Health Net of Arizona,
Inc. http:// www. health. net
2004
Serving: Cochise, Gila, Maricopa, Pima, Pinal and Santa Cruz counties
Enrollment in this Plan is limited. You must live or work in our
Geographic service area to enroll. See page 8 for requirements.
Enrollment codes for this Plan:
A71 Self Only
A72 Self and Family
RI 73-283
For changes
in benefits
see page 9.
A Health Maintenance Organization
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Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this 2004 Federal Employees Health Benefits (FEHB) Program plan brochure. The brochure describes the
benefits this plan offers you for 2004. Because benefits vary from year to year, you should review your plan's brochure every Open
Season Ð especially Section 2, which explains how the plan changed.
It takes a lot of information to help a consumer make wise healthcare decisions. The information in this brochure, our FEHB Guide,
and our web-based resources, make it easier than ever to get information about plans, to compare benefits and to read customer service
satisfaction ratings for the national and local plans that may be of interest. Just click on www. opm. gov/ insure!
The FEHB Program continues to be an enviable national model that offers exceptional choice, and uses private-sector competition to
keep costs reasonable, ensure high-quality care, and spur innovation. The Program, which began in 1960, is sound and has stood the
test of time. It enjoys one of the highest levels of customer satisfaction of any healthcare program in the country.
I continue to take aggressive steps to keep the FEHB Program on the cutting edge of employer-sponsored health benefits. We demand
cost-effective quality care from our FEHB carriers and we have encouraged Federal agencies and departments to pay the full FEHB
health benefit premium for their employees called to active duty in the Reserve and National Guard so they can continue FEHB
coverage for themselves and their families. Our carriers have also responded to my request to help our members to be prepared by
making additional supplies of medications available for emergencies as well as call-up situations and you can help by getting an
Emergency Preparedness Guide at www. opm. gov. OPM's HealthierFeds campaign is another way the carriers are working with us to
ensure Federal employees and retirees are informed on healthy living and best-treatment strategies. You can help to contain
healthcare costs and keep premiums down by living a healthy life style.
Open Season is your opportunity to review your choices and to become an educated consumer to meet your healthcare needs. Use this
brochure, the FEHB Guide, and the web resources to make your choice an informed one. Finally, if you know someone interested in
Federal employment, refer them to www. usajobs. opm. gov.
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 United States 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 health care 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).
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.
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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
United States 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
United States 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 are effective April 14, 2003.
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2004 Health Net of Arizona, Inc. 2 Table of Contents
Table of Contents
IntroductionÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉ............................................................................................... 5
Plain Language ................................................................................................................................................................................................ 5
Stop Health Care Fraud!.................................................................................................................................................................................. 5
Preventing medical mistakes........................................................................................................................................................................... 6
Section 1. Facts about this HMO plan........................................................................................................................................................... 8
How we pay providers .................................................................................................................................................................. 8
Your Rights ................................................................................................................................................................................... 8
Service Area.................................................................................................................................................................................. 8
Section 2. How we change for 2004.............................................................................................................................................................. 9
Program-wide changes.................................................................................................................................................................. 9
Changes to this Plan...................................................................................................................................................................... 9
Section 3. How you get care ....................................................................................................................................................................... 10
Identification cards ..................................................................................................................................................................... 10
Where you get covered care ....................................................................................................................................................... 10
Plan providers....................................................................................................................................................................... 10
Plan facilities ........................................................................................................................................................................ 10
What you must do to get covered care ....................................................................................................................................... 10
Primary care.......................................................................................................................................................................... 10
Specialty care........................................................................................................................................................................ 10
Hospital care......................................................................................................................................................................... 11
Circumstances beyond our control............................................................................................................................................. 12
Services requiring our prior approval ........................................................................................................................................ 12
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 .................................... 27
(c) Services provided by a hospital or other facility, and ambulance services ................................................................... 32
(d) Emergency services/ accidents......................................................................................................................................... 35
(e) Mental health and substance abuse benefits ................................................................................................................... 37
(f) Prescription drug benefits................................................................................................................................................ 39
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2004 Health Net of Arizona, Inc. 3 Table of Contents
(g) Special features ............................................................................................................................................................... 42
Flexible benefits option
Services for deaf and hearing impaired
Centers of excellence
High risk pregnancies
Case Management programs
(h) Dental benefits ................................................................................................................................................................ 43
(i) Non-FEHB benefits available to Plan members............................................................................................................. 44
Section 6. General exclusions --things we don't cover .............................................................................................................................. 45
Section 7. Filing a claim for covered services ............................................................................................................................................ 46
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
Should I enroll in Medicare?............................................................................................................................................... 49
Medicare + Choice. ............................................................................................................................................................. 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 can 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) .................................................................................................................. 58
Converting to individual coverage.................................................................................................................................... 58
Getting a Certificate of Group Health Plan Coverage ..................................................................................................... 58
Two new Federal Programs complement FEHB benefitsÉÉÉÉÉÉÉÉÉÉÉÉ.ÉÉÉÉ.ÉÉÉÉÉÉÉÉÉÉÉÉÉ... 59
The Federal Flexible Spending Account Program Ð FSAFEDSÉÉÉÉ.ÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉ.... 59
The Federal Long Term Care Insurance Program ..................................................................................................................... 62
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2004 Health Net of Arizona, Inc. 4 Table of Contents
Index........................................................................................................................................................................................................... 63
Summary of benefits...................................................................................................................................................................................... 64
Rates................................................................................................................................................................................................. Back cover
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2004 Health of Arizona, Inc. 5 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of Health Net of Arizona, Inc. under our contract (CS 2121) with the United States Office of
Personnel Management, as authorized by the Federal Employees Health Benefits law. The address for Health Net of Arizona,
Inc. administrative offices is:
Health Net of Arizona, Inc.
