Serving: Eastern and Central South Dakota, Northwestern Iowa, and Southwestern Minnesota.
Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See page 6 for requirements.
Enrollment codes for this Plan:
AV1 Self Only AV2 Self and Family
RI 73-811
For changes in benefits
see page 8.
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Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since
benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care
options best suited for themselves and their families.
In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost
this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and
on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all
reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal
employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive
outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated
services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the
FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship.
The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size, the FEHB Program is not
immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit packages and yet keep
health care affordable.
Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and your
family. We suggest you also visit our web site at www. opm. gov/ insure.
Sincerely,
Kay Coles James Director
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Notice of the Office of Personnel Management s
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
By law, the Office of Personnel Management ( OPM) , which administers the Federal Employees Health Benefits ( FEHB)
Program, is required to protect the privacy of your personal medical information. OPM is also required to give you this notice
to tell you how OPM may use and give out ( " disclose" ) your personal medical information held by OPM.
OPM will use and give out your personal medical information:
To you or someone who has the legal right to act for you ( your personal representative) ,
To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected,
To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and
Where required by law.
OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:
To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for
our assistance regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim.
For OPM and the General Accounting Office when conducting audits.
OPM may use or give out your personal medical information for the following purposes under limited circumstances:
For Government healthcare oversight activities ( such as fraud and abuse investigations) ,
For research studies that meet all privacy law requirements ( such as for medical research or education) , and
To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission ( an " authorization" ) to use or give out your personal medical information for
any purpose that is not set out in this notice. You may take back ( " revoke" ) your written permission at any time, except if
OPM has already acted based on your permission.
By law, you have the right to:
See and get a copy of your personal medical information held by OPM.
Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is
missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal
medical information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover
your personal medical information that was given to you or your personal representative, any information that you
authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a
disputed claim.
Ask OPM to communicate with you in a different manner or at a different place ( for example, by sending materials to a
P. O. Box instead of your home address) .
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Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree
to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also
call 202-606-0191 and ask for OPM s FEHB Program privacy official for this purpose.
If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the
following address:
Privacy Complaints
Office of Personnel Management
P. O. Box 707
Washington, DC 20004-0707
Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of
the Department of Health and Human Services.
By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal
medical information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of
the change. The privacy practices listed in this notice will be effective April 14, 2003.
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2003 Avera Health Plans 2 Table of Contents
Table of Contents
Introduction . ....................................................................................... 4
Plain Language ....................................................................................................................................................................................... 4
Stop Health Care Fraud! ......................................................................................................................................................................... 4
Section 1. Facts about this HMO plan ................................................................................................................................................... 6
We also have point-of service (POS) benefits....................................................................................................................... 6
How we pay providers .......................................................................................................................................................... 6
Your Rights........................................................................................................................................................................... 6
Service Area.......................................................................................................................................................................... 6
Section 2. How we change for 2003 ...................................................................................................................................................... 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...................................................................................................................................... 10
Services requiring our prior approval.................................................................................................................................. 11
Section 4. Your costs for covered services .......................................................................................................................................... 13
. Copayments .................................................................................................................................................................. 13
. Deductible..................................................................................................................................................................... 13
. Coinsurance .................................................................................................................................................................. 13
Your catastrophic protection 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................................. 25
(c) Services provided by a hospital or other facility, and ambulance services............................................................... 30
(d) Emergency services/ accidents .................................................................................................................................. 33
(e) Mental health and substance abuse benefits ............................................................................................................. 35
(f) Prescription drug benefits......................................................................................................................................... 37
(g) Special features ....................................................................................................................................................... 40
Employee Assistance program
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2003 Avera Health Plans 3 Table of Contents
(h) Dental benefits .............................................................................................................................................................. 41
(i) Point of service benefits ................................................................................................................................................. 42
Section 6. General exclusions --things we don't cover........................................................................................................................ 44
Section 7. Filing a claim for covered services ..................................................................................................................................... 45
Section 8. The disputed claims process................................................................................................................................................ 47
Section 9. Coordinating benefits with other coverage ........................................................................................................................ 49
When you have other health coverage ................................................................................................................................ 49
.. What is Medicare ......................................................................................................................................................... 49
.. Medicare managed care plan ....................................................................................................................................... 52
.. TRICARE and CHAMPVA......................................................................................................................................... 52
.. Workers' Compensation ............................................................................................................................................... 52
.. Medicaid ..................................................................................................................................................................... 53
.. Other Government agencies......................................................................................................................................... 53
.. When others are responsible for injuries...................................................................................................................... 53
Section 10. Definitions of terms we use in this brochure..................................................................................................................... 54
Section 11. FEHB facts ....................................................................................................................................................................... 56
Coverage information........................................................................................................................................................ 56
. No pre-existing condition limitation ......................................................................................................................... 56
. Where you get information about enrolling in the FEHB Program .......................................................................... 56
. Types of coverage available for you and your family............................................................................................... 56
Children's Equity Act .............................................................................................................................................. 56 .
When benefits and premiums start ............................................................................................................................ 57
. When you retire........................................................................................................................................................ 57
When you lose benefits ..................................................................................................................................................... 57
. When FEHB coverage ends ...................................................................................................................................... 57
. Spouse equity coverage............................................................................................................................................ 57
. Temporary Continuation of Coverage (TCC) .......................................................................................................... 57
. Converting to individual coverage ........................................................................................................................... 58
. Getting a Certificate of Group Health Plan Coverage.............................................................................................. 58
Long term care insurance is still available ............................................................................................................................................ 59
Index ......................................................................................................................................................................................... 60
Summary of benefits ............................................................................................................................................................................. 61
Rates ....................................................................................................................................................................................... Back cover
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2003 Avera Health Plans 4 Introduction/ Plain Language
Introduction
This brochure describes the benefits of Avera Health Plans, Inc. under our contract (CS 2863) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for the Avera Health Plans
administrative office is:
Avera Health Plans, Inc. 3900 West Avera Drive Suite 200
Sioux Falls, South Dakota 57108 5721
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.
If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self 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, 2003, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are summarized on page 8. Rates are shown at the end of this brochure.
Plain Language
All FEHB brochures are written in plain language 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 Avera 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 OPM know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM 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.
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.
Protect Yourself From Fraud -Here are some things you can do to prevent fraud:
.. Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your
doctor, other provider, or authorized plan or OPM representative. .. Let only the appropriate medical professionals review your medical record or recommend services.
