CDPHP Universal Benefits, Inc.
Formerly Capital District Physicians' Health Plan, Inc. (CDPHP)
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2005 |
A Prepaid Comprehensive Medical Plan
Serving: Upstate, Hudson Valley, and Central New York
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For changes in benefits, see page 7. |
Enrollment in this plan is limited. You must live or work in our Geographic service area to enroll. See page 6 for requirements.
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Special Notice: Codes QB1, QB2, PW1, and PW2 have been eliminated. If you were enrolled in one of these codes, you will be automatically transferred to SG1 or SG2, unless you make an Open Season change. |
Enrollment codes for this Plan:
SG1 Self Only
SG2 Self and Family
RI 73-549
Dear Federal Employees Health Benefits Program Participant:
Welcome to the 2005 Open Season! By continuing to introduce pro-consumer health care ideas, the Office of Personnel Management (OPM) team has given you greater, cost effective choices. This year several national and local health plans are offering new options, strengthening the Federal Employees Health Benefits (FEHB) Program and highlighting once again its unique and distinctive market-oriented features. I remain firm in my belief that you, when fully informed as a Federal subscriber, are in the best position to make the decisions that meet your needs and those of your family. Plan brochures provide information to help subscribers make these fully informed decisions. Please take the time to review the plan's benefits, particularly Section 2, which explains plan changes.
Exciting new features this year give you additional opportunities to save and better manage your hard-earned dollars. For 2005, I am very pleased and enthusiastic about the new High Deductible Health Plans (HDHP) with a Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA) component. This combination of health plan and savings vehicle provides a new opportunity to save and better manage your money. If an HDHP/HSA is not for you and you are not retired, I encourage you to consider a Flexible Spending Account (FSA) for health care. FSAs allow you to reduce your out-of-pocket health care costs by 20 to more than 40 percent by paying for certain health care expenses with tax-free dollars, instead of after-tax dollars.
Since prevention remains a major factor in the cost of health care, last year OPM launched the HealthierFeds campaign. Through this effort we are encouraging Federal team members to take greater responsibility for living a healthier lifestyle. The positive effect of a healthier life style brings dividends for you and reduces the demands and costs within the health care system. This campaign embraces four key "actions" that can lead to a healthy America: be physically active every day, eat a nutritious diet, seek out preventative screenings, and make healthy lifestyle choices. Be sure to visit HealthierFeds at www.healthierfeds.opm.gov for more details on this important initiative. I also encourage you to visit the Department of Health and Human Services website on Wellness and Safety, www.hhs.gov/safety/index.html, which complements and broadens healthier lifestyle resources. The site provides extensive information from health care experts and organizations to support your personal interest in staying healthy.
The FEHB Program offers the Federal team the widest array of cost-effective health care options and the information needed to make the best choice for you and your family. You will find comprehensive health plan information in this brochure, in the 2005 Guide to FEHB Plans, and on the OPM Website at www.opm.gov/insure. I hope you find these resources useful, and thank you once again for your service to the nation.
Sincerely,
Kay Coles James
Director
Notice of the United States Office of Personnel Management's
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
By law, the United States Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to give you this notice to tell you how OPM may use and give out ("disclose") your personal medical information held by OPM.
OPM will use and give out your personal medical information:
OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:
OPM may use or give out your personal medical information for the following purposes under limited circumstances:
By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any purpose that is not set out in this notice. You may take back ("revoke") your written permission at any time, except if OPM has already acted based on your permission.
By law, you have the right to:
For more information on exercising your rights set out in this notice, look at www.opm.gov/insure on the Web. You may also call 202-606-0745 and ask for OPM's FEHB Program privacy official for this purpose.
If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following address:
Privacy Complaints
Unites States Office of Personnel Management
P.O. Box 707
Washington, DC 20004-0707
Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the United States Department of Health and Human Services.
By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the change. The privacy practices listed in this notice are effective April 14, 2003.