950 N. Finance Center Drive
Tucson, Arizona 85710-1362
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, 2004, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2004, and changes are
summarized on page 9. 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 Health Net of Arizona, Inc.
We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States
Office of Personnel Management. If we use others, we tell you what they mean 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 http:// www. opm. gov/ insure
or e-mail OPM at fehbwebcomments@ opm. gov. You may also write to OPM at the
Office of Personnel Management, Insurance Services Program, Program Planning & Evaluation Group, 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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2004 Health of Arizona, Inc. 6 Introduction/ Plain Language/ Advisory
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 800/ 289-2818 and explain the situation.
If we do not resolve the issue:
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, with
your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under
Temporary Continuation of Coverage.
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.
Preventing Medical Mistakes
An influential report from the Institute of Medicine estimates that up to 98,000 Americans die every year from medical mistakes
in hospitals alone. That's about 3,230 preventable deaths in the FEHB Program a year. While death is the most tragic outcome,
medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even
additional treatments. By asking questions, learning more and understanding your risks, you can improve the safety of your own
health care, and that of your family members. Take these simple steps:
1. Ask questions if you have doubts or concerns.
Ask questions and make sure you understand the answers. Choose a doctor with whom you feel comfortable talking.
Take a relative or friend with you to help you ask questions and understand answers. 2. Keep and bring a list of all the medicines you take.
Give your doctor and pharmacist a list of all the medicines that you take, including non-prescription medicines. Tell them about any drug allergies you have.
Ask about side effects and what to avoid while taking the medicine. Read the label when you get your medicine, including all warnings.
Make sure your medicine is what the doctor ordered and know how to use it. Ask the pharmacist about your medicine if it looks different than you expected.
3. Get the results of any test or procedure.
Ask when and how you will get the results of test or procedures. Don't assume the results are fine if you do not get them when expected, be it in person, by phone, or by mail.
Call your doctor and ask for your results. Ask what the results mean for your care.
4. Talk to your doctor about which hospital is best for your health needs.
CALL --THE HEALTH CARE FRAUD HOTLINE
202-418-3300
OR WRITE TO:
United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415-1100
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2004 Health of Arizona, Inc. 7 Introduction/ Plain Language/ Advisory
Ask your doctor about which hospital has the best care and results for your condition if you have more than one hospital to choose from to get the health care you need.
Be sure you understand the instructions you get about follow-up care when you leave the hospital. 5. Make sure you understand what will happen if you need surgery.
Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation. Ask your doctor, "Who will manage my care when I am in the hospital?"
Ask your surgeon: Exactly what will you be doing?
About how long will it take?
What will happen after surgery?
How can I expect to feel during recovery?
Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reaction to anesthesia, and any medications you are taking.
Want more information on patient safety?
www. ahrq. gov/ consumer/ pathqpack. htm. The Agency for Healthcare Research and Quality makes available a wide-ranging
list of topics not only to inform consumers about patient safety but to help choose quality healthcare providers
and improve the quality of care you receive.
www. npsf. org. The National Patient Safety Foundation has information on how to ensure safer healthcare for you and
your family.
www. talkaboutrx. org/ consumer. html. The National Council on Patient Information and Education is dedicated to
improving communication about the safe, appropriate use of medicines.
www. leapfroggroup. org. The Leapfrog Group is active in promoting safe practices in hospital care.
www. ahqa. org. The American Health Quality Association represents organizations and healthcare professionals
working to improve patient safety.
www. quic. gov/ report. Find out what federal agencies are doing to identify threats to patient safety and help prevent
mistakes in the nation's healthcare delivery system.
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2004 Health Net of Arizona, Inc. 8 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that
contract with us. These Plan providers coordinate your health care services. 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.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers
accept a negotiated payment from us, and you will only be responsible for your copayments or coinsurance
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 Web site (http:// 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.
Health Net of Arizona, Inc. complies with the State of Arizona statutes and is licensed to operate an HMO in Arizona
Health Net of Arizona, Inc. has been in existence since 1981 (we were formerly Intergroup of Arizona, Inc.)
Health Net of Arizona, Inc. is a for-profit organization.
If you want more information about us, call 800/ 289-2818, or write to Health Net of Arizona, 950 N. Finance Center Drive, Tucson,
Arizona 85710-1362. You may also contact us by fax at 520/ 258-5176 or visit our Web site at www. health. net.
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 is:
Cochise, Gila, Maricopa, Pima, Pinal and Santa Cruz.
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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2004 Health Net of Arizona, Inc. 9 Section 2
Section 2. How we change for 2004
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also,
we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change
benefits.
Program-wide changes
We added information regarding two new Federal Programs that complement FEHB benefits, the Federal Flexible Spending Account Program -FSAFEDS and the Federal Long Term Care Insurance Program. See page 59 and 62.
We added information regarding Preventing medical mistakes. See page 6.
We added information regarding enrolling in Medicare. See page 49
We revised the Medicare Primary Payer Chart. See page 51.
Changes to this Plan
Your share of the non-Postal premium will increase by 11% for Self Only or 11% for Self and Family.
The primary care or specialist office visit copayment will increase from $10 per office visit to $15 per office visit.
The lab and x-ray and other diagnostic tests in a physician office or freestanding facility setting copayment of $10 has been eliminated.
The mail order prescription drug copayment will decrease from $30-$ 90-$ 125 (Generic / Brand name / Non-formulary) respectively to $25-$ 75-$ 112.50.
