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), your Employee Express confirmation letter, or write to us at Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., ATTN: Member Services Correspondence, 2101 E. Jefferson St., Rockville, MD 20852. Members may submit inquiries, requests and complaints through our website my.kaiserpermanente.org/federalemployees. A Member Services representative will work with you to answer questions and resolve issues, including ID card issues.

If you do not receive your ID card within 30 days after we have received your enrollment from your payroll office, or if you need replacement cards, call us at 301/468-6000 inside the Washington, DC metropolitan area or at 800/777-7902 outside the Washington, DC metropolitan area. Our TTY telephone number is 301/879-6380. You may also request replacement cards through our website at my.kaiserpermanente.org/federalemployees.

Where you get covered care

You get care from “Plan providers” and “Plan facilities.” You will only pay copayments or coinsurance, and you will not have to file claims, except for emergency, urgent care services outside our service area, and for covered services while you travel.

· Plan providers

Our 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 contract with the Mid-Atlantic Permanente Medical Group, P.C., to provide or arrange for primary care services and specialty care services for our members.

Our Provider Directory lists the Plan providers, with locations and phone numbers. Directories are updated annually and are available at the time of enrollment. However, our online Provider Directory is updated biweekly. Our website address is my.kaiserpermanente.org/federalemployees.

· Plan facilities

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members.

If you are visiting another Kaiser Permanente service area, you may receive health care services at those Kaiser Permanente facilities. Under the circumstances specified in this brochure you may receive follow-up or continuing care while you travel anywhere.

Our Provider Directory lists the Plan facilities. Directories are updated annually and are available at the time of enrollment. However, our online Provider Directory is updated biweekly. Our website address is my.kaiserpermanente.org/federalemployees.

What you must do to get covered care

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.

To choose a primary care physician you can either select one from our Provider Directory, on our website is my.kaiserpermanente.org/federalemployees or you can call us at 301/468-6000 inside the Washington, DC metropolitan area or at 800/777-7902 outside the Washington, DC metropolitan area. Our TTY telephone number is 301/879-6380. We are happy to assist you in selecting a primary care physician.

· Primary care

We require you to choose a primary care physician when you enroll. Your primary care physician can be an internal medicine physician, a pediatrician, or a family practice physician. 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 an approved 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 obtain authorization for all follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you an approved referral. You may see Plan gynecologists, optometrists, or mental health and substance abuse providers without a referral. Members may obtain mental health and substance abuse services without a primary care referral by directly calling our Behavioral Health Access Unit at 866/530-8778 to arrange for services.

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

· If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will work with the specialist, in consultation with you, to 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.

· 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 Plan specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive approved services from your current specialist temporarily until we can make arrangements for you to see a participating specialist.

· If you have a chronic and disabling condition and lose access to your Plan specialist because we:

· Terminate our contract with your Plan 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, 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 Member Service department immediately at 301/468-6000 inside the Washington, DC metropolitan area or at 800/777-7902 outside the Washington, DC metropolitan area. Our TTY telephone number is 301/879-6380. 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, is medically necessary, and follows generally accepted medical practice.

We call this review and approval process precertification. Your physician must obtain precertification for the following services:

· Acupuncture

· All inpatient services, except maternity

· Adenoids or tonsil removal

· Ambulance transport (non-emergency)