Section 1. Facts about this prepaid plan
Section 2. How we change for 2005
What you must do to get covered care
Circumstances beyond our control
Services requiring our prior approval
Section 4. Your costs for covered services
Your catastrophic protection out-of-pocket maximum
Section 5(c) Services provided by a hospital or other facility, and ambulance services
Section 5(d) Emergency services/accidents
Section 5(e) Mental health and substance abuse benefits
Section 5(f) Prescription drug benefits
Section 5(i) Non-FEHB benefits available to Plan members
Section 6. General exclusions - things we don't cover
Section 7. Filing a claim for covered services
Section 8. The disputed claims process
Section 9. Coordinating benefits with other coverage
When you have other health coverage
When other Government agencies are responsible for your care
When others are responsible for injuries
Section 10. Definitions of terms we use in this brochure
Section 12. Two Federal Programs complement FEHB benefits
The Federal Flexible Spending Account Program - FSAFEDS
The Federal Long Term Care Insurance Program
Summary of benefits for CDPHP UBI - 2005
2005 Rate Information for CDPHP UBI
This brochure describes the benefits of CDPHP Universal Benefits, Inc. (CDPHP UBI) under Capital District Physicians' Health Plan's contract (CS 2901) with the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. The address for CDPHP UBI administrative offices is:
CDPHP UBI
Patroon Creek Corporate Center
1223 Washington Avenue
Albany, NY 12206
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.
If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available before January 1, 2005, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2005, and changes are summarized on page 8. Rates are shown at the end of this brochure.
All FEHB brochures are written in plain language to make them responsive, accessible, and understandable to the public. For instance,
If you have comments or suggestions about how to improve the structure of
this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at www.opm.gov/insure
or e-mail OPM at fehbwebcomments@opm.gov.
You may also write to OPM at the U.S. Office of Personnel Management, Insurance
Services Programs, Program Planning & Evaluation Group, 1900 E Street,
NW, Washington, DC 20415-3650.
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits Program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.
Protect Yourself From Fraud - Here are some things that you can do to prevent fraud:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at (518) 641-3228 and explain the situation.
If we do not resolve the issue:
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 |
Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
Your child over age 22 (unless he/she is disabled and incapable of self support).
An influential report from the Institute of Medicine estimates that up to 98,000 Americans die every year from medical mistakes in hospitals alone. That's about 3,230 preventable deaths in the FEHB Program a year. While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments. By asking questions, learning more and understanding your risks, you can improve the safety of your own health care, and that of your family members. Take these simple steps:
1. Ask questions if you have doubts or concerns.
2. Keep and bring a list of all the medicines you take.
3. Get the results of any test or procedure.
4. Talk to your doctor about which hospital is best for your health needs.
5. Make sure you understand what will happen if you need surgery.
Exactly what will you be doing?
About how long will it take?
What will happen after surgery?
How can I expect to feel during recovery?
Want more information on patient safety?
Section 1. Facts about this prepaid plan
This Plan is a prepaid comprehensive medical plan. We require you to see specific physicians, hospitals, and other providers that contract with us. You are encouraged to select a personal doctor within the Plan's network The Plan is solely responsible for the selection of these providers in your area. Contact the Plan for a copy of their most recent CDPHP UBI provider directory.
Prepaid plans emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may have to submit claim forms. With the exception of emergency services, all services by non-participating practitioners and providers must be authorized in advance by CDPHP UBI. When you choose a non-participating provider, and the care has not been preauthorized by CDPHP UBI, you will pay all charges.
You should join a prepaid plan because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will be available and/or remain under contract with us.
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments or coinsurance.
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, providers, and facilities. OPM's FEHB Web site (www.opm.gov/insure) lists the specific types of information that we must make available to you. Some of the required information is listed below.
If you want more information about us, call 1-877-269-2134, or write to CDPHP UBI, Patroon Creek Corporate Center, 1223 Washington Ave., Albany, NY 12206. You may also contact us by fax at (518) 641-5005 or visit our Web site at www.cdphp.com.
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is: Albany, Broome, Chenango, Columbia, Delaware, Dutchess, Essex, Fulton, Greene, Hamilton, Herkimer, Madison, Montgomery, Oneida, Orange, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Tioga, Ulster, Warren, and Washington counties.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. We will not pay for any other health care services out of our service area unless the services have prior plan approval.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your dependents live out of the area (for example,
if your child goes to college in another state), you should consider enrolling
in a fee-for-service plan or an HMO that has agreements with affiliates in
other areas. If you or a family member move, you do not have to wait until
Open Season to change plans. Contact your employing or retirement office.
Section 2. How we change for 2005
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change benefits.