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2004 Health Net of Arizona, Inc. 10 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use
your copy of the Health Benefits Election Form, SF-2809, your health benefits
enrollment confirmation (for annuitants), or your Employee Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of your
enrollment, or if you need replacement cards, call us at 800/ 289-2818 or write to us at
Attn: Health Net of Arizona, Inc. 950 N. Finance Center Drive, Tucson, Arizona 85710-
1362. You may also request replacement cards through our Web site at www. health. net.
Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments, and/ or coinsurance, and you will not have to file claims.
Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan
providers according to national standards.
We list Plan providers in the provider directory, which we update periodically. The list is
also on our Web site.
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 Web site.
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. You can find a primary care physician
by looking in the provider directory, visiting our Web site or calling us at 800/ 289-2818.
Primary care Your primary care physician can be a Family Practice, General Practice, Internal Medicine or Pediatrician. Your primary care physician will provide most of your health
care, or give you a referral to see a specialist.
If you want to change primary care physicians or if your primary care physician leaves
the Plan, call us. We will help you select a new one.
Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the primary care
physician after the consultation, unless your primary care physician authorized a certain
number of visits without additional referrals. The primary care physician must provide or
authorize all follow-up care. Do not go to the specialist for return visits unless your
primary care physician gives you a referral. However, you may see a Plan Provider for
obstetrician/ gynecologist, Plan chiropractor, Health Net Vision provider for routine eye
exam, Plan provider for mental health and substance abuse services and diabetic
members may see an opthamologist for an annual eye examination 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 develop a treatment plan that
allows you to see your specialist for a certain number of visits without additional
referrals. Your primary care physician will use our criteria when creating your
What you must do
to get covered care
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2004 Health Net of Arizona, Inc. 11 Section 3
treatment plan (the physician may have to get an authorization or approval
beforehand).
If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he or
she decides to refer you to a specialist, ask if you can see your current specialist. If
your current specialist does not participate with us, you must receive treatment from a
specialist who does. Generally, we will not pay for you to see a specialist who does
not participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive
services from your current specialist until we can make arrangements for you to see
someone else.
If you have a chronic or disabling condition and lose access to your specialist because we:
terminate our contract with your specialist for other than cause; or
drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or
reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after you receive
notice of the change. Contact us or, if we drop out of the Program, contact your new
plan.
If you are in the second or third trimester of pregnancy and you lose access to your
specialist based on the above circumstances, you can continue to see your specialist until
the end of your postpartum care, even if it is beyond the 90 days.
Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of
facility.
If you are in the hospital when your enrollment in our Plan begins, call our Customer
Contact Center immediately at 800/ 289-2818. 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. If your plan
terminates participation in the FEHB Program in whole or in part, or if OPM orders an
enrollment change, this continuation of coverage provision does not apply. In such case,
the hospitalized family member's benefits under the new plan begin on the effective date
of enrollment.
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2004 Health Net of Arizona, Inc. 12 Section 3
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.
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 processÉ. Prior Authorization. Your physician must
obtain prior authorization for the following services: hospital stays, certain surgeries,
outpatient imaging and testing services, home health care, certain medications and organ
transplants.
When your primary care physician feels that you may need such a service, he or she will
submit a request for an authorization to Health Net. Once we receive the request, our
medical staff will review it. They review the treatment plan, covered benefits, medical
history and national treatment standards.
If a request is denied, it will automatically proceed to one of our doctors for review. He
or she will either support the decision for denial or approve the care requested. If a case
involves new medical technology, our doctors may review current medical literature
and/ or consult with medical experts. Our doctors will use this information to decide if the
care requested is appropriate.
Remember, your primary care physician must coordinate your medical care. If you need
specialty care, your primary care physician will determine the most appropriate specialist
based on your medical condition. If you go to a specialist or receive a service without
prior authorization (except for emergencies, OB/ GYN visits, chiropractic care, outpatient
mental health and/ or substance abuse, and diabetic members may see a plan
opthamologist for an annual eye exam), the services you receive will not be covered by
this Plan.
Services requiring our
prior approval
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2004 Health Net of Arizona, Inc. 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 $15 per
office visit and when you go in the hospital, you pay $100 per day up to 5 days per
admission.
Deductible We do not have a deductible.
Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.
Example: In our Plan, you pay 50% of our allowance for infertility services or surgically
implanted devices.
After your copayments total $2,000.00 per person or $4,000.00 per family enrollment in
any calendar year, you do not have to pay any more for covered services. However,
copayments and/ or coinsurance for the following services do not count toward your
catastrophic protection out-of-pocket maximum, and you must continue to pay
copayments and/ or coinsurance for these services:
Prescription drugs Infertility services
Be sure to keep accurate records of your copayments and/ or coinsurance since you are
responsible for informing us when you reach the maximum.
Your catastrophic protection
out-of-pocket maximum for
deductibles, coinsurance, and
copayments
16.
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Page 17
18
2004 Health Net of Arizona, Inc. 14 Section 5
Section 5. Benefits Ð OVERVIEW
(See page 9 for how our benefits changed this year and page 64 for a benefits summary.)
Note: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of
each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following subsections. To obtain
claim forms, claims filing advice, or more information about our benefits, contact us at 800/ 289-2818 or at our Web site at
http:// www. health. net
.