· Antenatal diagnostic tests outside of the doctor’s office

· Breast surgery not associated with cancer

· Cardiac rehabilitation

· Carpal tunnel surgery

· Chiropractic services

· Clinical trials

· Durable medical equipment

· Gastric bypass surgery

· Genetic testing

· Home health care

· Hospice care

· Hyperbaric oxygen therapy

· Hysterectomy

· Infertility treatment

· Infusion therapy

· Injectable medications

· Nasal surgery

· Occupational therapy

· Oral surgery and dental services covered under the medical plan

· Organ transplants

· Pain management services

· Physical therapy

· Pulmonary rehabilitation

· Prosthetics

· Radiation therapy

· Reconstructive surgery

· Sclerotherapy for varicose veins

· Sleep studies

· Specialty imaging

· Speech therapy

· Spinal surgery and other invasive spinal procedures not associated with cancer

· Surgical procedures

· Temporomandibular Joint treatment

· Tubes in the ears

· Uterine artery embolization

· Video capsule endoscopy

Requests for these services are made to your primary care physician just like any other referral. Your primary care physician submits the request, with supporting documentation. It takes an average of 2 working days to process the request. You should call your primary care physician’s office if you have not been notified of the outcome of the review within 5 working days. If your request is not approved, you have a right to appeal by calling inside the Washington, DC Metropolitan area at 301/468-6000 or toll free at 800/777-7902. Our TTY is 301/879-6380. After business hours, for urgent situations, you may call Appointments/Advice to request an appeal at 703/359-7878, 800/777-7904, TTY is 703/359-7616 or 800/700-4901. If you wish additional services, you must make the request to your primary care physician.

Emergency services do not require precertification. However, you or your family member must notify the Plan within 48 hours, or as soon as reasonably possible.

Copayments

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

Example: Under the High Option Plan, you pay a copayment of $10 when your visit takes place in a primary care department, and a copayment of $20 when your visit takes place in a specialty care department. Under the Standard Option Plan, you pay a copayment of $30 in both primary care and specialty care departments

Deductible

Under the Standard Option Plan, we have a $100 deductible for prescription drugs. There is no prescription drug deductible for the High Option Plan. We do not have any other deductibles.

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for certain services you receive. Example: In our Plan, you pay 50% of our allowance for infertility services, ovulation stimulants, weight management drugs, smoke cessation drugs, and oxygen and equipment for home use.

Fees when you fail to make your copayment or coinsurance

If you do not pay your copayment or coinsurance at the time you receive services, we will bill you. You will be required to pay a $10 charge for each bill sent for unpaid services.

Note: Affiliated physician office and other providers and facilities may bill you an additional charge along with any unpaid copayments, coinsurance or for missed appointments that you fail to cancel.

Your catastrophic protection out-of-pocket maximum

Under the High Option Plan, after your copayments and coinsurance total $1,750 per person or $3,500 per family enrollment in any calendar year, you do not have to pay any more for covered services.

Under the Standard Option Plan, after your copayments and coinsurance total $3,000 per person or $6,000 per family enrollment in any calendar year, you do not have to pay any more for covered services.

However, copayments for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments and coinsurance for these services:

· Prescription drugs

· Chiropractic and acupuncture services

· Dental services

· Follow-up continuing care outside the service area

· Infertility services

· Any non-FEHB benefit

Be sure to keep accurate records of your copayments and 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:

· Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and we cover them only when we determine they are medically necessary.

· Plan physicians must provide or arrange your care.

· We have no calendar year deductible for Medical services and supplies.

· 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. Different copayments apply for primary care visits and specialty care visits. Please refer to Section 10, Definitions, to learn more about when your primary and specialty care copayments will apply.

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Diagnostic and treatment services

Professional services of physicians and other health care professionals

· In a physician’s office

· In an urgent care department

· Second surgical opinion

$10 per visit in a primary care department (nothing for children from infancy through age 4)

$20 per visit in specialty care and urgent care departments

$30 per visit in a primary care department (nothing for children from infancy through age 4)

$30 per visit in specialty care and urgent care departments

· During a hospital stay

· In a skilled nursing facility

Note: See Section 5(c) for facility charges

Nothing

Nothing

At home (in the service area)

Nothing

Nothing

Lab, X-ray and other diagnostic tests

Tests, such as:

· Blood tests

· Urinalysis

· Non-routine Pap smears

· Pathology

· X-rays

· Non-routine mammograms

· Ultrasound

· Electrocardiogram and EEG

Nothing

Nothing

Lab, X-ray and other diagnostic tests (continued)

You pay

Standard Option

Specialty imaging such as:

· CAT scans

· MRI

· Pet scans

· Nuclear medicine studies

· Sleep studies

$50 per visit

$100 per visit

Preventive care, adult

Routine screenings, such as:

· Total blood cholesterol

· 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

· Bone mass measurement for prevention, diagnosis and treatment of osteoporosis

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

· Chlamydia screenings – women under age 20 who are sexually active and women over age 20 with multiple risk factors

· Routine Pap smear

· Travel consultations

Note: You should consult with your physician to determine what is appropriate for you.