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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. |
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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 1-877-269-2134 or write to us at Patroon Creek Corporate Center, 1223 Washington Ave., Albany, NY 12206. You may also request replacement cards through our Web site at www.cdphp.com. |
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You get care from "Plan providers" and "Plan facilities." You will only pay copayments and/or coinsurance, and you will not have to file claims. |
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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 set by the National Committee for Quality Assurance (NCQA). We list Plan providers in the CDPHP UBI provider directory, which we update periodically. The list is also available at Find-A-Doc on our Web site at www.cdphp.com. |
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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 CDPHP UBI provider directory, which we update periodically. The list is also available at Find-A-Doc on our Web site at www.cdphp.com. |
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It depends on the type of care you need. You can go to any participating provider you want, but we must approve some care in advance. |
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Because all covered services must be provided or arranged by CDPHP UBI participating providers, you are encouraged to select a personal doctor within the network to coordinate your care. Your primary care provider can be an internist, family practitioner, general practitioner, or pediatrician (for children). Alternate primary care providers are obstetricians and gynecologists. |
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- Terminate our contract with your specialist for other than cause; or - Drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program Plan; or - Reduce our service area and you enroll in another FEHB Plan, you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or if we drop out of the Program, contact your new plan. If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days. |
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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 1-877-269-2134. 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:
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. |
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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. |
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For certain services, you or 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 pre-certification. It is your responsibility to make sure this review process is followed. Your physician or specialist must obtain prior approval for the following services: hospitalization or skilled nursing facility care, home health care, inpatient rehabilitation unit or facility services, prosthetic devices, some identified medications, durable medical equipment, home dialysis, and hospice care. Prior approval is also required for physical therapy, occupational therapy, speech therapy, mental health/substance abuse, GHT, and other services such as off-plan referrals. Your physician contacts CDPHP's Resource Coordination Management Department with a description of the medical necessity of the request. A nurse reviewer reviews the request. Clinical information is obtained to support the medical necessity of the request. Clinical information is reviewed against established criteria. Decisions are based on the appropriateness of care. Ultimate determinations are made by the Plan's Medical Director. Upon approval you and your provider are notified via telephone and mail. Services that do not receive prior approval will not be covered by the Plan.
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Section 4. Your costs for covered services
You must share the costs of some services. You are responsible for:
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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 $20 per office visit and when you go in the hospital, you pay $100 per day, up to a maximum of $500 per confinement. |
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We do not have a deductible. |
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Coinsurance is the percentage of our negotiated fee that you must pay for your care. Example: In our Plan, you pay 20 percent of our allowance for durable medical equipment. |
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We do not have a catastrophic protection out-of-pocket maximum. |
Section
5. Benefits - OVERVIEW
(See page 8 for how our benefits changed this year and page 52 for
a benefits summary.)
Note: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about our benefits, contact us at (518) 641-3140 or 1-877-269-2134 or at our Web site at www.cdphp.com.
Section 5(a) Medical services and supplies provided by physicians and other health care professionals
Diagnostic and treatment services
Lab, X-ray and other diagnostic tests
Physical and occupational therapies
Hearing services (testing, treatment, and supplies)
Vision services (testing, treatment, and supplies)
Orthopedic and prosthetic devices
Durable medical equipment (DME)
Educational classes and programs
Oral and maxillofacial surgery
Section 5(c) Services provided by a hospital or other facility, and ambulance services
Outpatient hospital or ambulatory surgical center
Extended care benefits/Skilled nursing care facility benefits
Section 5(d) Emergency services/accidents
Emergency within our service area
Emergency outside our service area
Section 5(e) Mental health and substance abuse benefits
Mental health and substance abuse benefits
Section 5(f) Prescription drug benefits
Covered medications and supplies
Services for deaf and hearing impaired
Section 5(i) Non-FEHB benefits available to Plan members
Summary of benefits for CDPHP UBI, Inc. - 2005
2005 Rate Information for CDPHP UBI, Inc
Section 5(a) Medical services and supplies provided by physicians and other health care professionals
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IMPORTANT |
Here are some important things you should keep in mind about these benefits:
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IMPORTANT |
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Benefit Description |
You pay
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Professional services of physicians
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$20 per office visit
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Professional services of physicians
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$25 per visit |
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Nothing |
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$20 per office visit |
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At home |
$20 per visit |
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Not covered:
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All charges. |
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Diagnostic and treatment services - continued on next page
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Tests, such as:
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Nothing if you receive these services at a preferred facility; otherwise, $20 per office visit
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$20 per office visit |
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Routine screenings, such as:
- Fecal occult blood test - every five years starting at age 50 - Sigmoidoscopy, screening - every five years starting at age 50 - Double contrast barium enema—every five years starting at age 50 - Colonoscopy—once every 10 years starting at age 50. |
$20 per office visit
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Routine Prostate Specific Antigen (PSA) test - one annually for men age 40 and older |
$20 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. |
$20 per office visit |
Routine mammogram - covered for women age 35 and older, as follows:
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Nothing |
Routine immunizations, limited to:
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Nothing, office visit copay applies |
Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel. |
All charges.
