CALL ¾ 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 808-948-6499 or write to us at P.O. Box 860, Honolulu, HI 96808. You may also request replacement cards through our Web site at www.hmsa.com/portal/fedplan87/.

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. If you use our point-of-service program, you can also get care from non-Plan providers, but it will cost you more.

We look at some or all of the following criteria to determine if a provider is recognized and approved by us:

· Is the provider accredited by a recognized accrediting agency?

· Is the provider appropriately licensed?

· Is the provider certified by the proper government authority?

· Are the services rendered within the lawful scope of the provider’s respective licensure, certification, and/or accreditation?

· 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.

In order to receive Plan provider benefits for covered out-of-state services under this Plan, the services must be provided by a BlueCard PPO provider.

We list Plan providers in the provider directory, which we update periodically. The list is also on our Web site.

· Non-Plan providers

Non-Plan providers are physicians and other health care professionals who are not under contract with this Plan.

For out-of-state services under this Plan, Non-Plan provider benefits are applied for covered services rendered by non-BlueCard PPO providers, even if they participate in other Blue Cross and/or Blue Shield programs.

· 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.

What you must do to get covered care

You are encouraged to coordinate your care with a primary care physician who will provide or arrange most of your health care.

· Primary care

Your primary care physician can be a family practitioner, internist, obstetrician/gynecologist or pediatrician. Your primary care physician will provide most of your health care, or can refer you to see a specialist.

· Specialty care

You have direct access to Plan specialists when needed. However, you may wish to coordinate your specialty care with your primary care physician, who can help you arrange for the specialty care service you will need.

Here are some other things you should know about specialty care:

· If you are seeing a specialist when you enroll in our Plan, you are encouraged to coordinate your specialty care with your primary care physician. If he or she decides to refer you to a specialist, ask if you can see your current specialist.

· If you are seeing a specialist and your specialist leaves the Plan, talk to your primary care physician, who will arrange for you to see another specialist. If you decide to continue seeing your specialist, you will pay a copayment/coinsurance plus the difference between the eligible charge and the specialist billed charge.

· If you have a chronic and 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 program 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 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 precertification. Precertification is a special approval process to ensure medical treatments, procedures, place of treatment or devices meet medical necessity criteria prior to the services being rendered. If you are under the care of:

· An HMSA participating physician or contracting physician, he or she will:

· Obtain approval for you; and

· Accept any penalties for failure to obtain approval.

· A BlueCard PPO, BlueCard Plan provider or a non-Plan provider, you are responsible for obtaining precertification. If you do not receive precertification and receive any of the services described in this Section, benefits may be denied.

You or your physician must obtain precertification for the following services:

· Autologous chondrocyte implants

· Bone Density Test

· Custom durable medical equipment

· Certain kinds of drugs listed in our Select Prescription Drug Formulary (see section 5(f) and 5(g) for more information

· Genetic testing – if predictive in asymptomatic individuals with the following:

· Family history of breast cancer

· Family history of ovarian cancer

· Familial adenomatous polyposis

· Hereditary nonpolyposis colorectal cancer

· Growth hormone therapy

· High Dose Rate Brachytherapy

· Home IV Therapy

· In vitro fertilization

· Injectable Drugs

· Amevive

· Forteo

· Synagis

· Xolair

· Zevalin

· Organ and tissue transplants listed in Section 5(b)

· Physical Therapy and Occupational Therapy Visits

· You must receive approval from HMSA for any outpatient physical therapy visits, occupational therapy visits, or a combination of both beyond the first 10 visits.

· Positron Emission Tomography (PET)

· Routine care associated with clinical trials listed in Section 5(g) of this brochure

· Stereotactic radiosurgery utilizing particle beams

· Surgeries, therapies or procedures employing new technology

· Surgery for hyperhidrosis

· Surgery to correct morbid obesity

· Transplant evaluations, except for cornea and kidney transplant evaluations

This list of services requiring precertification may change periodically. To ensure your treatment or procedure is covered, call us at 808-948-6499.

Copayments

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you use your Plan pharmacy, you pay a copayment of $5 for generic drugs.

Deductible

We do not have a deductible.