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2003 Avera Health Plans 5 Introduction/ Plain Language
.. Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get
it paid. .. Carefully review explanations of benefits (EOBs) that you receive from us.
.. Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the matter, call us at 1-888-322-2115 and explain the situation.
If we do not resolve the issue call:
l Do not maintain as a family member on your policy:
.. your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
.. your child over age 22 (unless he/ she is disabled and incapable of self support).
.. If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or with
OPM if you are retired. .. You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits
or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan.
CALL --THE HEALTH CARE FRAUD HOTLINE 202-418-3300
OR WRITE TO: The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline 1900 E Street, NW, Room 6400
Washington, DC 20415
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2003 Avera Health Plans 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We encourage you to see the specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely responsible for the
selection of these providers in your area. Contact the Plan for a copy of their most recent provider directory.
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, coinsurance, and deductibles 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.
We also have Point-of-Service (POS) benefits:
Our HMO offers Point-of-Service (POS) benefits. This means you can receive covered services from a participating provider without a required referral, or from a non-participating provider. These out-of-network benefits have higher out-of-pocket costs than our in-network
benefits.
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 deductible, copayment and coinsurance. Participating
physicians and other health care professionals submit claims to us for services provided to you and they are reimbursed on a fee for service basis. The fee is an amount negotiated by the participating provider and Avera Health Plans. Participating hospitals that
provide services to Avera Health Plans members are reimbursed on a fee for service basis or on an amount that is calculated by multiplying the number of days you are hospitalized by a specified dollar amount. There are no contractual arrangements in place
between Avera Health Plans and participating providers that would create an incentive for providers to withhold care.
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.
. Avera Health Plans is a for profit division of Avera Health that was established to provide health care financing and delivery
services. . Avera Health Plans operates under a Certificate of Authority issued by the South Dakota Division of Insurance and the Iowa
Division of Insurance. . Avera Health Plans began operations in October of 1999 and provides health care coverage and services to over 10,000 individuals
in South Dakota, Iowa, Minnesota, and Nebraska.
If you want more information about us, call 605-322-4545 or 888-322-2115, or write to Avera Health Plans, 3900 W. Avera Drive, Suite 200, Sioux Falls, SD 57108-5721. You may also contact us by fax at 605/ 322-4535 or visit our website at
www. averahealthplans. com.
Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area in South Dakota is the following counties in Central and Eastern South Dakota: Aurora, Beadle, Bon Homme, Brookings, Brown, Brule,
Buffalo, Charles Mix, Clark, Clay, Codington, Davison, Deuel, Douglas, Edmonds, Faulk, Grant, Gregory, Hamlin, Hand, Hanson,
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2003 Avera Health Plans 7 Section 1
Hughes, Hutchinson, Jerauld, McPherson, Kingsbury, Lake, Lincoln, Marshall, McCook, Miner, Minnehaha, Moody, Roberts, Sanborn, Spink, Tripp, Turner, Union, Walworth, and Yankton.
In Iowa our Service Area is: Dickinson, Emmet, Lyon, O'Brien, Plymouth, Osceola, and Sioux counties.
In Minnesota our Service area is: Cottonwood, Jackson, Murray, Nobles, Pipestone and Rock counties.
Ordinarily, you must get your 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 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.
.
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2003 Avera Health Plans 8 Section 2
Section 2. How we change for 2003
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
.. A notice of the Office of Personnel Management's Privacy Practices is included.
.. A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.
.. Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHP
Program Enrollment.
.. Program information on Medicare is revised.
.. By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.
Changes to this Plan
.. Your share of the non-Postal premium will increase by 12% for Self Only or 14% for Self and Family.
.. We have changed the In Network specialty physician copay from $35 per visit to $15 per visit. (Section 5)
.. We have added two new screening services for colorectal cancer preventive care. The added screenings are:
.. Double contrast barium enema every five years starting at age 50.
.. Screening colonoscopy every 10 years starting at age 50.
.. We have changed the copay for In Network inpatient hospital maternity services from $250 to $100 per delivery.
.. We have changed the In Network inpatient copay from $250 to $100 per day to a maximum of $300 per admission for unlimited
days. No Deductible. (Section 5c and 5e)
.. We have increased the copayment for In Network non-formulary drugs from a pharmacy. The copayment for a 30-day supply is
now $35 or 50% of charges, whichever is greater. (Section 5f)
.. We have increased the copayment for In Network non-formulary mail order drugs. The copayment for a 90-day supply is now
$70 or 50% of charges, whichever is greater. (Section 5f)
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2003 Avera Health Plans 9 Section 2
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 605-322-4545 or 888-322-2115 or
wite to us at: Avera Health Plans
3900 W. Avera Drive, Suite 200 Sioux Falls, SD 57108 -5721
Where you get covered care When you get care from "Plan providers" and "Plan facilities." You will only pay copayments, deductibles, and/ or coinsurance, and you will not have to file claims. If you
use our point-of-service program, you can also get care from non-Plan providers, or from participating providers without a required referral, but it will cost you more.
. 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 www. averahealthplans. 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.
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. The name of the selected primary care physician will appear on your identification card. You do have the right to change your
primary care physician. Primary care physicians are listed in a primary care physician section of our provider directory.
. Primary care Your primary care physician can be a Family Practitioner, Internist, General Practitioner,
Obstetrician/ Gynecologist, or Pediatrician. Your primary care physician will provide most of your health care, or may 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.
. Specialty care Your primary care physician may refer you to a specialist for needed care. However, you
may see a specialist without a referral.
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 work with the specialist and with us to develop a treatment plan that allows you to access specialty care. Your primary
What you must do to get covered care
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2003 Avera Health Plans 10 Section 2
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 may continue to receive services under point-of-service (POS) benefits, but it will cost you more.
. 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, 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 may obtain approval 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 605-322-4545 or 888-322-2115. 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.