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Nothing |
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Nothing for children to age 19. $20 per visit age 19-22. |
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- Eye exams through age 17 to determine the need for vision correction. Limited to one every 24 months. - Ear exams through age 17 to determine the need for hearing correction - Examinations done on the day of immunizations (up to age 22) |
Nothing when performed during well child routine visits up to age 19. $20 per office visit, otherwise. |
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You pay |
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Complete maternity (obstetrical) care, such as:
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$20 per office visit for the initial diagnosis. You pay nothing thereafter. |
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Note: Here are some things to keep in mind:
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$100 copay per day up to a maximum of $500 per admission. The copayment does not apply to hospital inpatient charges for newborn nursery care.
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Not covered: Elective sonograms to determine fetal sex. |
All charges. |
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A range of voluntary family planning services, limited to:
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$20 per office visit |
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Note: We cover oral contraceptives under the prescription drug benefit.
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$25 per covered preferred brand name drug or device $40 per non-preferred drug
(30-day supply) |
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Not covered:
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All charges. |
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You pay |
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Diagnosis and treatment of infertility such as:
- intravaginal insemination (IVI) - intracervical insemination (ICI) - intrauterine insemination (IUI)
Note: Members must be at least 21 years of age but no more than 44 years old to be covered for infertility services. Note: We cover fertility drugs under the prescription drug benefit for up to six cycles per lifetime. |
$20 per office visit $100 copay per day up to a maximum of $500 per admission. For family coverage, inpatient copays are limited to two per calendar year |
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Not covered:
- in vitro fertilization - embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
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All charges. |
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$20 per office visit |
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Nothing |
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Not covered: Provocative food testing and sublingual allergy desensitization |
All charges. |
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You pay |
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Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 28.
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$20 per office visit |
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Intravenous (IV)/Infusion Therapy - Home IV and antibiotic therapy |
$20 per office visit if received as an outpatient. Covered in full if part of home health care. |
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Note: We only cover GHT when we preauthorize the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3. |
$20 per office visit |
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You pay |
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Physical and occupational therapy are limited to one course each for two consecutive months for each specific diagnosis and related conditions per calendar year:
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.
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$20 per office visit $20 per outpatient visit Nothing per visit during covered inpatient admission |
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Not covered:
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All charges. |
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Speech therapy is limited to one course for two consecutive months for each specific diagnosis and related conditions per calendar year. |
$20 per office visit $20 per outpatient visit Nothing per visit during covered inpatient admission. |
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Not covered:
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All charges. |
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$20 per office visit |
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Not covered:
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All charges. |
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You pay |
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$20 per office visit |
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$20 per office visit |
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Not covered:
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All charges. |
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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. |
$20 per office visit |
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Not covered:
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All charges. |
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You pay |
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20% of charges. Must be preauthorized |
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Nothing |
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20% of charges. Must be preauthorized |
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20% of charges. |
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Not covered:
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All charges. |
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You pay |
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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:
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20% of charges. Must be preauthorized |
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Your Plan physician will call us for authorization of this equipment. We will arrange with a health care provider to rent or sell you durable medical equipment. |
$20 per item, must be preauthorized |
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Not covered: Motorized wheelchairs. |
All charges. |
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Nothing |
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20% of charges. |
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Not covered:
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All charges. |
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You pay |
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$20 per office visit |
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No benefit
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All charges |
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Coverage is limited to:
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Nothing |
Section 5(b) Surgical and anesthesia services provided by physicians and other health care professionals
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IMPORTANT |
Here are some important things you should keep in mind about these benefits:
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IMPORTANT |
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Benefit Description |
You pay |
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A comprehensive range of services, such as:
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$20 per office visit |
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Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. |
$20 per office visit; nothing for hospital visit
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Not covered:
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All charges. |
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You pay |
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- 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 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. |
$20 per office visit; nothing for hospital visit |
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Not covered:
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All charges. |
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You pay |
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Oral surgical procedures, limited to:
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$20 per office visit; nothing for hospital visit
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Not covered:
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All charges. |
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You pay |
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Limited to:
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. |
$20 per office visit; nothing at hospital visit.