Eligible Charges

We calculate our payment and your copayment/coinsurance based on eligible charges. The eligible charge is the lower of either the provider’s actual charge or the amount we established as the maximum allowable fee.

Non-Plan providers are not under contract to limit their charges to our eligible charges. You are responsible for any charges in excess of eligible charges.

Coinsurance

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

Example: When you receive an annual routine chest x-ray, you pay a coinsurance of 20% for Plan providers.

Your catastrophic protection out-of-pocket maximum

After your copayments total $2,500 per person or $7,500 per family enrollment in any calendar year, you do not have to pay any more for covered services. However, coinsurance/copayments for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay coinsurance/copayments for these services:

· Dental Care

· Prescription Drugs

· Vision Care

Any payment from the difference of the actual and eligible charge for non-Plan service does not count toward meeting your catastrophic protection out-of-pocket maximum.

Be sure to keep accurate records of your coinsurance/copayments. We will also keep records of your coinsurance/copayments and track your catastrophic protection out-of-pocket maximum.

I

M

P

O

R

T

A

N

T

Here are some important things you should 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.

· Precertification is required for certain services, supplies, and drugs. Please refer to the precertification information shown in Section 3 to be sure which services, supplies, and drugs require precertification.

I

M

P

O

R

T

A

N

T

Professional services of physicians

· In physician’s office

· During a hospital stay

· In a skilled nursing facility

· Medical consultations – inpatient and outpatient

· At home

Plan Provider

$15 per visit

Non-Plan Provider

30% of eligible charges and any difference between our payment and the actual charge

Tests, such as:

· Blood tests

· Urinalysis

· Non-routine pap tests

· Pathology

· Pre-surgical labs

Plan Provider

Nothing

Non-Plan Provider

30% of eligible charges and any difference between our payment and the actual charge

· X-rays

· Non-routine Mammograms

· Cat Scans/MRI

· Ultrasound

· Electrocardiogram and EEG

· Pre-surgical diagnostic testing

Plan Provider

20% of eligible charges

Non-Plan Provider

30% of eligible charges and any difference between our payment and the actual charge

Routine screenings, limited to:

· Total Blood Cholesterol – one per calendar year

· Colorectal Cancer Screening, including

· Fecal occult blood test – one every calendar year, age 50 and above

· Sigmoidoscopy, screening – every 3-5 years starting at age 50

Nothing, if you receive services as a HealthPass screening

· Routine Prostate Specific Antigen (PSA) test – one annually for men age 50 and older

· Routine pap test – one per calendar year

· 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 and older, one every calendar year

Note: A woman of any age may receive the screening more often if she has a history of breast cancer or if her mother or sister has a history of breast cancer

Plan Provider

Nothing

Non-Plan Provider

30% of eligible charges and any difference between our payment and the actual charge

· Complete Blood Count – one per calendar year

· Fecal Occult Blood – one every calendar year, age 50 and above

· Urinalysis – one per calendar year

· Glucose screening – one every 3 years, age 45 and above

· Fasting lipoprotein profile (Total cholesterol, LDL, HDL, and triglycerides), once every 5 years

· Chlamydial infection screening

Plan Provider

Nothing

Non-Plan Provider

30% of eligible charges and any difference between our payment and the actual charge

· Routine Chest X-Ray – one per calendar year

· TB Tine Test – one per calendar year

· Sigmoidoscopy screening – every 5 years, age 50 and above

· Colonoscopy – once every 10 years, age 50 and above

· Double contrast barium enema (DCBE) – once every 5-10 years, age 50 and above

Plan Provider

20% of eligible charges

Non-Plan Provider

30% of eligible charges and any difference between our payment and the actual charge

· Routine Physical Exam – one per calendar year

· Well Woman Exam – one per calendar year

Plan Provider

Nothing

Non-Plan Provider

30% of eligible charges and any difference between our payment and the actual charge

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

All charges.

Immunizations are covered in accord with guidelines set by the Advisory Committee on Immunization Practices (ACIP)

· Standard Immunizations

· Immunizations for high risk conditions such as Hepatitis B

· Travel Immunizations

Plan Provider

20% of eligible charges

Non-Plan Provider

30% of eligible charges and any difference between our payment and the actual charge

· HealthPass

You and any dependent defined below are eligible for one routine physical exam or HealthPass exam listed in this section per calendar year.

