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, DC20415-1100

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 952-883-5000 or 1-800-883-2177 (hearing impaired individuals should call 952-883-5127). You may also request replacement cards through our Web site at www.healthpartners.com.

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 for the Plan you select, which we update periodically. For the most up-to-date information, visit www.consumerchoice.com/fehb, where information is updated weekly. There are separate provider directories for the HealthPartners Classic Plan and the HealthPartners Open Access Deductible Plan.

HealthPartners Classic Plan

The HealthPartners Classic Plan is a group practice prepayment plan that allows members to receive health services at more than 100 medical, mental health and dental facilities. HealthPartners Classic Plan medical providers include more than 700 primary care doctors and nearly 12,000 specialists to whom patients may be referred.

When you enroll in the HealthPartners Classic Plan, you select a primary care clinic. You’ll receive most of your care from that clinic. Each covered person in a family may select a different primary care clinic and may change clinic selections monthly.

HealthPartners Open Access Deductible Plan

The HealthPartners Open Access Deductible Plan lets you receive care from nearly 12,000 physicians in the HealthPartners Open Access Network across Minnesota and in western Wisconsin. Referrals are not required and you do not need to choose a primary care clinic. Any time you or a member in your family needs care, you may choose to see any provider in this network. With limited exceptions, if you seek care from a provider who is not listed in this directory, your care is considered out-of-network and may not be covered.

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: www.consumerchoice.com/fehb.

What you must do to get covered care

HealthPartners Classic Plan

It depends on the type of care you need. First, you and each family member should choose a primary care physician at the primary care clinic you enroll in. This decision is important since your primary care physician provides or arranges for most of your health care. For help selecting a primary care physician, call your clinic.

HealthPartners Open Access Deductible Plan

Any time you or a member in your family needs care, you may choose to see any provider in this network. With limited exceptions, if you seek care from a provider who is not listed in this directory, your care is considered out-of-network and may not be covered.

Primary care

HealthPartners Classic Plan

Your primary care physician* can be a family practitioner, internist, pediatrician, or general practitioner. 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.

* Although Obstetrics/Gynecology (Ob/Gyn) is not considered primary care, each care network allows members direct access – no referral required – to the Ob/Gyn providers associated with the care network.

HealthPartners Open Access Deductible Plan

Members in this Plan are not required to pick a primary clinic. However, we encourage people to work with a personal physician who will get to know them.

Your primary care physician can be a family practitioner, internist, Ob/Gyn, pediatrician, or general practitioner. Your primary care physician will provide most of your health care, or suggest that you see a specialist. You can see any specialist in the health plan network without a referral.

If you want to change your primary care physician or if your primary care physician leaves the Plan, simply choose another provider from the HealthPartners Open Access directory.

For the most up-to-date provider information, visit www.consumerchoice.com/fehb, where information is updated weekly.

Specialty care

HealthPartners Classic Plan

In most cases, 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, some clinics allow you to self-refer to certain specialists. These specialists are listed in the directory and on www.consumerchoice.com/fehb with the note “No Referral Required.”

No matter which primary care clinic you use, all members have direct access – no referral required – to the following specialized care:

Ob/Gyn providers associated with your care network

Mental Health/Chemical Health Network

Vision Care Network

Urgent Care Network

Here are other things you should know about specialty care:

If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care physician will use our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.

HealthPartners Open Access Deductible Plan

You have direct access to any specialist in the HealthPartners Open Access Network without a referral.

If you are seeing a specialist when you enroll in our Plan and 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 Member Services at 952-883-5000 or 1-800-883-2177 for assistance. You may receive services from your current specialist until we can make arrangements for you to see someone else.

Both Plans

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 120 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 HealthPartners Member Services immediately at 952-883-5000 or 1-800-883-2177 (hearing impaired individuals should call 952-883-5127). 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.

Circumstances beyond our control

Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care.

Services requiring our prior approval

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

We call this review and approval process prior authorization. Your physician must obtain prior authorization for services such as:

reconstructive surgery

promising therapies/new technologies

transplants

medically necessary dental care, such as orthognathic surgery

durable medical equipment and prosthetics

home health care

skilled nursing care

hospice care

habilitative therapy

The complete list, along with the criteria we use to review authorization requests, is available on www.healthpartners.com. or by calling HealthPartners Member Services at 952-883-5000 or 1-800-883-2177 (hearing impaired individuals should call 952-883-5127).

Your Plan physician is responsible for obtaining prior authorization.

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 admission.

Deductible

Adeductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count toward any deductible.

For the HealthPartners Open Access Deductible Plan, the calendar year deductible is $250 per person. Under a family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $500.