(a) Medical services and supplies provided by physicians and other health care professionals ............................................................ 15-26
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...................................................... 27-31
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services..................................................................................... 32-34
Inpatient hospital Outpatient hospital or ambulatory surgical center Extended care benefits/ skilled nursing care facility benefits Hospice care
Ambulance
(d) Emergency services/ accidents .......................................................................................................................................................... 35-36
Medical emergency Ambulance
(e) Mental health and substance abuse benefits..................................................................................................................................... 37-38
(f) Prescription drug benefits ................................................................................................................................................................. 39-41
(g) Special features ...................................................................................................................................................................................... 42
Flexible benefits option
Services for deaf and hearing impaired
Centers of excellence
High risk pregnancies
Case management programs
(h) Dental benefits ....................................................................................................................................................................................... 43
(i) Non-FEHB benefits available to Plan members .................................................................................................................................. 44
Summary of benefits...................................................................................................................................................................................... 64
17.
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Page 18
19
2004 Health Net of Arizona, Inc. 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.
Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
Office medical consultations
Second surgical opinion
$15 per office visit
Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility
Included in the facility copayment
At home $15 per visit
Not covered: hearing exams to determine extent of hearing loss, if you
are over age 18.
All charges.
18.
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Page 19
20
2004 Health Net of Arizona, Inc. 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
No charge for laboratory, X-ray and other
diagnostic tests at the physician's office or
freestanding facility.
If you receive these services at an
outpatient hospital setting a $10 copay per
visit will apply.
Outpatient imaging and testing, such as:
CAT/ Scans MRI
MRAs
Stress tests
PET/ SPECT scans
$100 per visit at the physician's office,
freestanding facility or at an outpatient
hospital setting
Preventive care, adult
Routine screenings, such as: Total Blood Cholesterol Ð once every three
years
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening Ð every five years starting at age 50
$15 per office visit
Routine Prostate Specific Antigen (PSA) test Ð one annually for men age 40
and older
$15 per office visit
Routine pap test
Note: The office visit is covered if pap test is received on the same day;
see Diagnosis and Treatment..
$15 per office visit
Routine mammogram Ðcovered 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
No charge for laboratory, X-ray and other
diagnostic tests at the physician's office or
freestanding facility.
If you receive these services at an
outpatient hospital setting a $10 copay per
visit will apply.
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel.
All charges.
Preventive care -Adult -continued on next page
19.
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Page 20
21
2004 Health Net of Arizona, Inc. 17 Section 5( a)
Preventive care, adult (continued) You pay
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster Ð once every 10 years, ages19 and over (except as provided for under Childhood immunizations)
Influenza vaccine, annually
Pneumococcal vaccine, age 65 and over or for high risk members under age 65.
Nothing when performed by non-physician
personnel or an affiliated flu shot clinic sponsored
by your primary care physician or Health Net of
Arizona, Inc.
Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics $15 per office visit
Well-child care charges for routine examinations, immunizations and care (up to age 22)
Examinations, such as: --Eye exams through age 17 to determine the need for vision
correction.
--Ear exams through age 17 to determine the need for hearing
correction
--Examinations done on the day of immunizations ( up to age 22)
$15 per office visit
Maternity care
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 12 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).
$15 per office visit, nothing for prenatal
and postnatal care after the initial diagnosis
of pregnancy. $50 outpatient copayment
will apply for services rendered in an
outpatient hospital setting. Inpatient
hospital copayment will apply for Delivery.
Maternity care -continued on next page
20.
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Page 21
22
2004 Health Net of Arizona, Inc. 18 Section 5( a)
Maternity care (continued) You Pay
Not covered: Routine sonograms, amniocenteses, ultrasound or any
other procedure to determine fetal age, size or sex; non-medically
necessary circumcision after the newborn period.
All charges.
Family planning
A range of voluntary family planning services, limited to:
Voluntary sterilization (See Surgical procedures Section 5 (b))
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs) (limited to one non-medically necessary removal in any 3 consecutive year period).
Diaphragms
Note: We cover oral contraceptives under the prescription drug benefit.
$15 per office visit if you receive these
services during your office visit.
$50 copay per visit if you receive these
services in an outpatient hospital setting.
Surgically implanted contraceptives (such as Norplant) 50% for surgically implanted contraceptives limited to one implant in any
3 consecutive year period. No charge for
removal, limited to one non-medically
necessary removal in any 3 consecutive
year period.
Not covered: reversal of voluntary surgical sterilization, genetic
counseling, diagnostic testing to establish paternity of a child and
genetic testing.
All charges.
Infertility services
Diagnosis and treatment of infertility, such as:
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
50% of all covered services
Infertility services -continued on next page
21.
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Page 22
23
2004 Health Net of Arizona, Inc. 19 Section 5( a)
Infertility services (continued) You Pay
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
Fertility drugs
All charges.
Allergy care
Testing and treatment
Allergy injection
$15 per office visit; nothing for allergy
injections performed by non-physician
personnel
Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy
desensitization, skin titration (Rinkel Method), cytotoxicity testing
(Bryans Test). RAST testing, MAST testing, urine autoinjection
All charges.
22.
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Page 23
24
2004 Health Net of Arizona, Inc. 20 Section 5( a)
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 30.
Respiratory and inhalation therapy
Dialysis Ð hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Ð Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: Ð We will only cover GHT when we preauthorize the treatment.
Call 800/ 863-7847 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 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.
$15 per office visit in provider office or
$50 per visit if provided in outpatient
hospital setting.
Dialysis Ð Hemodialysis and peritoneal dialysis
Note: A maximum of 6 out-of-area dialysis treatments per year are
provided when Prior Authorization has been obtained from Health Net of
Arizona, Inc.
$15 per visit in the provider office or
outpatient hospital setting.
Not covered: Experimental, investigational or alternative therapies All charges.
23.
23
Page 24
25
2004 Health Net of Arizona, Inc. 21 Section 5( a)
60 visits for the services of each of the following:
Qualified physical therapists and
Occupational therapists.
Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to
illness or injury.
Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for up to 60
sessions per Plan year.
Not covered:
long-term rehabilitative therapy
exercise programs
Therapies provided for the purposes of maintaining physical condition
Speech therapy
60 visits per plan year
Hearing services (testing, treatment, and supplies)
First hearing aid and testing only when necessitated by accidental injury
Hearing testing for children through age 17 (see Preventive care, children)
$15 per office visit
Not covered:
all other hearing testing, including hearing exams to determine the extent of hearing loss if you are over age 18
hearing aids, testing and examinations for them
All charges.
Physical and occupational therapies
24.
24
Page 25
26
2004 Health Net of Arizona, Inc. 22 Section 5( a)
One eye exam for refraction every 24 months
Note: Eye examinations for refraction is administered by Health Net
Vision. Call 800/ 443-4994.
Nothing
One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery
(such as for cataracts surgery, treatment of keratoconus, aphakia or
corneal transplants) Ð limited to a frame allowance of up to $75
$15 per office visit
Eye exam to determine the need for vision correction for children
through age 17 (see Preventive care, children)
$15 per office visit
Not covered:
Eyeglasses or contact lenses and, after age 17, examinations for them
Eye exercises and orthoptics and other vision training
Radial keratotoym, lasik and any other refractive surgery
All charges.
Foot care
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.
Note: See orthopedic and prosthetic devices for information on
podiatric shoe inserts.
$15 per office visit
Not covered:
Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot,
except as stated above
Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the
treatment is by open cutting surgery).
All charges.
Vision services (testing, treatment, and supplies) You pay
25.
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Page 26
27
2004 Health Net of Arizona, Inc. 23 Section 5( a)
Artificial limbs and eyes; including the initial purchase and subsequent purchases due to physical growth. Coverage is limited
to limbs that are necessary because of an illness, injury or surgery
causing anatomical functional impairment, or from a congenital
defect.
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.
Prosthetic devices when determined to be medically necessary and
result from an illness, injury or surgery causing anatomical functional
impairment, or from a congenital defect. Coverage includes the fitting
and purchase of a standard model. Replacement is covered only if
determined to be medically necessary and results from a change in your
physical condition.
Nothing
Not covered:
orthopedic and corrective shoes
arch supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other supportive devices
repair and/ or replacements of parts or devices worn out due to misuse or abuse
Model upgrades, deluxe, or specialized equipment
Over-the-counter items
All charges.
Orthopedic and prosthetic devices You pay
26.
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Page 27
28
2004 Health Net of Arizona, Inc. 24 Section 5( a)
Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of
durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds;
Standard size wheelchairs Ð one per lifetime;
Crutches, canes;
walkers;
Plan approved standard blood glucose monitors;
insulin pumps;
Plan approved peak flow monitors;
Medical supplies determined by Health Net to be medically necessary to operate and/ or maintain a covered prosthesis or item of Durable
Medical Equipment, subject to the following exclusions and
limitations.
Nothing
Not covered:
Motorized electric or specialized wheel chairs
ThAIRpy® vest, except when Health Net medical criteria is met, as determined by the Plan
Scooters or other power operated vehicles
More than one device to provide essentially the same functional assistance
Deluxe, specialized or customized equipment, model upgrades
Transcutaneious Electrical Nerve Stimulation (TEMS) units
Repair of replacement of equipment or parts due to misuse and/ or abuse
Prophylactic braces
Braces used primarily for sport activities
Foot orthotics which are not an integral part of a leg brace
All charges.
27.
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Page 28
29
2004 Health Net of Arizona, Inc. 25 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.
Nothing
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.
Housekeeping services
Services of a person who resides in the patient's home
Custodial care, rest cures, respite cures
Services performed by the patient's family member
All charges.
Chiropractic
Up to 12 visits per year for manipulation of the spine and extremities
Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application
$15 per office visit
28.
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Page 29
30
2004 Health Net of Arizona, Inc. 26 Section 5( a)
Alternative treatments You pay
Not covered:
Acupuncture services
Acupressure services
Naturopathic services
Hypnotherapy
Behavior training
Educational, recreational, art, dance sex, sleep or music therapies
Biofeedback, except for the treatment of urinary incontinence
Other forms of holistic or alternative therapies
All charges.
Educational classes and programs
Coverage is limited to classes offered by or through Health Net's Health
Education department. Recent classes and seminars include:
Smoking Cessation Ð Up to $100 for one smoking cessation program per member per lifetime, including all related expenses such as drugs.
Diabetes self-management
Lamaze
A nominal fee may be required for
classroom materials
29.
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31
2004 Health Net of Arizona, Inc. 27 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians
and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the facility (i. e. hospital, surgical center, etc.).
YOUR PHYSICIAN MUST GET PRIOR AUTHORIZATION OF SOME SURGICAL PROCEDURES. Please refer to the prior authorization information shown in Section 3 to be sure which services require prior
authorization and identify which surgeries require prior authorization.
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
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) Ð Orthopedic and prosthetic devices for device coverage information
$15 per office visit or $50 per outpatient
hospital visit
Surgical procedures -continued on next page
30.
30
Page 31
32
2004 Health Net of Arizona, Inc. 28 Section 5( b)
Surgical procedures (continued) You pay
Not covered:
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care.
All charges.
Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's appearance and
the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.
$15 per office visit or $50 per outpatient
hospital visit
All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance of breasts;
treatment of any physical complications, such as lymphedemas;
breast prostheses and surgical bras and replacements (see Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.
$15 per office visit or $50 per outpatient
hospital visit
Not covered:
Cosmetic surgery Ð any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges
31.