HealthPass is a screening program that provides you with information about how to build a healthier life by looking at your current lifestyle, health habits, and family medical history. For members age 14 to 17, HealthPass for Teens offers an interactive computer program, screenings and individual counseling.

You are eligible to receive a health risk assessment through HealthPass. For more information, contact the Customer Service Department at 808/948-6499.

After your assessment, we will work with you to develop a personal health action plan. We can also recommend other health improvement activities and provide support to help you meet your health goals. Yearly visits will enable you to measure your progress and alert you to any changes that might require additional actions to meet your health goals.

After you call the HealthPass office for an appointment, we'll send you a health questionnaire. Your answers will be combined with the results from your annual screening, which includes:

· Height and weight measurements

· Body fat analysis

· Blood pressure measurement

· Blood cholesterol, HDL and glucose screening tests

If applicable, we may recommend that you attend programs to learn more about:

· Nutrition

· Smoking cessation

· Weight management

· Exercise

Plan Provider

Nothing

Non-Plan Provider

Not a benefit

If you have certain risk factors that become apparent during your initial screening, you’ll be eligible for coverage for additional screenings. Examples include:

· Health maintenance physical examination

· Sigmoidoscopy

· Bone density testing for osteoporosis

· Fecal occult blood test

The HealthPass program operates under the direction of a physician who serves as the program's medical director. HealthPass health consultants are specially trained in preventive health, nutrition, and health promotion.

Plan Provider

Nothing

Non-Plan Provider

Not a benefit

· Childhood immunizations recommended by the American Academy of Pediatrics.

Plan Provider

Nothing

Non-Plan Provider

Any difference between our eligible charge and the actual charge

Examinations, such as:

· Eye exams through age 17 to determine the need for vision correction. See Vision services.

Plan Optometrist

$7 per visit

Plan Provider

20% of eligible charges

Non-Plan Provider

30% of eligible charges plus any difference between our payment and the actual charges

· Ear exams through age 17 to determine the need for hearing correction.

· Examinations through age 12 according to the following schedule:

· Birth up to 24 months: eight visits (one additional visit is covered when a newborn child is discharged within 48 hours of birth)

· Age two through twelve: one visit each calendar year

Plan Provider

Nothing

Non-Plan Provider

30% of eligible charges plus any difference between our payment and the actual charges

Laboratory tests through age 12:

· 2 tuberculin tests (tine or skin sensitivity)

Plan Provider

20% of eligible charges

Non-Plan Provider

30% of eligible charges plus any difference between our payment and the actual charges

Laboratory tests through age 12:

· 3 blood tests (Hemoglobin or Hematocrit)

· 3 urinalysis

Plan Provider

Nothing

Non-Plan Provider

30% of eligible charges plus any difference between our payment and the actual charges

Complete maternity (obstetrical) care, includes physician or certified nurse-midwife services for routine:

· Prenatal care

· Delivery

· Postnatal care

Note: Here are some things to keep in mind:

· We pay hospitalization, surgeon services (delivery), anesthesiology, lab and ultrasound the same as for illness and injury. See Section 5(c) for hospital benefits, Section 5(b) for Surgery and Anesthesia benefits, and Section 5(a) for Lab, X-ray and other diagnostic tests.

· See page 16, Professional Services of Physicians, and page 33, Hospital Benefit, for how we pay benefits for other circumstances, such as complications of pregnancy and extended stays for you or your baby.

· You do not need to precertify your delivery and 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. Your physician 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 cover newborn circumcision under the surgical procedures benefits. See Section 5(b) Surgery benefits.

Plan Provider

Nothing

Non-Plan Provider

30% of eligible charges plus any difference between our payment and the actual charges

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

All charges.

A range of voluntary family planning services, limited to:

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

Plan Provider

Nothing

Non-Plan Provider

30% of eligible charges plus any difference between our payment and the actual charges

· Surgically implanted contraceptives

· Injectable contraceptive drugs (such as Depo provera)

· Intrauterine devices (IUDs)

· Diaphragms/Cervical Caps

Note: Benefit payment for contraceptives is limited to one contraceptive method per period of effectiveness. We cover oral contraceptives under the prescription drug benefits. See Section 5(f) for benefit level

Plan Provider

20% of eligible charges

Non-Plan Provider

30% of eligible charges plus any difference between our payment and the actual charges

Not covered:

· Reversal of voluntary surgical sterilization

· Genetic counseling.

