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 (800) 826-2862 or write to us at 3011 W. Grand Blvd Suite 1600 Detroit, MI 48202. You may also request replacement cards through our Web site at www.totalhealthcareonline.com.

Where you get covered care

You get care from "Plan providers" and "Plan facilities." You will only pay copayments, deductibles, and/or coinsurance, and you will not have to file claims.

• Plan providers

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

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

• Plan facilities

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

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. When you enroll in our plan, you will select one of our conveniently located health centers. You and your family member(s) may choose a primary care physician to attend to your medial needs. All outside referrals and services must be coordinated through your primary care physician.

• Primary care

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

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

• Specialty care

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

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 develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care physician will use our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand).
• If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.
• If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.
• 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 800-826-2862. If you are new to the FEHB Program, we will arrange for you to receive care.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

• You are discharged, not merely moved to an alternative care center; or
• The day your benefits from your former plan run out; or
• The 92^nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such case, the hospitalized family member's benefits under the new plan begin on the effective date of enrollment.

Circumstances beyond our control

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

Services requiring our prior approval

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

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

• All Transplants (organ, bone marrow) 
• Custom durable medical equipment 
• Custom prosthetics and orthotics 
• Infertility treatment 
• Nursing home placement 
• Any treatment that is considered experimental
• Mental health/substance abuse

Copayments

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

Example: When you see your primary care physician you pay a copayment of $10 per office.

Deductible

We do not have a deductible.

Coinsurance

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

Example: In our Plan, you pay 50% of our allowance for drugs used to treat sexual dysfunction

Your catastrophic protection out-of-pocket maximum

After your copayments total $1,500 per person or $3,000 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

Prescription Drugs

Be sure to keep accurate records of your copayments {or whatever} since you are responsible for informing us when you reach the 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.
• Plan physicians must provide or arrange your care.
• The calendar year deductible is: 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

Note: The calendar year deductible applies to almost all benefits in this Section.
We say "(No deductible)" when it does not apply. {Delete the row if you don't have a deductible.}

Professional services of physicians

• In physician's office

$10 per office visit

Professional services of physicians

• In an urgent care center
• During a hospital stay
• Office medical consultations
• Second surgical opinion

$10 per office visit

At home

Nothing

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap tests
• Pathology
• X-rays
• Non-routine Mammograms
• CAT Scans/MRI
• Ultrasound
• Electrocardiogram and EEG

Nothing if you receive these services during your office visit; otherwise, $10 per office visit

Routine screenings, such as: {-add whatever benefits you want to add but keep these as a minimum; new boxes when the costs are different; same box if same cost.}

• 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

$10 per office visit

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

$10 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.

$10 per office visit

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

• From age 35 through 39, one during this five year period
• From age 40 through 64, one every calendar year
• At age 65 and older, one every two consecutive calendar years

$10 per office visit

Routine immunizations, limited to:

• Tetanus-diphtheria (Td) booster - once every 10 years, ages19 and over (except as provided for under Childhood immunizations)
• Influenza vaccine, annually

Pneumococcal vaccine, age 65 and older

$10 per office visit

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

All charges.

• Childhood immunizations recommended by the American Academy of Pediatrics

$10 per office visit

• Well-child care charges for routine examinations, immunizations and care (up to age 22)
• Examinations, such as:
  • - Eye exams through age 17 to determine the need for vision correction
  • - Ear exams through age 17 to determine the need for hearing correction
  • - Examinations done on the day of immunizations (up to age 22)

$10 per office visit

Complete maternity (obstetrical) care, such as:

• Prenatal care
• Delivery
• Postnatal care

Note: Here are some things to keep in mind:

• You do not need to precertify your normal delivery; see page xx for other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.
• We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment. Circumcision is covered under surgical benefits. See Section 5b.
• We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery benefits (Section 5b).

$10 per office visit

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))
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo provera)
• Intrauterine devices (IUDs)
• Diaphragms

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

$10 per office visit

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic counseling.

