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 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 our Member Services Department at (716) 631-8701 or (800) 501-3439, press 1.

Where you get
covered care

You get care from “Plan providers” and “Plan facilities.” You will only pay copayments and coinsurance, and you will not have to file claims. If you use our point of service program [see Section 5(i)], you can also get care from non-Plan providers but it will cost you more.

Plan providers

Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards.

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

Plan facilities

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The list is also on our Web site.

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. Our provider directory lists primary care doctors with their locations and phone numbers. We update directories on a regular basis. We send a directory to you when you enroll. You may also request one by calling our Western New York Marketing Department at (716) 631-5392 or (800) 453-1910. You can also find out if your doctor participates with us by calling one of the numbers listed above.

Primary care

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

If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.

Specialty care

You must receive a referral from your primary care physician for most specialty

care. When you receive a referral from your primary care physician, you must

return to the primary care physician after the consultation, unless your primary
care physician authorized a certain number of visits without additional referrals. The primary care physician must provide or authorize all follow-up care. Do
not go to the specialist for return visits unless your primary care physician gives
you a referral.

You do not need to obtain a referral from your primary care doctor to see the

following specialists as long as they participate with us:

· Obstetricians/Gynecologists

· Dermatologists

· Allergists

· Ophthalmologists

· Optometrists

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

1) If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will work with us 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 may have to get an authorization or approval beforehand.

2) If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you may use your POS benefit.

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

4) 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 are and you enroll in another FEHB Plan.

You may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

Hospital care

Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at (716) 631-8701, or (800) 501-3439, press 1. 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:

5) You are discharged, not merely moved to an alternative care center; or

6) The day your benefits from your former plan run out; or

7) 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

Procedures that Require Preauthorization (HMO)

At Independent Health, we have two types of prior approval. Under the HMO benefits, we have preauthorization. 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 preauthorization. We are committed to working with your doctor to ensure you receive the best possible medical care in the most appropriate medical setting. Because some medical conditions can be treated in a variety of ways, our Medical Director has developed a list of procedures that we must approve before they are performed. Your doctor will work with us to obtain our prior approval. There is nothing that you need to do.

All alcohol/substance abuse services or treatment

Autologous chondrocyte transplantation

Chiropractic services

Coronary stent brachytherapy for re-stenosis

Cosmetic procedures

CT Scan, PET Scan, MRI & MRA

Dental services related to accidental injury or congenital anamoly

Durable medical equipment (including diabetes equipment), prosthetics, and orthopedic appliances

Ductal lavage

Elective inpatient hospitalizations

Enhanced external corporeal pulsation (EECP)

Follow-up for urgent care out of area

Gamma knife surgery, gamma stereotactic knife,
stereotactic radiosurgery

Gastric bypass surgery

HDL/LDL sub type testing for assessment of coronary artery disease risk

Infertility drugs

Inpatient dental services

Intra-articular injections of hyalgan or synvisc

IDET (intradermal electrotherapy)

Investigational/Experimental procedures/New technology

Lung reduction surgery

Mental health services including psychological testing

Non-formulary insulin and diabetic supplies

Non-emergent ambulance/planned transfer

Out-of-area hospital admissions

Out-of-plan referrals

Oxygen

Photodynamic therapy

Physical, occupational and speech therapy services

Prosorba column for rheumatoid arthritis

Pulmonary rehabilitation

Reconstructive procedures (congenital)

Rhinoplasty

Self-injectable drugs

Septorhinoplasty

Spinal procedures to include Diskectomy, Lumbar laminectomy and
Spinal fusion

Synagis vaccine

Transplants

Procedures that require precertification (POS)

Under POS benefits, we call the prior approval process precertification. You are ultimately responsible for obtaining our prior approval before obtaining certain services. If you do not obtain precertification from us, we will apply a penalty to the covered charges or we may not cover the service at all in the event that we determine it is not medically necessary. You must obtain precertification from us for the following services:

Elective facility/inpatient admissions

Reconstructive Surgery

Accidental dental injuries

DME Items:

o BiPAP S/BiPAP ST

o Bone Growth Stimulator

o Breast pumps

o CPAP

o CPM

o Light Boxes

o LTV Ventilators

o TENS

o Ventilators

Home infusion services

Medical supplies

Pulmonary rehabilitation therapy

Skilled home care services (including home infusion services) prior to the beginning of the initial visit

Additional Expenses

Under the POS benefit, you pay the difference between the non-Plan provider’s charges and the amount that we pay for a covered service.

Coinsurance

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

Example: In our Plan, you pay 50% of our allowance for durable medical equipment. Coinsurance also applies when you use the POS benefit.

Copayments

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

Example: When you see your Plan primary care physician you pay a copayment of $15 per office visit.

Deductible

We do not have a deductible except as noted under the POS benefits.

Your catastrophic protection out-of-pocket maximum

We do not have an out-of-pocket maximum under the HMO benefits. You pay the copay or coinsurance for a covered service as indicated in the brochure.

Under the Point of Service (POS) benefits, your out-of-pocket maximum is $2,000 under Self Only and $4,000 under Self and Family coverage. After you have met the out-of-pocket maximum under the POS benefits, you will not pay coinsurance for covered POS services. However, you may owe additional expenses after our payment up to the provider’s charge for a covered service. See the POS benefits (Section 5i).

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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 do not have a calendar year deductible under the HMO benefits that you receive from Plan providers.

Please see Section 5(i) for information regarding POS benefits for out-of-network services.

Your physician must obtain preauthorization for certain services. Please see page 11 for a list of procedures that require preauthorization.

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

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Professional services of physicians

In physician’s office

$15 per office visit

Professional services of physicians

In an urgent care center

Office medical consultations

Second surgical opinion

$15 per office visit

At home

$15 per visit

During a hospital stay

In a skilled nursing facility

Nothing

Tests, such as:

8) Blood tests

9) Urinalysis

10) Non-routine pap tests

11) Pathology

Nothing

Radiology procedures such as:

12) X-rays

13) CT Scans/MRI

14) Ultrasound

15) Radiation therapy

$20 per visit for radiology services in addition to any copayment for office services

Diagnostic tests, such as:

16) Electrocardiogram and EEG

$15 per office visit for diagnostic tests

Non-routine Mammograms

Nothing

Routine screenings, such as:

17) Total Blood Cholesterol – once every three years

18) Colorectal Cancer Screening, including

Fecal occult blood test

Sigmoidoscopy, screening – every five years starting at age 50

Colonoscopy screening

Double contrast barium enema

$15 per office visit

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

$15 per office visit

Routine pap test

Note: The office visit is covered if pap test is received on the same day; see Diagnosis and Treatment, above.

$15 per office visit

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

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

20) From age 40 through 64, one every calendar year

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

Nothing

Routine bone density screening for:

Women age 65 and over

Women at increased risk age 60 and over

$20 per office visit

Preventive care, adult (continued)

You pay

Routine immunizations, such as:

22) Tetanus-diphtheria (Td) booster – once every 10 years, ages 19 and over (except as provided for under Childhood immunizations)

23) Influenza vaccine, annually

Pneumococcal vaccine

$15 per office visit

Note: If the only reason for your office visit is
an Influenza or Pneumococcal vaccine, you
pay nothing.

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

All charges.

24) Childhood immunizations recommended by the American Academy of Pediatrics

Nothing

25) Well-child care charges for routine examinations, immunizations and care

Examinations done on the day of immunizations

Nothing

26) Examinations, for dependents up to age 22, such as:

Eye chart exams to determine the need for vision correction

Ear exams to determine the need for hearing correction

$15 per office visit for eye and ear exams.