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2003 Avera Health Plans 11 Section 2
Your primary care physician has authority to refer you for most services. 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 precertification. Your physician must obtain precertification for the following services:
Chemotherapy Consideration of In Network Benefits for Out of Network Care (except emergency and
urgent care) Coronary Angiography/ Catheterization
Dialysis Durable Medical Equipment (Purchase or Total Rental), over $200
Home Health Services Hospice Care
Hyperbaric Chamber Treatment Infertility Studies
Inpatient Hospital Admissions Inpatient and Outpatient Alcoholism & Chemical Dependency Treatment
Inpatient and Outpatient Mental Health Services Lithotripsy
MRI/ MRA Non-Emergency Ambulance Transport
Occupational Therapy Organ Transplants
Outpatient Surgeries/ Procedures not performed in the Physician's Office Penile Implant
PET scans Physical Therapy
Prosthetic or Orthotic Devices, over $300 Radiation Therapy
Skilled Nursing Facility Admissions Sleep Studies
Speech Therapy Video EEGs
Injections of the following drugs when given in a Physician's Office must be precertified before administration of the drug:
Botulin Growth Hormone
Interferon Lupron
Betaserons
Under your point-of-service (POS) benefit these services need to be precertified. The ultimate responsibility for requesting precertification remains with you, however,
information provided by your provider's office will also satisfy this requirement. If you require any of the services listed above, you must contact Medical Management at 1-888-
605-1331 as soon as possible after the indication of need for the services.
The AHP Medical Management Department will review the Member profile information against standard criteria. A determination will be made by the Medical Management
Department within forty-eight (48) hours of the initial request or the next business day if the request is made on a weekend or holiday. The determination shall either be an
authorization for the requested service or additional review by the AHP Medical Director.
Services requiring our prior approval
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2003 Avera Health Plans 12 Section 2
If the determination is to authorize the requested service, you, the attending provider, and those providers involved in the provision of the service shall be notified of the decision in
writing. When the service is approved, the Medical Management Department will assign an authorization number.
When the request requires a need for further review, an intensified review will be performed by the AHP Medical Director. If additional documentation is required, you,
your representative, and/ or the Provider shall be responsible for submitting any necessary information. A determination either authorizing or denying the request for services will
be made in writing. The attending practitioner, those providers involved in the provision of the service and you shall be notified of the decision.
If the decision is to deny the service, you and those providers who are involved in the provision of the service shall be informed of the reasons for the denial and the disputed
claims process. (See page 47)
AHP will not deny coverage for the health care services listed in this section which you have already received solely on the basis of lack of precertification to the extent that the
health care services would otherwise have been covered had precertification been obtained.
Services listed in this section that you obtain under the point-of-service (out of network) are subject to precertification.
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2003 Avera 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 when you go in the hospital, you pay $100 per day to a maximum of $300
per admission.
. Deductible A deductible is a fixed expense you must incur for certain covered services and supplies
before we start paying benefits for them. Copayments do not count toward any deductible.
The calendar year deductible is $350 per person under our Plan. Under a family enrollment, the deductible is considered satisfied and benefits are payable for all family
members when the combined covered expenses applied to the calendar year deductible for family members reach $700 under our Plan.
Note: If you change plans during open season, you do not have to start a new deductible under your old plan between January 1 and the effective date of your new plan. If you
change plans at another time during the year, you must begin a new deductible under your new plan.
And, if you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the
deductible of your new option.
. Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.
Coinsurance doesn't begin until you meet your deductible.
Example: In our Plan, you pay 20% of our allowance for infertility services and durable medical equipment for services received in network.
After your coinsurance totals $1,500 per person or $3,000 per family enrollment in any calendar year, you do not have to pay any more for covered services. However,
copayments for the following services do not count toward your out-of-pocket maximum, and you must continue to pay copayments for these services:
. Physician office visits
. Preventive care examinations
. Chiropractic office visits
. Hospital services
. Skilled nursing facility services
. Outpatient mental health services
. Inpatient chemical dependency treatment
. Partial day chemical dependency treatment
. Prescription drugs
Be sure to keep accurate records of your coinsurance since you are responsible for informing us when you reach the maximum.
Your catastrophic protection out-of-pocket maximum for
coinsurance
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2003 Avera Health Plans 14 Section 4
Section 5. Benefits OVERVIEW
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 888-322-2115 or at our website at www. averahealthplans. com.
(a) Medical services and supplies provided by physicians and other health care professionals........................................................ 15-24
. 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 ................................................ 25-29
. Surgical procedures
. Reconstructive surgery
. Oral and maxillofacial surgery
. Organ/ tissue transplants
. Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services .............................................................................. 30-32
. Inpatient hospital
. Outpatient hospital or ambulatory surgical center
. Extended care benefits/ skilled nursing care facility benefits
. Hospice care
. Ambulance
(d) Emergency services/ accidents ................................................................................................................................................. 33-34 . Medical emergency . Ambulance
(e) Mental health and substance abuse benefits ............................................................................................................................ 35-36
(f) Prescription drug benefits ........................................................................................................................................................ 37-39
(g) Special features ............................................................................................................................................................................. 40 . Employee Assistance Program
(h) Dental benefits .............................................................................................................................................................................. 41
(i) Point of service benefits ................................................................................................................................................................ 42
Summary of benefits ............................................................................................................................................................................. 61
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2003 Avera Health Plans 15 Section 5( a)
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.
.. The calendar year deductible is: $350 per person and $700 per family for In-Network Services. For Out
of Network Services the calendar year deductible is $1,500 per person and $3000 per family. The calendar year deductible applies to almost all benefits in this Section.
.. 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 After the calendar year deductible
NOTE: The calendar year deductible applies to almost all benefits in this Section.
Diagnostic and treatment services You pay
Professional services of physicians
.. In physician's office
In Network: $10 per visit to your primary care physician
$15 per visit to a specialist
Out of Network: 40% after deductible, plus any difference
between our allowable charge and the provider's actual charge.
Professional services of physicians ..
In an urgent care center ..
During a hospital stay ..
In a skilled nursing facility ..
Office medical consultations ..
Second surgical opinion
In Network: 20% after deductible
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
At home Nothing
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2003 Avera Health Plans 16 Section 5( a)
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
.. Blood tests
.. Urinalysis
.. Non-routine pap tests
.. Pathology
.. X-rays
.. Non-routine Mammograms
.. Cat Scans/ MRI
.. Ultrasound
.. Electrocardiogram and EEG
In Network: 20% after deductible
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
Preventive care, adult You pay
Routine Screenings such as:
.. Total Blood Cholesterol once every three years
.. Colorectal Cancer Screening, including:
.. Fecal occult blood test annually
.. Double contrast barium enema every five years starting at age 50
.. Sigmoidoscopy, screening every five years starting at age 50
.. Screening Colonoscopy every ten years starting at age 50
.. Routine 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.