$10 per visit in a primary care department

$20 per visit in a specialty care department

$30 per visit in a primary care department

$30 per visit in a specialty care department

Preventive care, adult (continued)

You pay

Standard Option

Routine immunizations, limited to:

· Tetanus-diphtheria (Td) booster – once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

· Influenza vaccines, annually

· Pneumococcal vaccine, age 65 and older and for members at increased risk

· Travel immunizations and vaccines

Note: You pay one copayment if you receive your routine screening or immunization on the same day as your office visit.

$10 per visit in a primary care department

$20 per visit in a specialty care department

$30 per visit in a primary care department

$30 per visit in a specialty care department

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

· From age 35 to 39, one during this five year period

· From age 40 to 64, one every calendar year

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

Nothing

Nothing

· Not covered:

· Physical exams required for:

· Obtaining or continuing employment

· Participating in employee programs

· Insurance or licensing

· Court ordered for parole or probation

· Attending schools

All charges

All charges

Preventive care, children

· Childhood immunizations recommended by the American Academy of Pediatrics

· Examinations, such as:

· Eye exams to determine the need for vision correction

· Ear exams to determine the need for hearing correction

· Travel consultations

· Travel immunizations and vaccines

$10 per visit in a primary care department (nothing for children from infancy through age 4)

$20 per visit in a specialty care department

$30 per visit in a primary care department (nothing for children from infancy through age 4)

$30 per visit in a specialty care department

Preventive care, children (continued)

You pay

Standard Option

· Not covered:

· Physical exams required for:

· Obtaining or continuing employment

· Participating in employee programs

· Insurance or licensing

· Court ordered for parole or probation

· Attending school

All charges

All charges

Maternity care

Complete outpatient maternity (obstetrical) care, such as:

· Prenatal care

· Postnatal care

$10 for the first office visit to confirm pregnancy

Nothing for outpatient services once pregnancy is confirmed through the post-partum office visit

$30 for the first office visit to confirm pregnancy

Nothing for outpatient services once pregnancy is confirmed through the post-partum office visit

Inpatient – hospitalization during pregnancy and for delivery

We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5(c)) and Surgery benefits (Section 5(b)).

Note: Here are some things to keep in mind:

· You do not need to precertify your normal delivery.

· You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. Your inpatient stay will be extended if medically necessary.

· We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We cover other care of an infant who requires non-routine treatment only if the infant is covered under a Self and Family enrollment

$100 per inpatient admission for hospital charges

$250 per day up to $750 maximum per inpatient admission for hospital charges

Not covered:

· Sonograms that are not medically necessary.

All charges

All charges

Family planning

You pay

Standard Option

· Family planning services, including counseling

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

· Information on birth control

· Genetic counseling

Note: We cover surgically implanted time-release contraceptive drugs, injectable contraceptive drugs, intrauterine devices (IUDs), and diaphragms under the prescription drug benefit.

$10 per visit in a primary care department

$20 per visit in a specialty care department

$30 per visit in a primary care department

$30 per visit in a specialty care department

Not covered:

1) Reversal of voluntary surgical sterilization

All charges

All charges

Infertility services

Diagnosis and treatment of involuntary infertility

· Artificial insemination:

· intravaginal insemination (IVI)

· intracervical insemination (ICI)

· intrauterine insemination (IUI)

· Fertility drugs

Note: We cover injectable fertility drugs under the prescription drug benefit.

50% of our allowance

50% of our allowance

In vitro fertilization, (limited to three (3) attempts per live birth) if:

· your oocytes are fertilized with your spouse’s sperm; and

· you have been unable to become pregnant through a less costly infertility treatment for which coverage is available under the Plan; and

· you and your spouse have a history of infertility of at least 2 years duration; or

· the infertility is associated with endometriosis, exposure in utero to diethylstilbestrol, commonly known as DES, blockage of, or surgical removal of, one or both fallopian tubes (lateral or bilateral salpingectomy), or abnormal male factors, including oligospermia, contributing to the infertility.