Complete maternity (obstetrical) care, such as:

27) Prenatal care

28) Delivery

29) Postnatal care

Note: Here are some things to keep in mind:

30) You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.

31) 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.

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

Nothing

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

All charges.

A range of voluntary family planning services, limited to:

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

34) Surgically implanted contraceptives

35) Injectable contraceptive drugs (such as Depo provera)

36) Intrauterine devices (IUDs)

37) Diaphragms

Note: We cover oral contraceptives and certain contraceptive devices under the prescription drug benefit.

$15 per office visit

Not covered:

1) Reversal of voluntary surgical sterilization

2) Genetic counseling.

All charges

We will cover medical or surgical procedures which are medically necessary to diagnose or correct a malformation, disease, or dysfunction, resulting in infertility, and diagnostic tests and procedures that are necessary to determine infertility.

We limit infertility coverage to correctable medical conditions that have resulted in infertility. Your applicable office visit, inpatient and outpatient facility copayments depend on the type and location of treatment or services [See section 5(a), 5(b) and 5(c)]. Correctable medical conditions include: endometriosis, uterine fibroids, adhesive disease, congenital septate uterus, recurrent spontaneous abortions, and varicocele.

In order to be eligible for Infertility services, you must:

be at least 21 years of age and no older than 44; except for diagnosis and treatment for a correctable medical condition which incidentally results in Infertility

have a treatment plan submitted in advance to us by a physician who has the appropriate training, experience and meets other standards for diagnosis and treatment of infertility as promulgated by New York State

have a treatment plan that is in accordance with standards and guidelines established and adopted by the American College of Obstetricians and Gynecologists, the American Society for Reproductive Medicine, and the American Hospital Formulary Service

$15 per visit for services performed at an office, outpatient facility or ambulatory surgical center

Nothing for inpatient and laboratory services

$20 per visit for radiology services

Covered diagnostic tests and procedures including but not limited to the following procedures:

hysterosalpingogram

hysteroscopy

endometrial biopsy

laparoscopy

sonohysterogram

post coital tests

testis biopsy

semen analysis

blood tests

ultrasound

sperm washing

electroejaculation

We cover the following types of artificial insemination:

intravaginal insemination (IVI)

intracervical insemination (ICI)

intrauterine insemination (IUI)

Note: The number of allowable artificial insemination procedures is based on accepted medical practices.

38) Fertility drugs

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

Not covered:

Services for an infertility diagnosis as a result of current or previous sterilization procedures (s) and/or procedures(s) for reversal of sterilization.

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

in vitro fertilization

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

Services and supplies related to ART procedures

Costs associated with the collection and donation of sperm

Cost of donor sperm or donor egg and all related services

Over-the-counter medications, devices or kits, such as ovulation kits

Cloning or any services incident to cloning

All charges

40) Testing and treatment

41) Allergy injections

$15 per office visit

Allergy serum

Nothing

Not covered: Provocative food testing and sublingual allergy desensitization

All charges.

42) Chemotherapy

Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under Organ/Tissue Transplants on page 28.

43) Respiratory and inhalation therapy

44) Dialysis – Hemodialysis and peritoneal dialysis

45) Growth hormone therapy (GHT)

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

Note: – We only cover GHT when we preauthorize the treatment. Your prescribing physician will request prior authorization from us if GHT is medically necessary for your treatment. We review most prior authorization requests within 24 hours or receipt of all necessary information.

$15 per office visit

Radiation Therapy

$20 per office visit

Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy

Nothing

Up to two consecutive months per condition for the services of each of
the following:

qualified physical therapists and

occupational therapists

Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury.

$15 per outpatient visit

Nothing per visit during covered
inpatient admission

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for up to 36 sessions.

$15 per outpatient visit

Not covered:

46) Long-term rehabilitative therapy

47) Exercise programs

All charges.

Up to two consecutive months per condition for the services of a licensed Plan speech therapist

$15 per outpatient visit

Nothing per visit during covered
inpatient admission.