I n Network: $10 copay with PCP
$15 copay with specialist
Out of Network: All Charges
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
I n Network: Nothing
Out of Network: All Charges
Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel. All charges.
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2003 Avera Health Plans 17 Section 5( a)
Preventive care, children You pay
.. Childhood immunizations recommended by the American Academy
of Pediatrics I n Network: Nothing
Out of Network: All Charges
.. Well-child care charges for routine examinations, immunizations and
care (through age 18)
.. Examinations, such as:
.. Eye exams to determine the need for vision correction.
.. Ear exams through age 17 to determine the need for hearing
correction
.. Examinations done on the day of immunizations (through age 18)
In Network: Nothing with PCP to age 6
$10 with PCP age 7-18 $15 with a Specialist
Out of Network: All Charges
For Lab and X-ray: In Network:
20% after deductible
Out of Network: All Charges
Maternity care You pay
Complete maternity (obstetrical) care, such as:
.. Prenatal care
.. Delivery
.. Postnatal care
Note: Here are some things to keep in mind:
.. You do not need to precertify your normal delivery; see page 11 for
other circumstances, such as extended stays for you or your baby.
.. 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).
In Network: Nothing
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
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22
2003 Avera Health Plans 18 Section 5( a)
Family planning You pay
A range of voluntary family planning services, limited to:
.. Voluntary sterilization (See Surgical procedures Section 5( b))
.. Surgically implanted contraceptives (such as Norplant)
.. Injectable contraceptive drugs (such as Depo provera)
.. Intrauterine devices (IUDs)
.. Diaphragms
NOTE: We cover oral contraceptives under the prescription drug benefit.
In Network: $10 per visit to your primary care
physician $15 per visit to a specialist
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
Not covered: reversal of voluntary sterilization, genetic counseling and testing All Charges
Infertility services You pay
Diagnosis and treatment of infertility, such as:
.. Artificial insemination:
.. Intravaginal insemination (IVI)
.. Intracervical insemination (ICI)
In Network: 20% after deductible
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
Not covered:
.. Assisted reproductive technology (ART) procedures, such as:
.. in vitro 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
.. Infertility services after voluntary sterilization
.. Infertility Drugs
All charges.
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23
2003 Avera Health Plans 19 Section 5( a)
Allergy care You pay
Testing and treatment
Allergy injection
In Network: 20% after deductible
Out of Network: 40% after deductible plus any
difference between our allowable charge and the provider's actual charge.
Allergy serum In Network: Nothing
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
Not Covered: provocative food testing and sublingual allergy desensitizing All Charges
Treatment therapies You pay
.. 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 27.
.. Respiratory and inhalation therapy
.. Dialysis hemodialysis and peritoneal dialysis
.. Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy
.. Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: We will only cover GHT when we preauthorize the treatment. Call (800) 698-0190 for preauthorization. We will ask you to submit
information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise we will only cover
GHT services from the date you submit the information. If you do not ask or if we determine that GHT is not medically necessary, we will not cover
the GHT or related services and supplies. See Services requiring our prior approval in Section 3.
In Network: 20% after deductible
Out of Network: 40% after deductible plus any
difference between our allowable charge and the provider's actual charge.
Not covered:
.. Chelation Therapy
All charges.
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Page 23
24
2003 Avera Health Plans 20 Section 5( a)
Physical and occupational therapies You pay
.. Up to 2 consecutive months per condition for physical and occupational
therapy.
.. Level II Cardiac rehabilitation
Note: These services require precertification.
Note: We only cover therapy to restore bodily function when there has been a total or partial loss or bodily function due to illness or injury.
In Network: 20% after deductible
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
Not covered:
.. long-term rehabilitative therapy
.. lifestyle improvement services such as physical fitness programs health
or weight loss clubs, or clinics.
All charges.
Speech therapy You pay
Up to 2 consecutive months per condition. In Network:
20% after deductible
Out of Network: 40% after deductible plus any
difference between our allowable charge and the provider's actual charge.
Hearing services (testing, treatment, and supplies) You pay
.. Hearing testing for children through age 17 (see Preventive care,
children) In Network: $15 copay
Out of Network: All charges
Not covered:
.. all other hearing testing
.. hearing aids, testing and examinations for them
All charges.
Vision services (testing, treatment, and supplies) You pay
One complete exam per Calendar Year for eyeglasses (spectacles) or up to the spectacle exam amount for contact lens exam. In Network: Nothing
Out of Network: All charges
Vision services -continued on next page
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25
2003 Avera Health Plans 21 Section 5( a)
Vision services (testing, treatment, and supplies) (continued) You pay
Vision services for aphakia patients and for treatment of a disease or injury, limited to services for the prescribing and fitting of eyeglasses or
contact lenses for aphakia patients or soft contact lenses or scleral shells intended for use in the treatment of a eye disease or injury (one pair per
calendar year).
In Network: 20% after deductible
Out of Network: 40% after deductible plus any
difference between our allowable charge and the provider's actual charge.
Not covered:
.. Examination, purchase, or fitting of eyeglasses or contact lenses except
as specifically covered elsewhere.
.. Eye exercises and orthoptics
.. Radial keratotomy and other refractive surgery
All charges.
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.
In Network: $15 copay
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
Podiatry Services In Network:
20% after deductible.
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
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)
All charges.
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26
2003 Avera Health Plans 22 Section 5( a)
Orthopedic and prosthetic devices You pay
.. Artificial limbs and eyes; stump hose
.. Externally worn breast prostheses and surgical bras, including necessary
replacements, following a mastectomy
.. Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant following mastectomy. Note: We pay internal prosthetic devices as hospital
benefits; see Section 5( c) for payment information. See 5( b) for coverage of the surgery to insert the device.
.. Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
In Network: 20% after deductible.
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
Not covered:
.. orthopedic and corrective shoes
.. arch supports
.. foot orthotics
.. heel pads and heel cups
.. lumbosacral supports
.. corsets, trusses, elastic stockings, support hose, and other supportive
devices
.. prosthetic replacements provided more frequently than the products
useful life as stated by the manufacturer.
All charges.