50% of our allowance; Plan pays up to $100,000 in a member’s lifetime

50% of our allowance; Plan pays up to $100,000 in a member’s lifetime

Infertility services (continued)

You pay

Standard Option

Not covered:

These exclusions apply to fertile as well as infertile individuals and couples:

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

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

· Donor sperm and donor eggs, including the retrieval of eggs

· Cryopreservation including storage, freezing, and thawing of eggs, sperm, or embryo

· Intracytoplasmic sperm injection (ICSI)

· Surrogacy (host uterus/gestational carrier)

· Preimplantation Genetic Diagnosis (PGI)

· Medical and surgical retrieval of sperm

Note: Infertility services are not available when either member of the family has been voluntarily surgically sterilized.

All charges

All charges

Allergy care

· Testing and treatment

$10 per visit in a primary care department (nothing for children from infancy through age 4)

$20 per visit in a specialty care department

$30 per visit in a primary care department (nothing for children from infancy through age 4)

$30 per visit in a specialty care department

· Allergy injection

Note: Allergy serum is covered in full as a part of the office visit copayment.

$10 per visit

$30 per visit

Not covered:

· Provocative food testing

· Sublingual allergy desensitization

All charges

All charges

Treatment therapies

You pay

Standard Option

· Respiratory and inhalation therapy

· Intravenous/Infusion Therapy

Note: We cover growth hormone therapy (GHT) under the prescription drug benefit

· Qualified medical clinical trials that provide treatment for life-threatening conditions or for preventive, early detection, or treatment studies of cancer for Phases I, II, III and IV

· Dialysis – Hemodialysis and peritoneal dialysis

· Chemotherapy and radiation therapy

Note: We limit high dose chemotherapy in association with autologous bone marrow transplants to those transplants listed under Organ/tissue transplants .

$10 per visit in a primary care department (nothing for children from infancy through age 4)

$20 per visit in a specialty care department

$30 per visit in a primary care department (nothing for children from infancy through age 4)

$30 per visit in a specialty care department

Not covered:

· Long-term rehabilitative therapy

· Cognitive therapy

· Chemotherapy supported by a bone marrow transplant or with stem cell support, for any diagnosis not listed as covered

· Sleep therapy

· Thermography and related services

All charges

All charges

Physical and occupational therapies

Inpatient and outpatient rehabilitative physical and occupational therapy as defined below:

· Physical therapy by a qualified Plan therapist in consultation with a Plan physician to restore bodily function when you have a total or partial loss of bodily function due to illness or injury

· Occupational therapy by a Plan therapist in consultation with a Plan physician to assist you in resuming self-care and other activities of daily life when you have a total or partial loss of bodily function due to illness or injury

Inpatient Services – up to 2 consecutive months of therapy per condition

· We provide inpatient multidisciplinary rehabilitation in a prescribed, organized program in a plan facility or skilled nursing facility for up to two consecutive months for all covered rehabilitation services and supplies you may receive at different sites for the same condition.

Note: The inpatient admission charge is waived if your have been admitted directly from a hospital inpatient stay.

$100 per inpatient admission

$250 per day up to $750 maximum per inpatient admission

Physical and occupational therapies (continued)

You pay

Standard Option

Outpatient physical and occupational therapy

· We cover up to 30 office visits or 60 days (whichever is greater) per condition of out-patient physical therapy services

· We cover up to 90 days per condition of out-patient occupational therapy services

Habilitative services for children – from birth to age 19 for the treatment of congenital and genetic birth defects

· We cover services to help a child function age-appropriately within his or her environment and enhance his or her functional ability without an effective cure

Cardiac Rehabilitation provided or coordinated by a hospital or other facility which is approved by a physician and includes exercise stress testing, rehabilitative exercises, education and counseling

· We cover services for up to 12 weeks or 36 sessions following coronary surgery or a myocardial infarction

$20 per visit in a specialty care department

$30 per visit in a specialty care department

Not covered:

· Long-term rehabilitative therapy

· Exercise programs

· Cognitive rehabilitative programs

· Vocational rehabilitative programs

· Therapies done primarily for education purposes, except as may otherwise be covered above

· Services provided by local, state, and Federal Government agencies including schools

All charges

All charges

Speech therapy

Speech therapy by a Plan therapist in consultation with a Plan physician when medically necessary

· Inpatient Services -- up to 2 consecutive months of therapy per condition

Note: The admission charge is waived if you have been admitted directly from a hospital inpatient stay

$100 per inpatient admission

$250 per day up to a $750 maximum per inpatient admission

Speech therapy (continued)