All charges.

Diagnosis and treatment of infertility such as:

• Artificial insemination:
  • - intravaginal insemination (IVI)
  • - intracervical insemination (ICI)
  • - fertility drugs

$10 per office visit

Not covered:

• Assisted reproductive technology (ART) procedures, such as:
  • - in vitro fertilization
  • - embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
• Services and supplies related to ART procedures
• Cost of donor sperm
• Cost of donor egg

All charges.

• Testing and treatment
• Allergy injections  

$10 per office visit

Allergy serum

Nothing

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 xx.

• Respiratory and inhalation therapy
• Dialysis - hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy - Home IV and antibiotic therapy
• Growth hormone therapy (GHT)

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

Note: - We only cover GHT when we preauthorize the treatment.Call (800) 826-2862 for preauthorization. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date you submit the information. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

$10 per office visit

Not covered:

All charges.

60 visits for the services of each of the following:

• qualified physical therapists and
• occupational therapists

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

• Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for up to 21 days per condition

$10 per office visit

$10 per outpatient visit

Nothing per visit during covered inpatient admission

Not covered:

• Long-term rehabilitative therapy
• Exercise programs

All charges.

60 visits per condition

$10 per office visit

$10 per outpatient visit

Nothing per visit during covered inpatient admission.

Not covered:

• Long-term rehabilitative therapy
• Exercise programs

All charges.

• First hearing aid and testing only when necessitated by accidental injury
• Hearing testing for children through age 17 (see Preventive care, children)

$10 per office visit

Not covered:

• All other hearing testing
• Hearing aids, testing and examinations for them

All charges.

• The Plan will cover Vision care when the services are performed by a Plan optometrist and when the member is referred by a Plan physician.
• Eye examinations are limited to one (1) per member per contract year.

Nothing

Contract Lenses-Therapeutic

All Charges over $140

Not covered:

• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery

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.

$10 per office visit

Not covered:

• Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

All charges.

• Artificial limbs and eyes; stump hose
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy. Note: See 5(b) for coverage of the surgery to insert the device.
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

$10 per office visit

Not covered:

• Orthopedic and corrective shoes
• Arch supports
• Foot orthotics
• Heel pads and heel cups
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Prosthetic replacements provided less than {X} years after the last one we covered {Plan specific}

All charges.

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

• Hospital beds;
• Wheelchairs;
• Crutches;
• Walkers;
• Blood glucose monitors; and
• Insulin pumps.

Note: Call us at (800) 826-2862 as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

$10 per office visit

Not covered:

• Motorized wheelchairs.
• Insulin pumps

All charges.

• Home health care ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide.
• Services include oxygen therapy, intravenous therapy and medications.

$10 per office visit

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.

• Manipulation of the spine and extremities
• Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

$10 per office visit

Not covered:

• Naturopathic services
• Hypnotherapy
• Biofeedback

All charges.

Coverage is limited to:

• Smoking Cessation - Up to $100 for one smoking cessation program per member per lifetime, including all related expenses such as drugs.
• Diabetes self-management
• Pre-Natal classes
• CPR heart saver course
• CPR for infants and children
• Asthma education
• Hypertension education
• Prognosis newsletter
• Immunization van
• Catastrophic management plan

Nothing

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.
• Plan physicians must provide or arrange your care.
• Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
• The 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.).

I

M

P

O

R

T

A

N

T

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)

$10 per office visit

• Surgical treatment of morbid obesity -- a condition in which an individual weighs 100 pounds or 100% over his or her normal weight according to current underwriting standards; eligible members must be age 18 or over
• Insertion of internal prosthetic devices. See 5(a) - Orthopedic and prosthetic devices for device coverage information
• Voluntary sterilization (e.g., Tubal ligation, Vasectomy)
• 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.

$10 per office visit

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.