48) First hearing aid and testing only when necessitated by accidental injury

49) Hearing testing for children up to age 22 to determine the need for hearing correction. (see Preventive care, children)

$15 per office visit

Not covered:

50) All other hearing testing

51) Hearing aids, testing and examinations for them

All charges.

Eye examinations for medical conditions

Note: Refractive eye examinations are available through Independent Health’s EyeMed vision program. Please see Section 5(j) Non-FEHB benefits available to Plan members.

$15 per office visit

52) One pair of eyeglasses or contact lenses to correct an impairment
directly caused by accidental ocular injury or intraocular surgery
(such as for cataracts).

Note: Refractive eye examinations are available through Independent Health’s EyeMed vision program. Please see Section 5(j) Non-FEHB benefits available to Plan members.

$15 per office visit

Not covered:

53) Eye exercises and orthoptics

54) Radial keratotomy and other refractive surgery

55) Eye glasses or contact lenses

Note: Discounts for eyeglasses and contact lenses are available through Independent Health’s EyeMed program. Please see Section 5(j) for Non-FEHB benefits available to Plan members.

All charges.

Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

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

$15 per office visit

Not covered:

56) 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

57) 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.

58) Artificial limbs and eyes; stump hose

Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

50% coinsurance per device.

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

Nothing

60) 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.

Nothing

Not covered:

3) Hearing aids

61) Orthopedic and corrective shoes

62) Arch supports

63) Foot orthotics

64) Heel pads and heel cups

65) Lumbosacral supports

66) Corsets, trusses, elastic stockings, support hose, and other
supportive devices

67) Wigs or hair prosthesis

68) Prosthetic replacements provided less than 3 years after the last
one we covered

All charges.

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

Hospital beds;

Wheelchairs;

Crutches;

Walkers;

Note: You must receive preauthorization from the Medical Director before purchasing DME. When your physician prescribes this equipment, the physician and/or DME vendor will contact us to receive approval.

50% coinsurance per device.

Note: You have an annual maximum benefit of $1,000 for DME.

Insulin pumps

Blood glucose monitors

$15 per item

Not covered:

4) Personal convenience items

5) Humidifiers, air conditioners

6) Athletic or exercise equipment

7) Computer assisted communication devices

All charges.

69) Home health care ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide.

$15 per visit

70) Services include oxygen therapy, intravenous therapy and medications.

Nothing

Not covered:

71) Nursing care requested by, or for the convenience of, the patient or the patient’s family;

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

73) Private duty nursing;

74) Services primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication.

All charges.

The following services by a licensed Plan chiropractor

75) Manipulation of the spine and extremities

76) Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

Note: Chiropractic care must be provided in connection with the detection and correction by manual or mechanical means, of any structural imbalance, distortion or subluxation in the human body. You must receive a referral for chiropractic care from your Primary Care Physician.

$15 per office visit

No benefit. We do not cover services such as:

Acupuncture

Naturopathic services

Hypnotherapy

Biofeedback

All charges.

Coverage is limited to:

77) Diabetes self management

78) Nutritional counseling

Note: Please refer to Section 5(j) Non-FEHB benefits available to Plan

members for other classes such as Stop Smoking Classes.

$15 per office visit

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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 do not have a calendar year deductible for services received under the HMO benefits that you receive from Plan providers.

Please see Section 5(i) for information regarding POS benefits for out-of-network 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 PREAUTHORIZATION FOR SOME SURGICAL PROCEDURES. Please refer to the preauthorization information shown in Section 3 to be sure which services require preauthorization and identify which surgeries require preauthorization.