You pay

Standard Option

· Outpatient Services --up to 90 days per condition per year of outpatient speech therapy

Habilitative services for children – from birth to age 19 for the treatment of congenital and genetic birth defects

· We cover services to help a child function age-appropriately within his or her environment and enhance his or her functional ability without an effective cure

$20 per visit in a specialty care department

$30 per visit in a specialty care department

Not covered:

Speech therapy that is not medically necessary such as:

· Therapy for educational placement or other educational purposes

· Training or therapy to improve articulation in the absence of injury, illness, or medical condition affecting articulation

· Therapy for tongue thrust in the absence of swallowing problems

· Voice therapy for occupation or performing arts

· Services provided by local, state, and Federal Government agencies including schools

All charges

All charges

Hearing services (testing, treatment, and supplies)

· Hearing tests to determine the need for hearing correction

$10 per visit in a primary care department (nothing for children from infancy through age 4)

$20 per visit in a specialty care department

$30 per visit in a primary care department (nothing for children from infancy through age 4)

$30 per visit in a specialty care department

· Hearing aids for children under age 18

All charges in excess of $1,400 for each hearing impaired ear every 36 months

All charges in excess of $1,400 for each hearing impaired ear every 36 months

Not covered:

· Hearing aids, tests to determine their effectiveness, and examinations for them for all persons 18 and over

· All other hearing testing

All charges

All charges

Vision services (testing, treatment, and supplies)

You pay

High Option

You pay

Standard Option

· Eye exam in the Optometry Department

· Eye refractions in the Optometry Department

Note: Vision services performed outside the Optometry Department will be at the specialty copayment.

$10 per visit

$30 per visit

· Diagnosis and treatment of diseases of the eye

Note: These services are performed in a specialist department

$20 per visit in a specialty care department

$30 per visit in a specialty care department

· Eyeglass frames purchased at Plan Optical Shops

· Eyeglass lenses purchased at Plan Optical Shops

75% of our allowance

75% of our allowance

Total contact lens package at a Plan facility including

· Initial fitting for contact lenses

· Initial pair of contact lenses

· Insertion and removal of contact lens training

· Three months of follow-up office visits

Note: These services are provided only as a total package

85% of our allowance

85% of our allowance

Not covered:

· Eye exercises and orthoptics

· Radial keratotomy and other refractive surgery

· Eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), far-sightedness (hyperopia), and astigmatism

· Cosmetic contact lenses

· Cost of eyewear not purchased at Plan facilities

· Sunglasses without corrective lenses

All charges

All charges

Foot care

· Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease

Note: See orthopedic and prosthetic devices for information on podiatric shoe inserts.

$10 per visit in a primary care department

$20 per visit in a specialty care department

$30 per visit in a primary care department

$30 per visit in a specialty care department

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

Orthopedic and prosthetic devices

You pay

High Option

You pay

Standard Option

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

50% of our allowance

50% of our allowance

· Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implants following mastectomy.

Notes:

· See 5(b) for coverage of the surgery to insert the device.

· These items are covered only when preauthorized in writing by the Plan and when obtained through sources designated by the Plan.

Nothing

Nothing

· One hair prosthesis if your hair loss results from chemotherapy or radiation treatment for cancer

All charges in excess of $350

All charges in excess of $350

Not covered:

· Comfort, convenience, or luxury equipment or features

· External prosthetic and orthopedic devices, such as braces, foot orthotics, artificial limbs, and lenses following cataract removal

· Devices, equipment, supplies and prosthetics related to sexual dysfunction

· 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

All charges

All charges

Durable medical equipment (DME)

You pay

High Option

You pay

Standard Option

We cover prescribed DME for home use.

Covered items include

· Hospital beds

· Wheelchairs

· Canes

· Walkers

· Portable commodes

· Crutches

· Bilirubin lights and apnea monitors for infants up to age 3 for a period not to exceed 6 months

· Continuous Positive Airway Pressure (CPAP) and Bilevel Pressure device (BIPAP) equipment

· Oxygen and equipment for home use

50% of our allowance

50% of our allowance

Notes:

· These items are covered only when preauthorized in writing by the Plan and when obtained through sources designated by the Plan.

· Your Plan physician must recertify your medical need for oxygen and oxygen equipment every 30 days.