· Contraceptives such as condoms, foam, or creams which do not require a prescription

All charges.

Diagnosis and treatment of infertility limited to:

· Artificial insemination:

· intravaginal insemination (IVI)

· intracervical insemination (ICI)

· intrauterine insemination (IUI)

· In Vitro Fertilization

Note: Coverage is limited to a one time only benefit for one outpatient in vitro procedure in accord with Hawaii law and criteria established by us

Plan Provider

20% of eligible charges

Non-Plan Provider

30% of eligible charges plus any difference between our payment and the actual charges

Not covered:

· Assisted reproductive technology (ART) procedures, such as:

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

· Services and supplies related to ART procedures except in vitro fertilization

· Cost of donor sperm

· Fertility drugs

· Cost of donor egg

All charges.

· Testing (one per calendar year) and treatment

· Allergy injections

· Treatment materials

Plan Provider

20% of eligible charges

Non-Plan Provider

30% of eligible charges plus any difference between our payment and the actual charges

Allergy serum

Plan Provider

Nothing

Non-Plan Provider

30% of eligible charges plus any difference between our payment and the actual charges

Not covered: Provocative food testing and sublingual allergy desensitization

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 30.

· Respiratory and inhalation therapy

· Dialysis – hemodialysis and peritoneal dialysis

· Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy, self-administered injections, Outpatient injections and Intravenous nutrient solutions for primary diet

Note: Home IV Therapy and some injections require prior approval. See Services requiring our prior approval in Section 3.

· Medical foods and low-protein modified food products for the treatment of inborn errors of metabolism in accord with Hawaii Law and Plan guidelines

· Growth hormone therapy (GHT)

Note: We only cover GHT when we precertify the treatment. Call 808-948-6499 for more information on precertification. We will ask you to submit information that establishes that the GHT is medically necessary. 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.

Plan Provider

20% of eligible charges

Non-Plan Provider

30% of eligible charges plus any difference between our payment and the actual charges

Short term therapyfor 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. If you require more than 10 visits of outpatient physical therapy, outpatient occupational therapy, or a combination of both, for an injury or illness, a precertification request with a current progress evaluation and treatment plan should be completed. If the requested services extend beyond a 30-day period, an updated treatment plan is required with documentation of your progress. Plan providers obtain approval for you, non-Plan providers do not.

Plan Provider

20% of eligible charges

Non-Plan Provider

30% of eligible charges plus any difference between our payment and the actual charges

Not covered:

· Long-term rehabilitative therapy

· Exercise programs

· Cardiac Rehabilitation

All charges.

25 visits per calendar year

Plan Provider

20% of eligible charges

Non-Plan Provider

30% of eligible charges plus any difference between our payment and the actual charges

· Diagnostic hearing test

· Hearing Aids – one every five years

Note: Hearing testing for children through age 17 (see Section 5(a) Preventive care, children.)

Plan Provider

20% of eligible charges

Non-Plan Provider

30% of eligible charges plus any difference between our payment and the actual charges

Not covered:

· All other hearing testing

· Repair of hearing aids

· Hearing aid evaluation

All charges.

· Eyeglasses or contact lenses for certain medical conditions such as aphakia, cataract, and keratoconus.

Plan Provider

20% of eligible charges

Non-Plan Provider

30% of eligible charges plus any difference between our payment and the actual charges

· Annual vision exam

· Annual eye refractions

Note: For eye exams for children see Section 5(a) Preventive care, children.

Plan Optometrist

$7 per visit

Plan Provider

20% of eligible charges

Non-Plan Provider

30% of eligible charges plus any difference between our payment and the actual charges

Not covered:

· Eyeglasses or contact lenses except as stated above

· Eye exercises and orthoptics

· Radial keratotomy and other refractive surgery

· Contact lens fitting

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.