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A comprehensive range of services, such as:

79) Operative procedures

80) Treatment of fractures, including casting

81) Normal pre- and post-operative care by the surgeon

82) Correction of amblyopia and strabismus

83) Endoscopy procedures

84) Biopsy procedures

85) Removal of tumors and cysts

86) Correction of congenital anomalies (see Reconstructive surgery)

$15 per office visit

Nothing for inpatient services

87) 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, or a body mass index (BMI) greater than 40 or greater than 35 with serious medical conditions exacerbated or caused by obesity, such as diabetes, sleep apnea, etc. Eligible members must be age 18 or over

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

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

90) Treatment of burns

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

$15 per office visit

Nothing for inpatient services

Not covered:

91) Reversal of voluntary sterilization

92) Routine treatment of conditions of the foot; see Foot care

All charges.

93) Surgery to correct a functional defect

94) 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

95) 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: severe protruding ear deformities; cleft lip;
cleft palate; birth marks; webbed fingers; and webbed toes.

96) All stages of breast reconstruction surgery following a mastectomy, such as:

surgery to produce a symmetrical appearance of breasts;

treatment of any physical complications, such as lymphedemas;

breast prostheses and surgical bras and replacements
(see Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

$15 per office visit

Nothing for inpatient services

Not covered:

97) 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

98) Surgeries related to sex transformation

All charges.

Oral surgical procedures, limited to:

99) Reduction of fractures of the jaws or facial bones;

100) Surgical correction of cleft lip, cleft palate or severe
functional malocclusion;

101) Removal of stones from salivary ducts;

102) Excision of leukoplakia or malignancies;

103) Excision of cysts and incision of abscesses when done as independent procedures; and

104) Other surgical procedures that do not involve the teeth or their
supporting structures.

$15 per office visit

Nothing for inpatient services

Not covered:

105) Oral implants and transplants

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

All charges.

Limited to:

107) Cornea

108) Heart

109) Heart/lung

110) Kidney

111) Kidney/Pancreas

112) Liver

113) Lung: Single – Double

114) Pancreas

115) Allogeneic bone marrow transplants

116) 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 mediastinal, retroperitoneal and ovarian germ cell tumors

117) Autologous tandem transplant for the treatment of testicular and other germ cell tumors

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

Note: We cover related medical and hospital expenses of the donor when
we cover the recipient. These benefits are subject to the approval of the Medical Director.

$15 per office visit

Nothing for inpatient services

Not covered:

119) Donor screening tests and donor search expenses, except those performed for the actual donor

120) Implants of artificial organs

121) Transplants not listed as covered

8) Costs related to travel, food or lodging for the transplant recipient or donor

All charges.

Professional services provided in –

122) Hospital (inpatient)

123) Hospital outpatient department

124) Skilled nursing facility

125) Ambulatory surgical center

Office

Nothing

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

126) 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.

127) Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

128) We do not have a calendar year deductible under the HMO benefits that you receive from Plan providers.

129) Please see Section 5(i) for information on the POS benefits for out-of-network services.

130) 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.

131) The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are covered in Sections 5(a) or (b).

132) YOUR PHYSICIAN MUST GET PREAUTHORIZATION FOR HOSPITAL STAYS. Please refer to Section 3 to be sure which services require preauthorization.

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Room and board, such as

133) Ward, semiprivate, or intensive care accommodations;

134) General nursing care; and

135) 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.

Nothing

Other hospital services and supplies, such as:

136) Operating, recovery, maternity, and other treatment rooms

137) Prescribed drugs and medicines

138) Diagnostic laboratory tests and X-rays

139) Administration of blood and blood products

140) Blood or blood plasma, if not donated or replaced

141) Dressings, splints, casts, and sterile tray services

142) Medical supplies and equipment, including oxygen

143) Anesthetics, including nurse anesthetist services

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

Nothing

Inpatient Hospital(continued)

You pay

Not covered:

145) Custodial care

146) Non-covered facilities, such as nursing homes, schools

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

148) Private nursing care

All charges.