· We decide whether to rent or purchase the equipment, and we select the vendor. We will repair the equipment without charge, unless the repair is due to loss or misuse. You must return the equipment to us or pay us the fair market price of the equipment when it is no longer prescribed.

· Asthma-related equipment (spacers, peak-flow meters, and nebulizers) for adults and children, when purchased at a Plan pharmacy.

Spacers: $5 per spacer

Peak-Flow Meters: $10 per meter

Nebulizers: $30 per nebulizer

Spacers: $5 per spacer

Peak-Flow Meters: $10 per meter

Nebulizers: $30 per nebulizer

Durable medical equipment (DME) (continued)

You pay

Standard Option

We cover Diabetic Equipment and Supplies when purchased at a Plan pharmacy including:

· Diabetic equipment

· Insulin pumps

· Disposable needles and syringes (up to 3 boxes)

· Glucose test strips (up to 6 boxes of 50 count)

20% of our allowance

20% of our allowance

· Glucose meter

· Replacement batteries

· Control solutions

· Lancets

Note: Lancets, disposable needles and syringes and glucose test strips are available by Plan mail delivery or through Plan pharmacies. Other diabetic supplies in this section are available only at Plan pharmacies.

Refer to Section 5(f), Prescription drug benefits, for information about insulin coverage.

$10 per meter

$5 per package

$8 per package

$8 per package

$10 per meter

$5 per package

$8 per package

$8 per package

Not covered:

· Oxygen tents

· Motorized wheelchairs

· Comfort, convenience, or luxury equipment or features

· Exercise or hygiene equipment

· Non-medical items such as sauna baths or elevators

· Modifications to your home or car

· Electronic monitors of bodily functions, except apnea monitors and blood glucose monitors

· Disposable supplies except as specifically listed in this section

· Replacement of lost equipment

· Repairs, adjustments, or replacements necessitated by misuse

· More than one piece of durable medical equipment serving essentially the same function, except for replacements other than those necessitated by misuse or loss

· Devices, equipment, supplies, and prosthetics for the treatment of sexual dysfunction disorders

· External and internally implanted hearing aids for all persons age 18 and over

· Experimental or research equipment

· Dental appliances

Home health services

You pay

Standard Option

If you are homebound and reside in the service area, we cover home health care ordered by a Plan physician and provided by a registered nurse, licensed practical nurse, licensed vocational nurse, physical therapist, occupational therapist, speech and language pathologist, or home health aide

· Services include oxygen therapy, intravenous therapy and medications

Note: Your Plan physician will periodically review the home health services for continuing appropriateness and medical need.

Nothing

Nothing

Not covered:

· Nursing care requested by, or for the convenience of, the patient or the patient’s family

· Custodial care

· Homemaker services

· Services outside the service area

· Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative

· General maintenance care of colostomy, ileostomy, and ureterostomy

· Medical supplies or dressings applied by you or a family caregiver

· Care that a Plan physician determines may be provided in a Plan facility or skilled nursing facility if we provide or offer to provide that care in one of those facilities

· Transportation and delivery service costs of durable medical equipment, medications, drugs, medical supplies, and supplements to the home

· Personal care items

All charges

All charges

Chiropractic

You pay

Standard Option

Chiropractic services, including spinal manipulation of the neck and back, up to 20 visits per calendar year, for the following services

· Evaluation and management

· Routine chiropractic x-rays provided in the chiropractor’s office

· Chiropractic adjustments

· Adjunctive therapies (e.g., hot and cold packs)

· Educational materials

Note: You receive these services when your Plan physician, in consultation with the Complementary and Alternative Medicine Department, determines that such care will result in improvement in your condition.

$20 per office visit

All charges

Not covered:

· Structural supports

· Nutritional supplements

All charges

All charges

Alternative treatments

Acupuncture services up to 20 visits per calendar year, for the following services:

· Evaluation and management

· Note: You receive these services when your Plan physician, in consultation with the Complementary and Alternative Medicine Department, determines that such care will result in improvement in your condition.