Plan Provider

20% of eligible charges

Non-Plan Provider

30% of eligible charges plus any difference between our payment and the actual charges

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.

· Artificial limbs and eyes

· Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy

· Prosthetic devices, such as artificial limbs and lenses following cataract removal

· Orthopedic devices, such as braces

· Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy. Note: See 5(b) for coverage of the surgery to insert the device.

Plan Provider

20% of eligible charges

Non-Plan Provider

30% of eligible charges plus any difference between our payment and the actual charges

Not covered:

· Orthopedic and corrective shoes

· Podiatric shoes

· Arch supports

· Foot orthotics, except for specific diabetic conditions

· Heel pads and heel cups

· Lumbosacral supports

· Corsets, trusses, elastic stockings, support hose, and other supportive devices

· Bionic services and devices

All charges.

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

· Hospital beds;

· Wheelchairs;

· Crutches;

· Walkers;

· Blood glucose monitors; and

· Insulin pumps.

Plan Provider

20% of eligible charges

Non-Plan Provider

30% of eligible charges plus any difference between our payment and the actual charges

Not covered:

· Convenience items such as motorized wheelchairs

All charges.

· Home health care ordered by a Plan physician and provided by a qualified home health agency for the treatment of an illness or injury when you are homebound. Homebound means that due to an illness or injury, you are unable to leave home or if you leave home, doing so requires a considerable and taxing effort

· Services provided for up to 150 visits per calendar year

Note: If you need home health care services for more than 30 days, a physician must certify that there is further need for the services and provide a continuing plan of treatment at the end of each 30-day period of care.

Plan Provider

20% of eligible charges

Non-Plan Provider

30% of eligible charges plus any difference between our payment and the actual charges

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.

No Benefit

All charges

No Benefit

All charges

Not covered:

Biofeedback and other forms of self-care or self-help training and any related diagnostic testing

All charges

· Smoking Cessation – Ready, Set, Quit

A program for smokers who need help to quit smoking. For more information call 808/952-4400 on Oahu or 1-888-225-4122 toll-free from the neighbor islands.

Nothing

Coverage is limited to:

· Life Style Management – Health Odyssey

HMSA’s Health Odyssey programs provide a series of practical, fun-filled health education classes to help you create a healthier, happier life.

Sessions are interactive and include a broad range of life style topics such as goal setting, developing new habits, stress management, nutrition and fitness. Call your local HMSA Office for more information or to register for Health Odyssey.

Nothing

· Disease Management

HMSA provides new and individualized programs to help you better manage chronic illnesses. These disease management programs allow you to take a much larger and more responsible role in controlling your illness.

HMSA’s Care Connection programs currently available to help you and your physician are for: asthma, chronic obstructive pulmonary disease, diabetes, and cardiac (coronary artery disease and heart failure) conditions, and mental health or substance abuse. To find out if these programs are right for you, talk with your primary care physician.

Prenatal Care Program

The Good Pregnancy – He Hapai Pono

He Hapai Pono is designed to help you have a healthy pregnancy and delivery. As soon as you become pregnant, you’ll want to ask your primary care physician to register you in our program. You’ll receive personally tailored information, your choice among several best selling books on pregnancy and childcare for free, and continued education and support from a nurse care manager through your pregnancy and delivery. To register call 888/400-2776 or visit the Web site at www.hmsa.com/myhealth/.

Nothing

Not covered except as offered through HMSA programs:

· Weight reduction programs

· Smoking Cessation programs

· Nutrition Counseling

All charges

I

M

P

O

R

T

A

N

T

Here are some important things you should 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.

· The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5(c) for charges associated with the facility (i.e. hospital, surgical center, etc.).

· YOU MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.

I

M

P

O

R

T

A

N

T

Cutting Surgery includes preoperative and postoperative care.

Note: Non-Plan providers may bill separately for preoperative care, the surgical procedure and post operative care. In such cases, the total charge is often more than the eligible charge. You are responsible for any amount that exceeds the eligible charge.