For the HealthPartners Classic Plan, there is a $50 annual deductible for emergency dental services for accidental injury when care is provided by a non-Plan dentist. Copayments or coinsurance for any other service do not count toward this deductible.

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

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

Coinsurance

Coinsurance is the percentage of our negotiated fee that you must pay for your care.

Example: In our Plan, you pay 20% of our allowance for infertility services and durable medical equipment.

Your catastrophic protection out-of-pocket maximum

After your copayments and/or coinsurance total $3,000 per person or $5,000 per familyin any calendar year, you do not have to pay any more for covered 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.

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Here are some important things you should keep in mind about these benefits:

The calendar year deductible is $250 per person and $500 per family. Some services in this section are subject to the deductible.

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.

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.

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Professional services

In an office

In an urgent care center

Office medical consultations

Second surgical opinion

Testing and treatment of sexually transmitted diseases and testing for HIV and HIV-related conditions provided by a Plan or non-Plan provider

$15 per office visit

$15 per office visit

During a hospital stay

In a skilled nursing facility

Nothing

Nothing

Not covered: Genetic counseling and studies not required for diagnosis and treatment.

All charges.

All charges.

Lab, X-ray and other diagnostic tests

Tests, such as:

Blood tests

Urinalysis

Non-routine pap tests

Pathology

X-rays

Non-routine Mammograms

Ultrasound

Electrocardiogram and EEG

Nothing

Nothing

MRI/CT scans

20% of charges

20% of charges

Routine health exams, periodic health assessments, and cancer screenings, such as:

Total Blood Cholesterol – once every three years

Colorectal Cancer Screening, including

Fecal occult blood test

Sigmoidoscopy, screening – every five years starting at age 50

Double contrast barium enema – every five years starting at age 50

Colonoscopy screening – every ten years starting at age 50

Routine Prostate Specific Antigen (PSA) test – one annually for men age 40 and older

Routine pap test

Routine hearing and eye exams

Routine mammogram – covered for women age 35 and older, as follows:

From age 35 through 39, one during this five year period

From age 40 through 64, one every calendar year

At age 65 and older, one every two consecutive calendar years

Adult immunizations

Note: The above frequency guidelines are minimum benefits offered under the Plan. These services may be provided more frequently if they are medically necessary.

Nothing

Nothing

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel.

All charges.

All charges.

Child health supervision services, including well-child care charges for routine examinations and care (up to age 22)

Childhood immunizations recommended by the American Academy of Pediatrics

Routine hearing and eye exams

Nothing

Nothing

Prenatal care

Postnatal care

Nothing

Nothing

Delivery

Note: Here are some things to keep in mind:

You do not need to prior authorize your normal delivery; see page 13 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 and 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.

SeeHospital benefits (Section 5c) and Surgery benefits (Section 5b).

SeeHospital benefits (Section 5c) and Surgery benefits (Section 5b).

Not covered: Routine sonograms to determine fetal age, size or sex.

All charges.

All charges.

A range of voluntary family planning services, such as:

Family planning services provided by a Plan provider or non-Plan provider

Nothing

Nothing

Voluntary sterilization (See Surgical procedures Section 5 (b))

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital – after deductible

10% of outpatient charges, up to a calendar year maximum of $1,500 – after deductible

Surgically implanted contraceptives

Injectable contraceptive drugs (such as Depo provera)

Intrauterine devices (IUDs)

Note: We cover oral contraceptives and diaphragms under the prescription drug benefit.

20% of charges

20% of charges

Not covered:

Reversal of voluntary surgical sterilization

Genetic counseling.

All charges.

All charges.

Diagnosis and treatment of infertility such as:

Artificial insemination:

intravaginal insemination (IVI)

intracervical insemination (ICI)

intrauterine insemination (IUI)

Fertility drugs

Note: We cover injectible fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit. We cover the diagnosis of infertility services provided by a Plan or non-Plan provider, in accordance with our Medical Policy.

20% of charges

20% of charges

Not covered:

Assisted reproductive technology (ART) procedures, such as:

in vitro fertilization

embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)

Services and supplies related to ART procedures

Cost of donor sperm or egg

Cost of storage of donor sperm, ova or embryo

Treatment of infertility after reversal of sterilization

Artificial insemination for surrogate pregnancy

All charges.

All charges.

Testing and treatment

$15 per office visit

$15 per office visit

Allergy injection and serum

Nothing

Nothing

Not covered: Provocative food testing and sublingual allergy desensitization

All charges.

All charges.

Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 32.