149) Operating, recovery, and other treatment rooms

150) Prescribed drugs and medicines

151) Diagnostic laboratory tests, X-rays, and pathology services

152) Administration of blood, blood plasma, and other biologicals

153) Blood and blood plasma, if not donated or replaced

154) Pre-surgical testing

155) Dressings, casts, and sterile tray services

156) Medical supplies, including oxygen

157) Anesthetics and anesthesia service

Note: – We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

$15 per visit

Not covered: Blood and blood derivatives not replaced by
the member

All charges.

Skilled nursing facility (SNF) and subacute facility: We provide a comprehensive range of benefits for up to 45 days per calendar year when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by us.

All necessary services are covered, including:

bed, board and general nursing care

drugs, biologicals, supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor.

Nothing

Not covered: Custodial care, maintenance care, respite care, or convenience care

All charges.

We cover up to 210 days of Hospice services on an inpatient or outpatient basis (including medically necessary supplies and drugs) for a terminally ill member. Covered care is provided in the home or hospice facility under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six months or less. As a part of hospice care, we cover up to five (5) visits of bereavement counseling for covered family.

Hospice care includes Advance Care Planning (ACP) prior to admittance to a hospice Plan program or facility. ACP means home visits, from a program sponsored by a plan hospice provider, to assist members in preparing for issues they face following a life threatening or terminal diagnosis. ACP is limited to a maximum of six (6) ACP visits per calendar year. This benefit is in addition to the hospice care benefit described above.

Nothing

Not covered: Independent nursing, homemaker services

All charges.

158) Local professional ambulance service when medically appropriate. See 5(d) for emergency service

$25 per trip

Not covered:

Wheelchair van transportation

All charges.

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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 do not have a calendar year deductible under the HMO benefits that you receive from Plan providers.

POS benefits do not apply to emergency services. Please see Section 5(i) regarding your POS benefits. POS benefits may apply if you do not contact Independent Health for urgent care 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.

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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 within the service area:

If you believe that you have an emergency, call 911 or go to the nearest emergency room. If you aren’t sure, call your primary care doctor as soon as you can. You may also contact Independent Health’s TeleSource 24-hour Medical Help Line at (800) 501-3439, press 2. A nurse will return your call and talk to you and tell you what to do at home or tell you to go to the primary care doctor’s office or the nearest emergency room.

What to do in case of emergency outside the service area:

Go to the nearest emergency room. Call Independent Health as soon as you can (within 48 hours if possible). For urgent care services, call Independent Health’s TeleSource 24-hour Medical Help Line at (800) 501-3439, press 2. If you do not contact us, you will owe a deductible and coinsurance. Please see Section 5(i) for information regarding the POS benefits.

Emergency care at a doctor’s office

Emergency care at an urgent care center

$15 per doctor’s office or urgent care center visit

Emergency care in the outpatient department of a hospital, including
doctors’ services

Note: We waive the copay if the emergency results in an inpatient admission to the hospital.

$50 per hospital emergency room visit

Not covered: Elective care or non-emergency care. See Section 5(i) for
POS benefits.

All charges.

Emergency care at a doctor’s office

Emergency care at an urgent care center

Urgent care at a doctor’s office or urgent care center

$15 per visit plus the difference, if any, between the Plan’s reimbursement and the provider’s
billed charges.

Note: We require a $15 copay for each provider per date of service.

Emergency care as an outpatient or inpatient at a hospital, including
doctors’ services.

Note: We waive the copay if the emergency results in an inpatient admission to the hospital.

$50 per hospital emergency room visit

Not covered:

9) Elective care or non-emergency care

10) Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

11) Medical and hospital costs resulting from a normal full-term deliver of a baby outside the service area

See Section 5(i) for POS benefits.

All charges.

Professional ambulance service for the prompt evaluation and treatment of a medical emergency and/or transportation to a hospital for the treatment of an emergency condition.

Note: See 5(c) for non-emergency service.

$25 per trip

Not covered

Wheel chair transportation

All charges

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