Durable medical equipment (DME) You pay
Rental or purchase at our option and the option to select appropriate new, used or refurbished DME, including repair and adjustment of DME
prescribed by your Plan physician. Rental costs shall not exceed the allowable charge for the DME purchase. Coverage for oxygen units is
limited to one stationary and one portable unit, based on medical necessity. Under this benefit we also cover:
.. Crutches
.. Walkers
.. Wheelchairs
.. Nebulizers
In Network: 20% after deductible.
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
Not covered
.. motorized equipment
.. commonly available batteries for durable medical equipment.
All charges.
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27
2003 Avera Health Plans 23 Section 5( a)
Home health services You pay
.. 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.
In Network: 20% after deductible.
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
Not covered:
.. Nursing care requested by, or for the convenience of, the patient or the
patient's family;
.. Home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or rehabilitative.
All charges.
Chiropractic You Pay
.. Chiropractic Services from a doctor of chiropractic who deals with the
relationship of the nervous system and the spinal column in the restoration and maintenance of health.
Note: Services are limited to 20 visits per calendar year.
In Network: $15 copay
Out of Network: All charges
Alternative treatments You pay
No Benefit. All charges
Educational classes and programs You pay
Diabetic Education, Supplies and Equipment
.. Equipment and supplies including medical nutrition therapy.
.. Diabetes self-management training and education provided by a
licensed healthcare provider certified as a diabetic educator by the National Certification Board for Diabetic Educators. Coverage limited
to persons newly diagnosed with diabetes, or persons requiring a change in diabetes therapy, persons with comorbidities, or persons whose
diabetic condition is unstable.
Note: Coverage is limited to 2 comprehensive sessions per lifetime, and up to 8 follow up visits per year.
In Network: 20% after deductible.
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
Educational classes and programs -continued on next page
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28
2003 Avera Health Plans 24 Section 5( a)
Educational classes and programs (continued) You pay
Smoking Cessation-Up to $300 per lifetime for smoking cessation drug products and up to $200 per lifetime of contract for one smoking
cessation program approved by AHP.
In Network: 20% after deductible.
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
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29
2003 Avera Health Plans 25 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.
.. The calendar year deductible is: $350 per person and $700 per family for In Network services. For Out of
Network services the calendar year deductible is $1, 500 per person and $3, 000 per family. The calendar year deductible applies to almost all benefits in this Section.
.. 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.).
.. YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please
refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.
I M
P O
R T
A N
T
Benefit Description You pay After the calendar year deductible
NOTE: The calendar year deductible applies to almost all benefits in this Section.
Surgical procedures You pay
A comprehensive range of services, such as: .. Operative procedures
.. Treatment of fractures, including casting
.. Normal pre-and post-operative care by the surgeon
.. Correction of amblyopia and strabismus
.. Endoscopy procedures
.. Biopsy procedures
.. Removal of tumors and cysts
.. Correction of congenital anomalies (see reconstructive surgery)
.. 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. .. Insertion of internal prosthetic devices. See 5( a) Orthopedic and
prosthetic devices for device coverage information.
In Network: 20% after deductible.
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
.. Voluntary sterilization
.. Treatment of burns
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.
In Network: 20% after deductible.
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
Surgical procedures -continued on next page
28.
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2003 Avera Health Plans 26 Section 5( b)
Reconstructive surgery You pay
.. 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, such as
lymphedemas;
.. breast prostheses and surgical bras and replacements (see
Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.
In Network: 20% after deductible.
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
Not covered: .. Cosmetic surgery and other supplies and services for conditions that
are not the result of disease, injury, trauma, congenital, or developmental abnormalities, which are meant to improve
appearances, including but not limited to breast augmentation or reduction, rhinoplasty, liposuction, and cosmetic dental services
.. Surgeries related to sex transformation
All charges.
29.
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31
2003 Avera Health Plans 27 Section 5( b)
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to: .. Reduction of fractures of the jaws or facial bones;
.. Surgical correction of cleft lip, cleft palate or severe functional
malocclusion; .. Removal of stones from salivary ducts;
.. Excision of leukoplakia or malignancies;
.. Excision of cysts and incision of abscesses when done as independent
procedures; and .. Other surgical procedures that do not involve the teeth or their
Supporting structures.
In Network: 20% after deductible.
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
Not covered: .. Procedures that involve the teeth or their supporting structures (such
as the periodontal membrane, gingival and alveolar bone).
.. Services and supplies related to Ridge Augumentation, Inplantology,
and Preventive Vestivuloplasty.
.. Dental Services, not specifically listed as Covered Services, including
dental x-rays, shortening of the mandible or maxillae for cosmetic purposes.
All charges.
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32
2003 Avera Health Plans 28 Section 5( b)
Organ/ tissue transplants You pay
Limited to: .. Cornea
.. Heart
.. Heart/ lung
.. Kidney
.. Kidney/ Pancreas
.. Liver
.. Lung: Single Double
.. Pancreas
.. Allogeneic (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
Note: We cover related medical and hospital expenses of the donor when we cover the recipient.
In Network: 20% after deductible.
Out of Network: All charges
Medical expenses for the testing to identify a suitable donor, surgical extraction, storage and transportation costs incurred that are directly related
to the donation of the organ used in an organ transplant procedure. The maximum benefit payable for organ procurement shall not exceed $20,000
for each covered organ transplant procedure that is not covered by any other group health plan or coverage arrangement.
In Network: 20% after deductible.
Out of Network: All charges
Organ/ tissue transplants continued on next page
31.
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2003 Avera Health Plans 29 Section 5( b)
Organ/ tissue transplants (continued) You pay
Necessary and reasonable transportation, lodging and meal expenses are covered benefits subject to all of the following conditions:
.. Expenses will be covered benefit if incurred for the confinement
period during which the transplant occurs and the immediate inpatient post-operative care period, including expenses incurred for travel to
the site of the covered transplant procedure. .. Meal and Lodging expenses will be a covered benefit during the
transplant confinement period and immediate post-operative care period up to a combined daily maximum of $150 for the recipient,
attendant, and if a bone marrow transplant procedure, the bone marrow transplant donor.
.. In no event shall the total of necessary and reasonable expenses exceed
$10,000 for each transplant .. Coverage for transportation, lodging and meal expenses are per
transplant procedure and are not an annual benefit. .. Expense reimbursement is available only while the Organ Transplant
Recipient is covered by AHP.
All charges in excess of $150 per day and in excess of $10,000 transplant limit.
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
.. Expenses related to transplants of animal organs
All charges.