Respiratory and inhalation therapy

Dialysis – hemodialysis and peritoneal dialysis

Intravenous (IV)/Infusion Therapy

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital – after deductible

10% of outpatient charges, up to a calendar year maximum of $1,500 – after deductible

Blood and blood plasma (unless replaced) and blood derivatives for the treatment of blood disorders

Nothing

Nothing

Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit.

See Services requiring our prior approval in Section 3.

20% of charges

20% of charges

Not covered: Growth hormones which are not for growth hormone deficiency or chronic renal insufficiency.

All charges.

All charges.

Usually two months per condition per year for the services of each of the following:

qualified physical therapists;

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. You must achieve significant functional improvement, within a predictable period of time (generally within a period of two months), toward your maximum potential ability to perform functional daily living activities.

Habilitative care rendered for congenital, developmental or medical conditions which have significantly limited the successful initiation of normal speech and motor development.

Note: To be considered habilitative, significant functional improvement and measurable progress must be made toward achieving functional goals and your maximum potential ability, within a predictable period of time. Our Plan Medical Director will determine whether measurable progress has been made based on objective documentation.

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital – after deductible

10% of outpatient charges, up to a calendar year maximum of $1,500 – after deductible

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for Phase I. Phase II is provided if we determine it is medically necessary. Phase III is not covered.

$15 per office visit

Nothing for inpatient or outpatient hospital

$15 per office visit

Nothing for inpatient or outpatient hospital

Not covered:

Long-term rehabilitative therapy

Exercise programs

All charges.

All charges.

Speech therapy for congenital, developmental or medical conditions which have significantly limited the successful initiation of normal speech development.

Usually 60 visits or two months per condition per year

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital – after deductible

10% of outpatient charges, up to a calendar year maximum of $1,500 – after deductible

Not covered:

Long term rehabilitative therapy

All charges.

All charges.

Hearing services (testing, treatment, and supplies)

First hearing aid and testing only when necessitated by accidental injury

Hearing testing for children through age 17

Note: See Preventive care, adult; Preventive care, children

Nothing

Nothing

Hearing aids for members age 18 or younger who have hearing loss due to functional congenital malformation of the ears that is not correctable by other covered procedures. Coverage is limited to one hearing aid for each ear every three years.

20% of the charges

20% of the charges

Not covered:

All other hearing testing

All other hearing aids, testing and examinations for them

All charges.

All charges.

Eye exam to determine the need for vision correction

Annual eye refractions

Note: See Preventive care, adult; Preventive care, children

Nothing

Nothing

Diagnosis and treatment of illness and injury to the eye

$15 per office visit

$15 per office visit

Initial evaluation, lenses and fitting for contact or eyeglass lenses if medically necessary for the post-surgical treatment of cataracts or for the treatment of aphakia or keratoconous

$15 per office visit

All charges for lens replacement beyond the initial pair

$15 per office visit

All charges for lens replacement beyond the initial pair

Not covered:

Eyeglasses or contact lenses except as described above

Eye exercises

Radial keratotomy and other refractive surgery

All charges.

All charges.

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

$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.

All charges.

We cover the following:

Orthopedic devices, such as braces and foot orthotics

Prosthetic devices, such as artificial limbs and eyes

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 Section 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.

Orthopedic and corrective shoes when approved by this Plan based on our criteria

20% of charges

20% of charges

Wigs required due to hair loss caused by alopetia areata

20% of charges, and all charges beyond the $350 calendar year limit

20% of charges, and all charges beyond the $350 calendar year limit

Not covered:

Over-the-counter foot orthotics

Replacement or repair of any covered items if they are damaged or destroyed by member misuse, abuse or carelessness; lost; or stolen

Duplicate or similar items

Items which are primarily educational in nature or for hygiene, vocation, comfort, convenience or recreation

Other equipment and supplies, including but not limited to assistive devices, that we determine are not eligible for coverage

All charges.

All charges.

Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as oxygen and dialysis equipment. Under this benefit, we also cover:

Hospital beds;

Wheelchairs

Crutches;

Walkers;

Blood glucose monitors;

Insulin pumps

Diabetic supplies, and

Disposable needles and syringes needed for the administration of covered medications.

Note: We reserve the right to determine if an item will be approved for rental vs. purchase.

20% of charges

20% of charges

Not covered:

Replacement or repair of any covered items if they are damaged or destroyed by member misuse, abuse or carelessness; lost; or stolen

Duplicate or similar items

Items which are primarily educational in nature or for hygiene, vocation, comfort, convenience or recreation

Household equipment, such as exercise cycles, air purifiers, water purifiers, air conditioners, non-allergenic pillows, mattresses or water beds

Household fixtures, such as escalators or elevators, ramps, swimming pools or saunas

Modifications to the home, such as wiring, plumbing or charges to install equipment

Vehicle, car or van modifications, such as hand brakes, hydraulic lifts and car carriers

Rental of medically necessary durable medical equipment while your own equipment is being repaired, that is beyond one month rental

Other equipment and supplies, including but not limited to assistive devices, that we determine are not eligible for coverage

All charges.