$20 per visit

All charges

Not covered:

· Herbal and nutritional supplements

All charges

All charges

Educational classes and programs

· Health education for conditions such as diabetes, post-coronary, and nutritional counseling

$10 per visit in a primary care department

$20 per visit in a specialty care department

$30 per visit in a primary care department

$30 per visit in a specialty care department

· General health education classes such as prenatal, weight management, smoking cessation, and stress management

Nominal fees ranging from $10 to $75 per class

Nominal fees ranging from $10 to $75 per class

Not covered:

· Educational classes and programs not offered through this Plan

All charges

All charges

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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.

· Plan physicians must provide or arrange your care.

· We have no calendar year deductible for Surgical and anesthesia services.

· Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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

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

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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

· Pre-surgical testing

· Correction of amblyopia and strabismus

· Endoscopy procedures

· Biopsy procedures

· Removal of tumors and cysts

· Foot surgery including open cutting surgery to remove bunions and spurs

· Correction of congenital anomalies (see Reconstructive surgery)

$20 per visit in a specialty care department

$50 per outpatient surgery

$100 per inpatient admission for hospital charges

$30 per visit in a specialty care department

$100 per outpatient surgery

$250 per day up to $750 maximum per inpatient admission for hospital charges

Surgical procedures(continued)

You pay

Standard Option

· 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

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

· Treatment of burns

· Insertion of surgically implanted time-release contraceptive drugs and intrauterine devices (IUDs). Note: We cover the cost of these devices under the prescription drug benefit (see Section 5(f))

· Insertion of other implanted time-release drugs. Note: We cover the cost of these devices under the prescription drug benefit (see Section 5(f))

Not covered:

· Reversal of voluntary sterilization

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

All charges

All charges

Reconstructive surgery

You pay

Standard Option

· Surgery to correct a functional defect

· Surgery to correct a condition caused by injury or illness if:

· it 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 of breasts;

· treatment of any physical complications, such as lymphedemas; and

· breast prostheses and surgical bras and replacements (see Orthopedic and 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.

$20 per visit in a specialty care department

$50 per outpatient surgery

$100 per inpatient admission for hospital charges

$30 per visit in a specialty care department

$100 per outpatient surgery

$250 per day up to $750 maximum per inpatient admission for hospital charges

Not covered:

· Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance and/or treat a mental condition through change in bodily form

· Surgeries related to sex transformation

All charges

All charges

Oral and maxillofacial surgery

Oral surgical procedures, limited to:

· Reduction of fractures of the jaws or facial bones

· Surgical correction of cleft lip, cleft palate, or severe functional malocclusion

· Removal of stones from salivary ducts

· Excision of leukoplakia or malignancies

· Excision of cysts and incision of abscesses when done as independent procedures

· Medical and surgical treatment of TMJ (non-dental)

· Other surgical procedures that do not involve the teeth or their supporting structures

$20 per visit in a specialty care department

$50 per outpatient surgery

$100 per inpatient admission for hospital charges

$30 per visit in a specialty care department

$100 per outpatient surgery

$250 per day up to $750 maximum per inpatient admission for hospital charges

Oral and maxillofacial surgery (continued)

You pay

Standard Option

Not covered:

· Oral implants and transplants

· Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone) except as covered under the accidental dental benefit.

· Shortening of the mandible or maxillae for cosmetic purposes and correction of malocclusion.

All charges

All charges

Organ/tissue transplants

Limited to:

· Cornea

· Heart

· Heart/Lung

· Kidney

· Kidney/Pancreas

· Liver

· Lung: Single – Double

· Pancreas

· Allogeneic donor bone marrow transplants

· Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute lymphocytic or non-lymphocytic leukemia; advanced Hodgkin’s lymphoma; advanced non-Hodgkin’s lymphoma; advanced neuroblastoma; testicular, mediastinal, retroperitoneal and ovarian germ cell tumors, breast cancer; multiple myeloma and epithelial ovarian cancer

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

Unless otherwise authorized by your physician, transplants are covered only at institutions that we designate as “Centers of Excellence” for that specific transplant. If your physician or the transplant facility determines that you do not satisfy the criteria for receiving the transplant, we will pay only for the covered services and supplies you receive before you are notified of that determination.

$20 per visit in a specialty care department

$50 per outpatient surgery

$100 per inpatient admission for hospital charges

$30 per visit in a specialty care department

$100 per outpatient surgery

$250 per day up to $750 maximum per inpatient admission for hospital charges