Anesthesia You pay
Professional services provided in
.. Hospital (inpatient)
In Network: 20% after deductible.
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
Professional services provided in
.. Hospital outpatient department
.. Skilled nursing facility
.. Ambulatory surgical center
.. Office
In Network: 20% after deductible.
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
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2003 Avera Health Plans 30 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.
.. In this section, unlike sections (a) and (b), the calendar year deductible applies to only a few
benefits. In that case, we added "( calendar year deductible applies)". The calendar year deductible is: $350 per person and $700 per family. For Out of Network Services the calendar
year deductible is $1,500 per person and $3,000 per family.
.. 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).
.. YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please
refer to Section 3 to be sure which services require precertification.
I M
P O
R T
A N
T
Benefit Description You pay
NOTE: The calendar year deductible applies only when we say below: "( calendar year deductible applies)"
Inpatient hospital
Room and board, such as .. ward, semiprivate, or intensive care accommodations;
.. general nursing care; and
.. meals and special diets.
NOTE: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.
In Network: $100 per day copay to a maximum of
$300 per admission for unlimited days. No deductible.
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
Hospitalization for maternity care In Network: $100 copay per delivery.
Out of Network:
40% after deductible plus any difference between our allowable charge and the
provider's actual charge.
Inpatient hospital -continued on next page
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2003 Avera Health Plans 31 Section 5( c)
Inpatient hospital (continued) You pay
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 not donated or replaced
.. Dressings, splints, casts, and sterile tray services
.. Medical supplies and equipment, including oxygen
.. Anesthetics, including nurse anesthetist services
.. Take-home items
.. Medical supplies, appliances, medical equipment, and any covered
items billed by a hospital for use at home (Note: calendar year deductible applies.)
Nothing
Not covered: .. Custodial care
.. Non-covered facilities, such as nursing homes, schools
.. Personal comfort items, such as telephone, television, barber
services, guest meals and beds .. Private nursing care
All charges.
Outpatient hospital or ambulatory surgical center You pay
.. Operating, recovery, and other treatment rooms
.. Prescribed drugs and medicines
.. Diagnostic laboratory tests, X-rays, and pathology services
.. Administration of blood, blood plasma, and other biologicals
.. Blood and blood plasma, if not donated or replaced
.. Pre-surgical testing
.. Dressings, casts, and sterile tray services
.. Medical supplies, including oxygen
.. Anesthetics and anesthesia service
NOTE: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.
Calendar year deductible applies.
In Network: 20% after deductible.
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
The administration of whole blood and blood plasma Nothing
Not covered: The purchase of whole blood and blood components, unless such blood components are classified as drugs in the United
States Pharmacopoeia.
All charges.
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2003 Avera Health Plans 32 Section 5( c)
Extended carebenefits/ skilled nursingcarefacilitybenefits You pay
The following services are covered: .. Skilled nursing care, whether provided in an inpatient skilled nursing
unit, a skilled nursing facility, or in a home health care program. .. Room and board in a skilled nursing facility.
.. Special diets in a skilled nursing facility, if specifically ordered.
.. 100 days per calendar year.
Note: Care must be approved by AHP in lieu of continued or anticipated hospitalization.
In Network: $100 per day copay to a maximum of
$300 per admission for unlimited days. No deductible
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
Not covered: Confinement in a nursing home for custodial, convalescent, intermediate level, or domiciliary care, rest cures or care,
or services to assist in activities of daily living.
All Charges
Hospice care You pay
Coverage is provided when:
.. The member elects hospice care instead of traditional covered
services; .. The member has been diagnosed with a terminal disease and a life
Expectancy of six months or less: and .. Hospice has been approved by AHP
The following services are covered:
.. Admission to a hospice facility, hospital, skilled nursing care facility
for room and board, supplies and services for pain management and other acute/ chronic symptom management.
.. Part-time intermittent nursing care by a Registered Nurse (RN),
Licensed Practical Nurse/ Licensed Vocational Nurse (LPN/ LVN), or home health aide for patient care up to 8 hours per day.
.. Social services under the direction of a participating provider.
.. Psychological and dietary counseling.
Note: Hospice care may be provided as inpatient or outpatient services with a combined benefit limit of 185 days.
Calendar year deductible applies
In Network: 20% after deductible
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
Ambulance You pay
.. Local professional ambulance service when medically appropriate Calendar year deductible applies
In Network: 20% after deductible
Out of Network: 20% after deductible
Not covered:
.. Non-Emergency Travel, unless approved and arranged by AHP.
All Charges
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2003 Avera Health Plans 33 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
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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. .. The calendar year deductible is: $350 per person and $700 per family for In Network Services. For Out of Network
Services the calendar year deductible is $1, 500 per person and $3, 000 per family. The calendar year deductible applies to almost all benefits in this Section.
.. 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 an emergency condition arises, members should proceed to the nearest emergency facility. If the emergency condition is such that a member cannot go safely to the nearest participating emergency facility,
then the member should seek care at the nearest emergency facility. An urgent care situation is a degree of illness or injury, which is less severe than an emergency condition, but requires prompt medical attention within twenty-four (24) hours. If an
urgent care situation occurs, members should contact their primary care provider immediately and follow the primary care provider's instructions.
Emergencies outside our service area: If an emergency occurs when traveling outside of AHP's service area, members should go to the nearest emergency facility to receive care. The member or a designated relative or friend must notify AHP
and the member's primary care provider as soon as reasonably possible, and no later than 48 hours after physically or mentally able to do so. In-Network coverage will be provided for emergency conditions outside of the service area unless the
member has traveled outside the service area for the purpose of receiving such treatment.
Benefit Description You pay
Emergency within our service area You pay
.. Emergency care at a doctor's office
.. Emergency care at an urgent care center
.. Emergency care as an outpatient or inpatient at a hospital, including
doctors' services
20% after deductible
Emergency outside our service area You pay
.. Emergency care at a doctor's office
.. Emergency care at an urgent care center
.. Emergency care as an outpatient or inpatient at a hospital, including
doctors' services
20% after deductible
Emergency outside our service area continued on next page
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2003 Avera Health Plans 34 Section 5( d)
Emergency outside our service area (continued) You pay
Not covered: .. Elective care or non-emergency care
.. Emergency care provided outside the service area if the need for care
could have been foreseen before leaving the service area
All charges
Ambulance
Professional ambulance service when medically appropriate.
