with
AltiusExtra, a brighter smile is more attainable and affordable than ever
before.
Cosmetic Surgery: There is virtually no part of the body that
can't be enhanced and improved by cosmetic surgery. Thanks to new techniques in
surgery and anesthesia, many procedures are easier, less painful, and
recovery is faster.
Massage Therapy: Therapeutic massage is an
enjoyable, non-invasive way to improve health, fitness, and general wellness.
Health Club Membership: The health clubs participating with
AltiusExtra offer discounts on individual and family memberships.
Cosmetic Dermatology: Cosmetic Dermatology offers new ways to help
skin look better.
Regular member specials and drawings for free services are unique to
AltiusExtra! This is a popular feature of Altius Extra and is on-track for
expansion in 2002!
We continually expand 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! 41
41 Page 42 43
2002 Altius
Health Plans Section 6 42
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 and we agree,
as discussed under Services requiring our prior approval on
page 11.
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;
Alternative treatments such as acupunture, acupressure, naturopathic or
homeopathic services, hypnotherapy, and biofeedback;
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;
Telephone
consultations;
Services or supplies given by a health care provider who
lives in the same household as the patient;
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. 42
42 Page 43 44
2002 Altius Health Plans 43 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 the 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 43
43 Page 44 45
2002 Altius
Health Plans 44 Section 7
(Continued) To receive reimbursement
for copayments, coinsurance, and deductibles that you have paid under your
primary plan for eligible
prescription medications, you need to submit the
following:
Original receipts or a printout from your pharmacy signed by the
Pharmacist that filled the prescription; and
Altius Coordination of Benefits (COB) claim form; and
A copy of the
explanation of benefits, payments, or denial from any primary payer --such as
the Medicare Summary Notice
(MSN)
To obtain a COB claim form, and for
any questions or assistance, call us at 801-323-6200 or 1-800-377-4161.
Submit your claims to:
Altius Health Plans Coordination of
Benefits Department
10421 South Jordan Gateway, Suite 400 South Jordan, UT
84095
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. 44
44 Page
45 46
2002 Altius Health Plans 45
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 2, 1900 E Street, Washington, D. C. 20415-3620. 45
45 Page 46 47
2002 Altius Health Plans 46 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
include 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 or from the year in which you were denied
precertification or prior
approval. This is the only deadline that may not
be extended.
OPM may disclose the information it collects during the review
process to support their disputed claim decision. This information will become
part of the court record.
You may not 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. 46
46
Page 47 48
2002
Altius Health Plans 47 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, your primary payer must process your claim
first. After the primary plan pays, we will pay the balance of what
the
primary plan shows that you owe for covered services (such as copayments,
coinsurance and deductibles), up to our regular benefit.
However, we will
not pay more than our allowance. We will waive any copayments, and/ or
coinsurance 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. If you or your spouse worked for at least 10 years in
Medicare-covered
employment, you should be able to qualify for premium-free Part A insurance.
(Someone who was a Federal employee on January 1,
1983 or since
automatically qualifies.) Otherwise, if you are age 65 or older, you may be able
to buy it. Contact 1-800-MEDICARE for
more information.
Part B (Medical
Insurance). Most people pay monthly for Part B. Generally, Part B premiums are
withheld from your monthly Social Security
check or your retirement check.
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 (Original
Medicare) is available everywhere in the United States. It is the way everyone
used to get their benefits and
is the way most people get their Medicare
Part A and Part B benefits now. You may go to any doctor, specialist, or
hospital that accepts
Medicare. The Original Medicare Plan pays its share
and you pay your share. Some things are not covered under Original Medicare,
like
prescription drugs.
(Part A or Part B) 47
47 Page 48 49
2002 Altius
Health Plans 48 Section 9
When you are enrolled in Original
Medicare along with this plan, you still need to follow the rules in this
brochure for us to cover your care.
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.) 48
48 Page 49 50
2002 Altius Health Plans 49 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
c) Are a former spouse of an annuitant
d) Are a former spouse of an active employee
Please note, if your Plan provider does not participate in Medicare, you will
have to file a claim with Medicare 49
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2002 Altius Health Plans 50 Section 9
Claims process
when you have the Original Medicare Plan— You probably will never have to
file a claim form when you have both our
Plan and the Original Medicare
Plan.
When we are the primary payer, we process the claim first.
When
Original Medicare is the primary payer, Medicare processes
your claim first.
In most cases, your 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 the Original Medicare --When
Original 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 another type of
Medicare+ Choice plan— 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 provide all the benefits that the
Original
Medicare covers. 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, even out of the managed care
plan's network and/ or service
area (if you use our Plan providers), but we will not waive any of our
copayments, coinsurance, or deductibles. If
you enroll in a Medicare managed
care plan, tell us. We will need to know whether you are in the Original
Medicare Plan or in a Medicare
managed plan so we can correctly coordinate
benefits with Medicare.
Suspended FEHB coverage to enroll in 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's service area.
If you do not enroll in Medicare Par A or Part B If you do not have
one or both Parts of Medicare, you can still be covered
under the FEHB
Program. We will not require you to enroll in Medicare 50
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2002 Altius Health Plans 51 Section 9
Part B and, if you can't get premium-free Part A, we will not ask you to
enroll in it.
TRICARE TRICARE is the health care program for members,
eligible dependents of military persons, and retirees of the military. TRICARE
includes the
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 illness or injury that the Office of Workers'
Compensation Programs (OWCP) or a similar
Federal or State agency determines
they must provide; or
OWCP or a similar agency pays for through a third
party injury settlement or other similar proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its
maximum benefits for your treatment, we will cover your care. 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 medical or hospital care for injuries 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. 51
51 Page
52 53
2002 Altius Health Plans 52
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.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 12.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. 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