All charges.

We cover home health care ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), or home health aide, as shown below:

Physical therapy, occupational therapy, speech therapy, respiratory therapy and home health aide services

$15 per visit

$15 per visit

TPN/intravenous therapy, skilled nursing services, prenatal and postnatal services, child health services and phototherapy

Nothing

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.

All charges.

All charges.

Chiropractic services for rehabilitative care, provided to diagnose and treat acute neuromusculo-skeletal conditions, limited to:

Manipulation of the spine and extremities

Adjunctive procedures such as massage therapy, ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application, when they are performed in conjunction with other treatment by a chiropractor, are part of a prescribed treatment plan and are not billed separately

$15 per office visit

$15 per office visit

Not covered:

Naturopathic services

Hypnotherapy

All charges.

All charges.

We cover the following services:

Acupuncture – by a certified Plan acupuncturist for:

anesthesia

pain management

chemical dependency

headaches

nausea

Biofeedback for:

incontinence

headaches

musculo-skeletal spasms which do not respond to other treatments

mental/nervous disorders

neurological retraining

$15 per office visit

$15 per office visit

Not covered:

Naturopathic services

Hypnotherapy

All charges.

All charges.

We cover education for the management of chronic health problems (such as diabetes) and smoking cessation

$15 per office visit/session

$15 per office visit/session

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Here are some important things you should keep in mind about these benefits:

The calendar year deductible is $250 per person and $500 per family. Some services in this section are subject to the deductible.

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.

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 services described in this section are for the charges billed by a physician or other health care professional for your surgical care. The amount that you pay for these services depends on where the services are provided and follow the benefits described in Section 5(a) and (c), unless otherwise specified below.

YOUR PHYSICIAN MUST GET PRIOR AUTHORIZATION FOR 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.

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A comprehensive range of services, such as:

Operative procedures, including normal pre- and post-operative care by the surgeon

Treatment of fractures, including casting

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

Insertion of internal prosthetic devices. See 5(a) – Orthopedic and prosthetic devices for device coverage information

Voluntary sterilization

Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital – after deductible

10% of outpatient charges, up to a calendar year maximum of $1,500 – after deductible

Not covered:

Reversal of voluntary sterilization

Routine treatment of conditions of the foot; see Foot care

All charges.

All charges.

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; port wine stains; webbed fingers; and webbed toes.

Note: Port wine stains do not have to result in a functional defect to be covered.

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 outpatient hospital visit

$100 per admission for inpatient hospital

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital – after deductible

10% of outpatient charges, up to a calendar year maximum of $1,500 – after deductible

Not covered:

Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

Surgeries related to sex transformation, unless determined medically necessary by the Plan Medical Director

All charges.

All charges.

Oral surgical procedures, limited to:

Reduction of fractures of the jaws or facial bones;

Surgical correction of cleft lip, cleft palate;

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, including non-dental treatment of temporomandibular joint dysfunction (TMJ).

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital

$15 per office visit or outpatient hospital visit

$100 per admission for inpatient hospital – after deductible

10% of outpatient charges, up to a calendar year maximum of $1,500 – after deductible

Orthognathic surgery for the treatment of a skeletal malocclusion when a functional occlusion cannot be achieved through non-surgical treatment alone and a demonstrable functional impairment exists.

25% of charges

25% of charges

Not covered:

Oral implants and transplants

Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

Orthodontic services (pre or post operative) associated with orthognathic surgery

All charges.

All charges.

Transplant services are covered at our designated centers of excellence for transplants and are limited to:

Cornea

Heart

Heart/lung

Kidney

Kidney/Pancreas for diabetes

Liver

Lung: Single – Double, for primary pulmonary hypertension, Eisenmenger’s syndrome, end stage pulmonary fibrosis, alpha 1 antitrypsin disease, cystic fibrosis and emphysema

Allogeneic (donor) bone marrow transplants or peripheral stem cell support associated with high dose chemotherapy for acute myelogenous leukemia; acute lymphotytic leukemia; chronic myelogenouis leukemia; severe combined immunodeficiency disease; Wiscott-Aldrich syndrome; and aplastic anemia

Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute lymphocytic or non-lymphocytic leukemia; Hodgkin’s ly