See 5( c) for non-emergency service.
In Network: 20% after deductible
Out of Network: 20% after deductible
Not covered: .. Non-emergency travel unless approved and arranged By AHP All charges
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2003 Avera Health Plans 35 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:
.. 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. ..
The calendar year deductible or, for facility care, the inpatient deductible apply to almost all benefits in this Section. We added "( No deductible)" to show when a deductible does not apply.
.. The calendar year deductible is $350 per person and $700 per family for In Network Services. For Out of
Network Services the calendar year deductible is $1,500 per person and $3,000 per family. The calendar year deductible applies to almost all benefits in this Section.
.. 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 After the calendar year deductible
Mental health and substance abuse benefits You pay
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 other illness or conditions.
Mental health and substance abuse benefits -continued on next page
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2003 Avera Health Plans 36 Section 5( e)
Mental health and substance abuse benefits (continued) You pay
.. Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social workers
.. Medication management
In Network: $15 copay. No deductible
Out of Network: 40% after deductible plus any
difference between our allowable charge and the provider's actual
charge.
.. Diagnostic tests In Network:
20% after deductible
Out of Network: 40% after deductible plus any
difference between our allowable charge and the provider's actual
charge.
.. Services provided by a hospital or other facility.
.. Services in approved alternative care settings such as partial
hospitalization, halfway house, residential treatment, full-day hospitalization, facility based intensive outpatient treatment.
In Network: $100 per day copay to a maximum of
$300 per admission for unlimited days. No deductible.
Out of Network:
40% after deductible plus any difference between our allowable
charge and the provider's actual charge.
.. Chemical Dependency, Outpatient Treatment from a licensed or
certified provider. In Network: 20% after deductible
Out of Network: 40% after deductible plus any
difference between our allowable charge and the provider's actual
charge.
Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all the authorization processes found on pages 10 and 11.
Limitation We may limit your benefits if you do not obtain a treatment plan.
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2003 Avera Health Plans 37 Section 5( e)
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.
.. The calendar year deductible does not apply to benefits in this Section.
.. Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing
works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
There are important features you should be aware of. These include:
.. Who can write your prescription? A licensed physician or licensed dentist must write the prescription.
.. Where you can obtain them? You must fill the prescription at a participating pharmacy, or by mail for a
maintenance medication.
.. We use a formulary. We cover non-formulary drugs prescribed by a Plan doctor. If your physician believes a
name brand product is necessary or there is no generic available, your physician may prescribe a name brand drug from a formulary list. This list of name brand drugs is a preferred list of drugs that we selected to meet
patient needs at a lower cost. To order a prescription drug brochure, call (888) 322-2115.
.. These are the dispensing limitations. Prescription drugs are dispensed in a 30-day supply, or less, if less is
needed. A 90-day supply of maintenance drugs may be obtained through mail order. A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a name
brand drug, when a Federally-approved generic drug is available, you have to pay the higher copay for the brand name drug.
.. Why use generic drugs? Generic drugs offer a safe and economic way to meet your prescription drug needs.
The generic name of a drug is its chemical name; the name brand is the name under which the manufacturer advertises and sells a drug. Under federal law, generic and name brand drugs must met the same standards for
safety, purity, strength, and effectiveness. A generic prescription costs you and us less than a name brand prescription.
.. When you have to file a claim. Read section 7 regarding the procedure for filing a pharmacy claim.
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2003 Avera Health Plans 38 Section 5( e)
Benefit Description You pay
Covered medications and supplies You pay
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order
program:
.. Drugs and medicines that by Federal law of the United States require
a physician's prescription for their purchase except those listed as Not covered.
.. Insulin
.. Drugs for sexual dysfunction
.. Contraceptive drugs and devices
In Network: (30 day supply) Generic: $10 copay
Formulary/ Preferred: $20 copay Non-Formulary: $35 copay or 50% of
charges, which ever is greater.
In Network: (90 day supply-mail order) Generic: $20 copay
Formulary/ Preferred: $40 copay Non-Formulary: $70 copay or 50% of
charges, which ever is greater.
Out of Network: All Charges
Diabetic supplies and insulin
.. A 30-day supply of diabetic needles, syringes, wipes, strips, and
pump supplies; and .. Either a 30-day supply or one 10-ml bottle, whichever is greater, of
injectable insulin.
Note: Each of the above shall constitute a separate prescription "supply" for copay purposes, and together they constitute the maximum amount of diabetic
treatment that may be dispensed at any one time.
In Network: (30 day supply) Generic: $10 copay
Formulary/ Preferred: $20 copay Non-Formulary: $35 copay or 50% of
charges, which ever is greater.
In Network: (90 day supply-mail order) Generic: $20 copay
Formulary/ Preferred: $40 copay Non-Formulary: $70 copay or 50% of
charges, which ever is greater.
Out of Network: All Charges
Birth Control Drugs and Devices including, but not limited to:
.. IUDS
.. Implantable birth control devices, e. g., Norplant and Depo-Provera
In Network: (30 day supply) Generic: $10 copay
Formulary/ Preferred: $20 copay Non-Formulary: $35 copay or 50% of
charges, which ever is greater.
In Network: (90 day supply-mail order) Generic: $20 copay
Formulary/ Preferred: $40 copay Non-Formulary: $70 copay or 50% of
charges, which ever is greater.
Out of Net Work: All Charges
Covered medications and supplies continued on next page
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2003 Avera Health Plans 39 Section 5( e)
Covered medications and supplies You pay
Not covered:
.. Drugs and supplies for cosmetic purposes
.. Drugs to enhance athletic performance
.. Fertility drugs
.. Drugs obtained at a non-Plan pharmacy; except for out-of-area
emergencies
.. Vitamins, nutrients and food supplements even if a physician
prescribes or administers them
.. Nonprescription medicines
All charges
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2003 Avera Health Plans 40 Section 5( g)
Section 5 (g). Special features
Feature Description
Employee Assistance Program Employee Assistance Program for individual and family problems that have a negative impact upon personal or work life. Benefits include up to three counseling sessions with a behavioral health professional per contract year,
access to behavioral health professionals with a wide range of expertise in family, couples, individual, and substance abuse related services, and access to
toll-free Referral Service line 24 hours/ 7 days a week.
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2003 Avera Health Plans 41 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
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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.