$10 per office visit

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 or severe functional malocclusion;
• Removal of stones from salivary ducts;
• Excision of leukoplakia or malignancies;
• Excision of cysts and incision of abscesses when done as independent procedures; and
• Other surgical procedures that do not involve the teeth or their supporting structures.
• Treatment of TMJ, including surgical and non-surgical intervention, corrective orthopedic appliances and physical therapy

$10 per office visit

Not covered:

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

All charges.

Limited to:

• Cornea
• Heart
• Heart/lung
• Kidney
• Kidney/Pancreas
• Liver
• Lung: Single - Double
• Pancreas
• Allogeneic bone marrow transplants
• Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors
• Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach, and pancreas
• National Transplant Program (NTP)

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.

Nothing

Not covered:

• Donor screening tests and donor search expenses, except those performed for the actual donor
• Implants of artificial organs
• Transplants not listed as covered

All charges.

Professional services provided in -

• Hospital (inpatient)

Nothing

Professional services provided in -

• Hospital outpatient department
• Skilled nursing facility
• Ambulatory surgical center
• Office

$10 per office visit

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

Room and board, such as

• Ward, semiprivate, or intensive care accommodations;
• General nursing care; and
• Meals and special diets. 

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

Nothing

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medicines
• Diagnostic laboratory tests and X-rays
• Blood or blood plasma, if not donated or replaced
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home (Note: calendar year deductible applies.)

Nothing

Not covered:

• Custodial care
• Non-covered facilities, such as nursing homes, schools
• Personal comfort items, such as telephone, television, barber services, guest meals and beds
• Private nursing care

All charges.

• 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, if not donated or replaced
• Pre-surgical testing
• Dressings, casts, and sterile tray services
• Medical supplies, including oxygen
• 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.

Nothing

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

All charges.

The plan provides benefits for up to a maximum of 730 days per condition.

Nothing

Skilled nursing facility (SNF):

Nothing

Not covered: Custodial care

All charges.

Hospice care is covered in the home or hospice facility when life expectancy is 6 months or less and when all necessary medical procedures have been exhausted. Services include inpatient and outpatient care and family counseling: these services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness.

Nothing

Not covered: Independent nursing, homemaker services

All charges.

• Local professional ambulance service when medically appropriate

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.

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:

 Call your primary care doctor. If you are unable to contact your doctor, call 911 or go to the nearest emergency room. Be sure to tell the emergency room personnel that you are a Plan member so that they can notify the Plan.

Emergencies within our service area: If you or a family member needs to be hospitalized, the Plan must be notified within 48 hours, unless it is not possible. If you or a family member are hospitalized in a non-Plan facility and the Plan doctor believe care can be better provided in a Plan hospital, you will be transferred when medically feasible.

$40 per hospital emergency room visit for emergency services that are covered of this Plan, If the emergency results in admission to a hospital, the copay is waived.

Emergencies outside our service area:Benefits are available for any medically ecessary health services outside our service area that is immediately required because of unforeseen illness.

• Emergency care at a doctor's office
• Emergency care at an urgent care center

$10 per visit

• Emergency care as an outpatient or inpatient at a hospital, including doctor's services

$40 per hospital emergency room visit (waived if admitted)

Not covered: Elective care or non-emergency care

All charges.

• Emergency care at a doctor's office
• Emergency care at an urgent care center

$10 per visit

• Emergency care as an outpatient or inpatient at a hospital, including doctor's services

$40 per hospital emergency room visit (waived if admitted)

• Elective care or non-emergency care
• Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
• Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

All charges

Professional ambulance service when medically appropriate.

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

Nothing

Not covered: Air ambulance

All charges.

I

M

P

O

R

T

A

N

T

When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for similar benefits for other illnesses and conditions.

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

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

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

YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

I

M

P

O

R

T

A

N

T

All diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan that we approve. The treatment plan may include services, drugs, and supplies described elsewhere in this brochure.

Note: Plan benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you receive the care as part of a treatment plan that we approve.