Cutting & Non-cutting surgical procedures, such as:

· Operative Procedures

· Treatment of fractures, including casting

· Acne treatment destruction of localized lesions by chemotherapy (excluding silver nitrate)

· Cryotherapy

· Diagnostic injections including catheters injections into joints, muscles, and tendons

· Electrosurgery

· Correction of amblyopia and strabismus

· Diagnostic and 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 Section 5(a) Orthopedic and prosthetic devices for device coverage information

Plan Provider

(cutting) Nothing

(non-cutting) 20% of eligible charges

Non-Plan Provider

(cutting and non-cutting)

30% of eligible charges and any difference between our payment and the actual charge

Cutting and Non-cutting surgical procedures (continued)

· Voluntary sterilization (e.g., Tubal ligation, Vasectomy)

· Treatment of burns

· Newborn Circumcision

Plan Provider

(cutting) Nothing

(non-cutting) 20% of eligible charges

Non-Plan Provider

(cutting and non-cutting)

30% of eligible charges and any difference between our payment and the actual charge

Not covered:

· Reversal of voluntary sterilization

· Routine treatment of conditions of the foot; see Foot care

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; webbed fingers; and webbed toes.

· 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.

Plan Provider

(cutting) Nothing

(non-cutting) 20% of eligible charges

Non-Plan Provider

(cutting and non-cutting)

30% of eligible charges and any difference between our payment and the actual charge

Not covered:

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

· Surgeries related to sex transformation

All charges.

Oral 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.

Plan Provider

(cutting) Nothing

(non-cutting) 20% of eligible charges

Non-Plan Provider

(cutting and non-cutting)

30% of eligible charges and any difference between our payment and the actual charge

Not covered:

· Oral implants and transplants

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

· Dental surgeries generally done by dentists and not physicians

· Services, drugs or supplies for nondental treatment of temporomandibular joint (TMJ) syndrome

All charges.

Limited to:

· Cornea

· Heart

· Heart/lung

· Kidney

· Kidney/Pancreas

· Liver

· Lung: Single – Double

· 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

· Autologous tandem transplants for testicular or other germ cell tumors

Plan Provider

(cutting) Nothing

(non-cutting) 20% of eligible charges

Non-Plan Provider

(cutting and non-cutting)

30% of eligible charges and any difference between our payment and the actual charge

· Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach, and pancreas

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.

This coverage is secondary and the living donor’s coverage is primary when:

· You are the recipient of an organ from a living donor, and

· The donor’s health coverage provides benefits for organs donated by a living donor

Transplant evaluations:

· Must receive our approval (with the exception of corneal and kidney transplant evaluations)

· Means those procedures, including laboratory and diagnostic tests, consultations, and psychological evaluations, which a hospital or facility uses in evaluating a potential transplant candidate

Transplant (with the exception of corneal and kidney) must:

· Receive our approval. Without our approval for specific transplants, benefits are not available.

· Be received from a facility that:

· is under contract with us for that type of transplant; and

· accepts you as a transplant candidate.

· This restriction does not apply to intestinal transplants.

Please refer to the precertification information shown in

Section 3

Plan Provider

(cutting) Nothing

(non-cutting) 20% of eligible charges

Non-Plan Provider

(cutting and non-cutting)

30% of eligible charges and any difference between our payment and the actual charge

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

· Non-human organs

All charges.

Professional services provided in:

· Hospital (inpatient)

· Hospital outpatient department

· Skilled nursing facility

· Ambulatory surgical center

· Office

Plan Provider

20% of eligible charges

Non-Plan Provider

30% of eligible charges and any difference between our payment and the actual charge

Professional services include:

· General anesthesia

· Regional anesthesia

· Monitored anesthesia when you meet the Plan’s high-risk criteria

I

M

P

O

R

T

A

N

T

Here are some important things you should 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.

· 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 in Sections 5(a) or (b).

I

M

P

O

R

T

A

N

T

You pay

Room and board, such as

· Semiprivate 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.

Plan Provider

Nothing

(based on semiprivate room rate)

Non-Plan Provider

30% of eligible charges and any difference between our payment and the actual charge (based on semiprivate room rate)

Special care units, such as:

· Intensive care

· Cardiac care units

Plan Provider

Nothing

Non-Plan Provider

30% of eligible charges and any difference between our payment and the actual charge

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 cost, blood processing, blood bank services

· Dressings, splints, casts, and sterile tray services

· Medical supplies and equipment, including oxygen

· Anesthetics, including nurse anesthetist services

· Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Plan Provider

Nothing

Non-Plan Provider

30% of eligible charges and any difference between our payment and the actual charge

Not covered:

· Custodial care, rest cures, domiciliary or convalescent care

· Non-covered facilities, such as adult day care, intermediate care facilities, schools

· Personal comfort items, such as telephone, television, barber services, guest meals and beds

· Private nursing care

· Additional charges for autologous blood

All charges.