.. The calendar year deductible is: $350 per person and $700 per family for In-Network Services. For Out of
Network Services the calendar year deductible is $1, 500 per person and $3, 000 per family. The calendar year deductible applies to almost all benefits in this Section.
.. We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes
hospitalization necessary to safeguard the health of the patient. See Section 5 (c) for inpatient hospital benefits. We do not cover the dental procedure unless it is described below.
.. Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works.
Also read Section 9 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.
In Network: $15 per visit to a specialist
20% after deductible for other covered services.
Out of Network: 40% after deductible plus any
difference between our allowable charge and the provider's actual charge.
Dental benefits
We have no other dental benefits.
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2003 Avera Health Plans 42 Section 5( i)
Section 5 (i). Point of service benefits
Point of Service (POS) Benefits
Facts about this Plan's POS option At your option, you may choose to obtain benefits covered by this Plan from non-Plan doctors and hospitals whenever you need care,
except for the benefits listed below under "What is not covered." Benefits not covered under Point of Service must either be received from or arranged by Plan doctors to be covered. When you obtain covered non-emergency medical treatment from a non-Plan doctor
without a referral from a Plan doctor, you are subject to the deductibles, coinsurance and maximum benefit stated below.
What is covered Most of the covered services described in Section 5 allow you to choose a non-participating provider, except those listed in "What is
not covered". When you choose non-participating providers, covered services provided by those providers are covered at the "out of network" level as described in Section 5. All covered services provided by a participating or in-network provider, are covered at the
in-network benefit level.
Services do not need to be obtained within the Plan service area to be eligible for coverage under POS.
Precertification Services received out-of-network are subject to the same precertification or prior approval requirements as described in Section 3.
You do not need to obtain a referral from a Plan doctor prior to seeking a non-Plan doctor, but you or the non-plan doctor must obtain prior approval before receiving any of the procedures listed in Section 3 as requiring prior approval. Failure to obtain prior approval
may result in benefits being denied, however we will not deny coverage solely on the basis of lack of precertification to the extent that the health care services would have been covered had precertification been obtained.
Deductible The plan deductible for Point of Service benefits is $1,500 for an individual and $3,000 for a family.
Coinsurance The coinsurance requirement for covered Point of Service benefits is 40% of the Plan's allowable charge to be paid by you, and 60%
to be paid by the Plan, after the deductible. You will also be responsible for any difference between our allowable charge and the non-participating provider's actual charge.
Maximum benefit The catastrophic maximums you will have to pay for Point of Service care is $10,000 for an individual or a family. Out of pocket
expenses under POS do not qualify for the Plan's in-network catastrophic maximum.
Hospital/ extended care When you use a non-participating hospital it is an out of network service, however, if you use a participating hospital you will receive
in network benefits even if you use non-plan doctors.
Emergency benefits True emergency care is always payable as an in-Plan benefit.
What is not covered The following covered services do not have Point of Service coverage:
.. Adult Preventive Care
.. Children Preventive Care
.. Vision Examination for eyeglasses or contact lenses
.. Chiropractic Services
.. Organ/ Tissue Transplants
.. Prescription Drugs
Section 5 (i). Point of service benefits continued on next page
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2003 Avera Health Plans 43 Section 5( i)
How to obtain benefits You may access covered Point of Service benefits directly. You may also contact us and ask us to consider In-Network benefits
for out of network services that are medically necessary and not available within the Plan's network by calling Medical Management at 1-888-605-1331.
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2003 Avera Health Plans 44 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury,
or condition.
We do not cover the following:
.. Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);
.. Services, drugs, or supplies you receive while you are not enrolled in this Plan;
.. Services, drugs, or supplies that are not medically necessary;
.. Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;
.. Experimental or investigational procedures, treatments, drugs or devices;
.. Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were
carried to term or when the pregnancy is the result of an act of rape or incest;
.. Services, drugs, or supplies related to sex transformations; or
.. Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.
.. Services, drugs, or supplies you receive without charge while in active military service.
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2003 Avera Health Plans 45 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, coinsurance, or deductible.
You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:
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 and also to get a copy of the claim form, call us at (888) 322-2115.
When you must file a claim --such as for services your receive outside of the Plan's service area --submit it on a HCFA-1500 claim form that includes the information shown
below. Bills and receipts should be itemized and show:
Covered member's name and ID number;
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: Avera Health Plans 3900 West Avera Drive, Suite 200
Sioux Falls, SD 57108-5721
Prescription drugs Network pharmacies will usually submit your claims electronically for you. If you need to submit a claim on your own, contact Customer Service at (888) 322-2115 to obtain a
claim form.
When you file a claim form, you must include a receipt from the pharmacy showing the following:
Name of the drug;
Amount Dispensed;
Price you paid for the drug.
Submit your claims to: Avera Health Plans 3900 West Avera Drive, Suite 200
Sioux Falls, SD 57108-5721
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
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2003 Avera Health Plans 46 Section 7
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.
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2003 Avera Health Plans 47 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 preauthorization:
Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: Avera Health Plans Attn: Appeals Coordinator
3900 West Avera Drive, Suite 200 Sioux Falls, SD 57108-5721; 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, NW, Washington, DC 20415-3620.
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2003 Avera Health Plans 48 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 more than one claim, you must clearly identify which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request.
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 preauthorization/ prior approval, then call us at (888) 605-1331 and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ 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 may call OPM's Health Benefits Contracts Division 2 at 202/ 606-3818 between 8 a. m. and 5 p. m. eastern time.
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2003 Avera Health Plans 49 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays health care expenses without regard to
fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer. We, like
other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit. We will
not pay more than our allowance.
. 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 (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people
get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay
your share. Some things are not covered under Original Medicare, like prescription drugs.
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. This includes following procedures
for precertification of procedures and treatments.
. The Original Medicare Plan
(Part A or Part B)
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2003 Avera 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 then provide
secondary benefits for covered charges. You will not need to do anything. To find out if you need to do something to file your claim, call us at (888) 322-2115.
We do not waive any costs if the original Medicare Plan is your primary payer
(Primary payer chart begins on next page.)
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2003 Avera Health Plans 51 Section 9
The following chart illustrates whether the Original Medicare Plan 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 with theFederalgovernment(including whenyouora familymemberare eligibleforMedicaresolely becauseofadisability), .
2) Are an annuitant, .
.
3) Are a reemployed 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