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Page 32
33
2004 Health Net of Arizona, Inc. 29 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.
$15 per office visit or $50 per outpatient
hospital visit
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
Routine or general care of teeth or dental structures
Extractions or impacted or abscessed teeth
Dental splints, dental implants, dental prostheses or dentures
Accidental injury to the teeth or gums caused by chewing
All charges.
32.
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Page 33
34
2004 Health Net of Arizona, Inc. 30 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single ÐDouble
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
Donor searches limited to $5,000 per organ per lifetime
FDA approved Ventricular Assist Device only when bridges to transplant.
Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in a National Cancer
Institute-or National Institutes of Health-approved clinical trial at a
Plan-designated center of excellence and if approved by the Plan's
medical director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor
when we cover the recipient.
Place of service copayment applies
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
All charges.
33.
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35
2004 Health Net of Arizona, Inc. 31 Section 5( b)
Professional services provided in Ð
Hospital (inpatient)
Nothing
Professional services provided in Ð
Hospital outpatient department Skilled nursing facility
Ambulatory surgical center Office
Nothing
Anesthesia You pay
34.
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Page 35
36
2004 Health Net of Arizona, Inc. 32 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility,
and ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including
with Medicare.
The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge
(i. e., physicians, etc.) are covered in Sections 5( a) or (b).
YOUR PHYSICIAN MUST GET PRIOR AUTHORIZATION STAYS. Please refer to Section 3 to be sure which services require prior authorization.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board, such as
ward, semiprivate, or intensive care accommodations;
general nursing care; 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.
$100 per day up to 5 days per admission
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
Medical supplies and medical equipment, including oxygen
Anesthetics, including nurse anesthetist services
$100 per day up to 5 days per admission
Inpatient hospital -continued on next page.
35.
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37
2004 Health Net of Arizona, Inc. 33 Section 5( c)
Inpatient hospital (continued) You pay
Not covered:
Custodial care
Non-covered facilities, such as nursing homes, schools
Personal comfort items, such as telephone, television, barber services, guest meals, travel expenses, take-home supplies and beds
Collection and/ or storage of blood products for any unscheduled or non-covered medical procedure
Private nursing care
All charges.
Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
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: Ð 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.
$50 per visit
Not covered: blood and blood derivatives not replaced by the member All charges.
Extended care benefits/ skilled nursing care facility benefits
Skilled nursing facility (SNF):
Coverage is provided when a full-time skilled nursing care is medically
necessary and confinement in a SNF is medically appropriate as
determined by a plan doctor and approved by Health Net. Covered
services include:
Bed, board and general nursing care
Drugs, biologicals, supplies and equipment ordinarily provided or arranged by the SNF when prescribed by a plan doctor.
$100 per day up to 5 days per admission
Not covered: custodial care, domiciliary care or convalescent care All charges.
36.
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38
2004 Health Net of Arizona, Inc. 34 Section 5( c)
Hospice care You pay
Members who are diagnosed as having an illness giving them a life
expectancy of 6 months or less may request Hospice care. All Hospice
care must be provided by a licensed participating Hospice and include
inpatient and outpatient care related to the condition.
Nothing
Not covered: Independent nursing, homemaker services All charges.
Ambulance
Local professional ambulance service when medically appropriate
Air ambulance when prior authorized or if the member's condition is an emergency and the location of the accidental injury and/ or
illness is inaccessible by ground vehicles or transport by ground
ambulance would be detrimental to the member's health.
Nothing
37.
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2004 Health Net of Arizona, Inc. 35 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
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 Ð what
they all have in common is the need for quick action.
What to do in case of emergency:
If you are faced with medical emergency, call 911 or go to the nearest emergency room.
Please notify your primary care physician within 48 hours following emergency services, or as soon as reasonably possible
to do so.
Emergency services do not include the use of a hospital emergency room or other emergency medical facility for routine
medical care, or follow-up or continuing care unless prior authorization has been given by your primary care physician or
Health Net.
Emergencies within our service area: call 911 or go to the nearest emergency room
Emergencies outside our service area: call 911 or go to the nearest emergency room
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2004 Health Net of Arizona, Inc. 36 Section 5( d)
Benefit Description You pay
Emergency within or outside our service area
Emergency care at a doctor's office $15 per visit
Emergency care at an urgent care center $50 per visit
Emergency care as an outpatient or inpatient at a hospital, including doctors' services $100 per visit (waived if admitted; $100 per day up to 5 days per admission inpatient
hospital admission applies
Not covered:
Elective care or non-emergency care, continuing, routine or follow-up care without prior authorization
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area
All charges.
Ambulance
Professional ambulance service when medically appropriate and in an
emergency situation. Air ambulance when prior authorized or if the
member's condition is an emergency and the location of the accidental
injury and/ or illness is inaccessible by ground vehicles or transport by
group ambulance would be detrimental to the member's health
See 5( c) for non-emergency service.
Nothing
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2004 Health Net of Arizona, Inc. 37 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
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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.
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 PRIOR AUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.
I M
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T
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider
and contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.
Note: Plan benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when you receive
the care as part of a treatment plan that we approve.
Your cost sharing responsibilities are no
greater than for other illnesses or
conditions.
Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social
workers
Medication management
$15 per visit
Mental health and substance abuse benefits -continued on next page
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2004 Health Net of Arizona, Inc. 38 Section 5( e)
Mental health and substance abuse benefits (continued) You pay
Diagnostic tests $15 per visit
Services provided by a hospital or other facility
Services in approved alternative care settings such as half-way house,
residential treatment or full-day hospitalization
$100 per day up to 5 days per admission
Services in approved alternative care settings such as partial hospitalization or facility based intensive outpatient treatment $50 per visit
Not covered: Services we have not approved.