Outpatient medical services provided by a hospital or ambulatory surgical center, such as:

· Diagnostic laboratory tests, X-rays, and pathology services

· Pre-surgical testing is covered but only when you meet our criteria

Plan Provider

20% of eligible charges

Non-Plan Provider

30% of eligible charges and any difference between our payment and the actual charge

Services associated with outpatient surgery and provided by a hospital or ambulatory surgical center, such as:

· Operating, recovery, and other treatment rooms

· Prescribed drugs and medicines

· Diagnostic laboratory tests, X-rays, and pathology services

· Administration of blood, blood plasma, and other biologicals

· Blood and blood plasma cost, blood processing, blood bank services

· Dressings, casts, and sterile tray services

· Medical supplies, including oxygen

· Anesthetics

· Anesthesia service (Section 5(b))

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures except those services that are described in the Dental Benefits section.

Plan Provider

Nothing

Non-Plan Provider

30% of eligible charges and any difference between our payment and the actual charge

Skilled nursing facility (SNF):

A facility that provides continuous skilled nursing services as ordered and certified by your attending physician

Room and Board is covered, but only for semiprivate rooms when:

· You are admitted by your physician

· Care is ordered and certified by your physician

· We approve the confinement

· Confinement is not primarily for comfort, convenience, a rest cure, or domiciliary care

· If days exceed 30, the attending physician must submit a report showing the need for additional days at the end of each 30-day period

· The confinement is not longer than 100 days in any one
calendar year

Services and supplies are covered, including routine surgical supplies, drugs, dressings, oxygen, antibiotics, blood transfusion services, and diagnostic and therapy benefits

Plan Provider

Nothing(based on semiprivate room)

Non-Plan Provider

30% of eligible charges and any difference between our payment and the actual charge

Not covered: Custodial care, rest cures, domiciliary or convalescent care

All charges.

A hospice program provides care (generally in a home setting) for patients who are terminally ill and who have a life expectancy of six months or less

· Inpatient residential room and board

· Referral visits

Plan Provider

Nothing

Non-Plan Provider

Not a benefit

Not covered:

· Independent nursing

· homemaker services

All charges.

Ground professional ambulance service is covered when:

· Medically appropriate

· Services to treat your illness or injury are not available in the hospital or nursing facility where you are an inpatient

Nothing

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 – what they all have in common is the need for quick action.

What to do in case of emergency:

If you are in an emergency situation, please call your primary care doctor. Your primary care doctor will provide the necessary care, refer you to other Plan providers or make arrangements with other providers. If you are unable to contact your doctor, contact the local emergency system (e.g., the 911 telephone system) or go to the nearest hospital emergency room. If you are hospitalized in non-Plan facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

Emergencies within and outside our service area:

Emergency care is covered within or outside our Service Area. Please refer to the “You Pay” column below for the applicable emergency care copayment and coinsurance for Plan and non-Plan providers.

Professional emergency services of physicians

· In physician’s office

· In an urgent care center

· As an outpatient or inpatient at a hospital

· In an emergency room

Plan Provider

$15 per visit

Non-Plan Provider

20% of eligible charges

· Emergency diagnostic tests

· Emergency x-rays

· Emergency surgery (non-cutting)

Plan Provider

20% of eligible charges

Non-Plan Providers

20% of eligible charges

· Emergency laboratory tests

· Emergency surgery (cutting)

Plan Provider

Nothing

Non-Plan Provider

20% of eligible charges

· Emergency room facility

Note: If you are admitted as an inpatient following a visit to the emergency room, hospital inpatient benefits apply and not emergency room benefits.

Plan Provider

$50

Non-Plan Provider

20% of eligible charges

Not covered: Elective care or non-emergency care

All charges.