Note: OPM will base its review of disputes about treatment plans on the
treatment plan's clinical appropriateness. OPM will generally not
order us to pay or provide one clinically appropriate treatment plan in
favor of another.
All charges.
Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:
To access Mental Health and/ or Substance Abuse benefits, you must contact MHN
Health Services at 800/ 977-0281. Services are covered as necessary for the diagnosis
and treatment of acute conditions and as outlined below.
Limitation We may limit your benefits if you do not obtain a treatment plan.
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2004 Health Net of Arizona, Inc. 39 Section 5( f)
Section 5 (f). Prescription drug benefits
I
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O
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T
A
N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
I
M
P
O
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T
A
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T
There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician must write the prescription.
Where you can obtain them. You may fill the prescription at a Plan pharmacy, or by mail for maintenance medication.
We use a formulary. (Preferred Drug List). Plan doctors in accordance with the Plan's Preferred Drug List prescribe drugs. Generic drugs are available at the lowest copayment level. Preferred brand name drugs are
available for a slightly higher copayment. Unless otherwise excluded, other FDA-approved brand name
drugs are available at the highest copayment level. The Preferred Drug List is update periodically throughout
the year. To order a current Preferred Drug List call 800/ 289-2818 or visit our Web site at http:// www. health. net.
These are the dispensing limitations. Prescription drugs obtained at a plan pharmacy will be dispensed for up to a 31-day supply. Mail order prescriptions are limited to Health Net's mail order provider and will be
dispensed for up to a 93-day supply. Some medications may be dispensed in quantities less than those stated
due to the prepackaging by the pharmaceutical manufacturer. Insulin, diabetic supplies and inhalers have
quantity per copayment limitations, as stated below. Refills are only covered when authorized by a plan
physician and/ or Health Net. You will be financially liable for the cost of medications obtained after you are
no longer eligible for coverage under the plan.
Members called to Active Duty or during a National Emergency. Members may contact our Customer Contact Center at 800/ 289-2818. Our Customer Contact Center will work with our Pharmacy Department to
authorize the medications and/ or supplies and which provider to obtain the services from.
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 brand name drugs must meet the same standards
for safety, purity, strength, and effectiveness. A generic prescription costs you Ð and us Ð less than a name
brand prescriptions.
When you have to file a claim. If you are required to pay for a prescription in an out-of-area emergency situation, you must submit an itemized statement to Health Net of the charges you paid, along with a
completed claim form. Claim forms can be obtained by calling Health Net at 800/ 289-2818. Proof of
payment must accompany the request for reimbursement. Claims should be addressed to: Health Net of
Arizona, Attn: Pharmacy Department, 950 N. Finance Center Drive, Tucson, Arizona 85710-1362.
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2004 Health Net of Arizona, Inc. 40 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or 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 Ð limited to 2 vials per copayment
Disposable needles and syringes for the administration of covered medications Ð limited to 100 per copayment
Diabetic supplies, including lancets, glucose test strips, visual reading testing strips, and urine testing strips Ð limited to 100 per
copayment
Insulin cartridges for the legally blind Ð limited to the equivalent to 2 vials of insulin per copayment
Automatic lancing devices Ð limited to one every six months per copayment
Insulin aids (insulin pen) Ð limited to one every six months per copayment
Glucogon (requires prior authorization) Ð limited to one per copayment
Spacers and holding chambers for inhaled medications Ð limited to one per six months per copayment
Inhalers Ð up to 2 (nasal or oral), or up to a 31-day supply, whichever is less, per copayment
Drugs for sexual dysfunction require Prior authorization and have dispensing limitations. Contact plan for details.
Oral contraceptive drugs
Growth hormone
$10 per generic prescription or refill
obtained from a plan pharmacy
$30 per preferred brand name prescription
or refill obtained from a plan pharmacy
$45 per non-preferred brand name
prescription or refill obtained from a plan
pharmacy
$25 per generic prescription or refill
obtained through our mail order program
$75 per preferred brand name prescription
or refill obtained through our mail order
program
$112.50 per non-preferred brand name
prescription or refill obtained through our
mail order program
Note: If there is no generic equivalent
available, you will still have to pay the
brand name copay.
Covered medications and supplies -continued on next page
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2004 Health Net of Arizona, Inc. 41 Section 5( f)
Covered medications and supplies (continued) You pay
Self-injectable drugs require prior authorization (brand name copayment applied to insulin). $40 per prescription or refill, up to a 31-day supply. Quantity limitation may apply to
specific drugs.
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 (except prenatal), nutrients and food supplements even if a physician prescribes or administers them
Nonprescription medicines
Anorexiants, appetite suppressants, diet aids, weight loss medications, and drugs used to treat obesity.
Any drug consumed at the place where it is dispensed or that is dispensed or administered by the physician
Drugs prescribed for non-covered services
Take home drugs; drugs prescribed for use after discharge from a hospital, nursing home, skilled nursing facility or other inpatient
facility must be obtained from a plan pharmacy
Replacement prescriptions
All charges.
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2004 Health Net of Arizona, Inc. 42 Section 5( g)
Section 5 (g). Special features
Feature Description
Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative benefit.
Alternative benefits are subject to our ongoing review.
By approving an alternative benefit, we cannot guarantee you will get it in the future.
The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits.
Our decision to offer or withdraw alternative benefits is not subject to OPM review
under the disputed claims process.
Services for deaf and
hearing impaired
We provide a TTY line for the deaf and hearing imposed 800/ 977-6757.
Centers of excellence We contract with many respected institutions in our regions, such as, University Medical Centers, Barrow's Neurological Institute, Maricopa County Burn Unit,
St. Joseph's Hospital and Phoenix Children's Hospital.
High risk pregnancies We contract with Matria Healthcare, Inc. This program is directed at high-risk pregnancies including pre-term labor, multiple gestations, tocolytic therapy,
hypertension, diabetes and hydration therapy. The goal is to achieve optimal
pregnancy prolongation by providing increased level of education and
surveillance.
Case Management
Programs
Alere Medical, Inc. -Congestive Heart Failure monitoring program. High acuity, Class 3-4 CHF members are eligible for this program. The goal is to
assure compliance with weight management, medications, diet and decrease
hospitalization and emergency room visits.
Renaissance Ð All End Stage Renal Disease (ESRD) and Chronic Kidney Disease (CKD) members are eligible for this program. Renaissance will strive
to reduce morbidity, mortality and improve quality of life.
Health Share Ð An online tool accessible from Health Net's internet Web site that assists members to identify participating hospitals with the highest quality
service for a particular procedure based on key factors such as mortality rate,
patient volume and outcomes.
Complex Case Management Ð Health Net's Case Managers work with our members to promote quality, cost-effective outcomes. The focus is on
members who require assistance throughout the continuum of care, such as
COPD, Asthma, Diabetes, Coronary Artery Disease (CAD) and those with
multiple co-morbidities. Members who are hospitalized with either acute
complex illness or trauma, or members with chronic disease states, are
screened for case management activity.
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47
2004 Health Net of Arizona, Inc. 43 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.
Plan dentists must provide or arrange your care.
We have no calendar year deductible.
We cover hospitalization for dental procedures only when a nondental 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
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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 jawbone and supporting tissues
(does not include injury caused by the act of chewing). The need for
these services must result from an accidental injury.
$15 per office visit in providers office or
$50 per visit if provided in outpatient
hospital setting
Dental benefits
We have no other dental benefits.
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48
2004 Health Net of Arizona, Inc. 44 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed
claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket maximums.
Dental Coverage -Health Net of Arizona, Inc. is pleased to provide you and your enrolled family members with
access to dental care through Employers Dental Services (EDS) at no additional premium. Health Net FEHB
members are automatically enrolled in this program.
Highlights of the plan include:
Easy to Use Select any provider from the Employer's Dental Services network
Show your EDS identification card when you receive services View the EDS Network and New Patient provider availability online at
http:// www. mydentalplan. net
Low copayments for preventive and basic services
Discount on Orthodontics for Children and Adults Prescription Discount Program for dental medications
WellRewards Program – a discount program that rewards you for being a Health Net member. You'll save on a range
of products and services designed to help you stay healthy. Products and services available include:
Acupuncture Chiropractic Care Cosmetic Surgery Eyewear
Hearing aids Lasik & PRK surgery Massage therapy Nutrition counseling
Sleep Improvement Weight Management
If you would like more information regarding WellRewards, please call our Customer Contact Center at 1-800-289-
2818, or TTY 1-800-977-6567 for the hearing impaired, Monday through Friday, 7 a. m. to 6 p. m., excluding holidays.
Medicare+ Choice Enrollment
This Individual Plan offers Medicare beneficiaries the opportunity to enroll in a plan through Medicare or Health Net.
As indicated on page 49, annuitants and former spouses with FEHB coverage and Medicare Parts A and B eligibility
may elect to:
1. Stay on FEHB and not enroll in a Medicare+ Choice plan.
2. Stay on FEHB and enroll in a Medicare+ Choice plan if available in your service area.
3. Suspend their FEHB coverage and enroll in a Medicare+ Choice plan when available in their area. They
may later re-enroll if they choose
Contact your retirement system for information on your FEHB enrollment and changing to a Medicare+ Choice plan or
you may contact us at 800/ 977-7522, Monday through Friday 7: 00 a. m. to 6: 00 p. m. for more information. Hearing
impaired assistance Monday through Friday 7: 00 a. m. to 6: 00 p. m. TTY 800/ 977-6567.
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49
2004 Health Net of Arizona, Inc. 45 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; Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program; or
Services, drugs, or supplies you receive without charge while in active military service.
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2004 Health Net of Arizona, Inc. 46 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 or coinsurance.
You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us
directly. Check with the provider. If you need to file the claim, here is the process:
Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form.
For claims questions and assistance, call us at 800/ 289-2818.
When you must file a claim --such as for services you receive outside of the Plan's
service area --submit it on the HCFA-1500 or a claim form that includes the information
shown below. Bills and receipts should be itemized and show:
Covered member's name and ID number;
Name and address of the physician or facility that provided the service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary payer --such as the Medicare Summary Notice (MSN); and
Receipts, if you paid for your services.
Submit your claims to: ACS/ Health Net, Inc, P. O. Box 14225, Lexington, KY 40512-
4225
Prescription drugs Follow the process as stated above, but send your request for reimbursement to the following address.
Submit your claims to: Health Net of Arizona, Inc. Attn: Pharmacy Department, 950
N. Finance Center Drive, Tucson, Arizona 85710-1362
Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely
filing was prevented by administrative operations of Government or legal incapacity,
provided the claim was submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond.
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2004 Health Net of Arizona, Inc. 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 Ð 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: Health Net of Arizona, Inc., Attn: Commercial Appeals and Grievances Department, P. O.
Box 18015, Tucson, Arizona 85731-1362; 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 requestÑ 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: United States Office of Personnel Management, Insurance Services Programs, Health Insurance Group 3,
1900 E Street, NW, Washington, DC 20415-3630.
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2004 Health Net of Arizona, Inc. 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.
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 800/ 289-2818 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