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Not covered:
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All charges. |
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Professional services provided in -
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Nothing |
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Professional services provided in -
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$20 per office visit |
Section 5(c) Services provided by a hospital or other facility, and ambulance services
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IMPORTANT |
Here are some important things you should keep in mind about these benefits:
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IMPORTANT |
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Benefit Description |
You pay |
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Room and board, such as
Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate. |
$100 copay per day up to a maximum of $500 per admission. For family coverage, inpatient copays are limited to two per calendar year. The copayment does not apply to hospital inpatient charges for newborn nursery care. |
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Other hospital services and supplies, such as:
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Nothing |
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Not covered:
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All charges. |
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$50 per day |
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20% of charges |
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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. |
$20 per day |
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Not covered: Blood and blood derivatives not replaced by the member. Storage of blood and blood derivatives, except in the case of autologous blood donations required for a scheduled surgical procedure. |
All charges. |
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Extended care benefits/Skilled nursing care facility benefits |
You pay |
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Skilled nursing facility (SNF): up to 90 days in lieu of hospitalization. |
Nothing |
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Not covered: Custodial care |
All charges. |
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Up to 210 days combined inpatient and outpatient |
Nothing |
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Not covered: Independent nursing, homemaker services |
All charges. |
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$50 per trip |
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All charges |
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Section 5(d) Emergency services/accidents
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IMPORTANT |
Here are some important things to keep in mind about these benefits:
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IMPORTANT |
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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. |
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What to do in case of emergency: You should go directly to the emergency room, call 911 or the appropriate emergency response number, or call an ambulance if the situation is a medical emergency as defined above. Emergencies within our service area:If you are unsure whether your condition is an emergency, contact your primary care physician for assistance and guidance. However, if you believe you need immediate medical attention, follow the emergency procedures. Emergencies outside our service area:If you have an emergency outside of CDPHP's service area, simply go to the nearest hospital emergency room. If you are required to pay for services at the time of treatment, please request an itemized bill. Send the bill along with your name and member ID number to CDPHP's Member Services Department, Patroon Creek Corporate Center, 1223 Washington Ave., Albany, NY 12206. If you are not admitted to the hospital for further services or care, you will be responsible for a $50 copayment. If you are admitted immediately, the emergency room copayment is waived and the hospital services will cost you $100 copay per day up to a maximum of $500 per admission. After receiving emergency medical care, be sure your primary care physician is notified within forty-eight (48) hours, unless it is not reasonably possible to do so. He or she will need to know what services were provided before scheduling any of your follow-up care. All follow-up care must be provided or directed by a Plan physician. Examples of follow-up care are removal of stitches, cast removal, and X-rays. |
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You pay |
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$20 per visit |
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$25 per visit |
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$50 per visit $100 per day if admitted, up to a maximum of $500 per confinement, limited to two copayments per family per calendar year. |
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Not covered: Elective care or non-emergency care |
All charges. |
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$20 per visit |
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$25 per visit |
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$50 per visit $100 per day if admitted, up to a maximum of $500 per confinement, limited to two copayments per family per calendar year. |
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Note: See 5(c) for non-emergency service. |
$50 per trip |
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Not covered: Non-emergency or routine transport |
All charges. |
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Section 5(e) Mental health and substance abuse benefits
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IMPORTANT |
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:
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IMPORTANT |
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Benefit Description |
You pay
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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. |
Your cost sharing responsibilities are no greater than for other illnesses or conditions. |
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$20 per visit |
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$20 per visit or test |
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$20 outpatient $100 copay per day up to a maximum of $500 per admission. For family coverage, inpatient copays are limited to two per calendar year. |
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Not covered: Services we have not approved. Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another. |
All charges. |
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Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following network authorization processes: Mental Health CareYou have direct access to in-network mental health care. A direct access toll-free telephone number, 1-800-700-4824, to ValueOptions, will connect you to a qualified mental health clinician who will assist and arrange for treatment. For your convenience, the telephone number for mental health services is imprinted on your CDPHP UBI ID card. Alcohol/Substance Abuse Benefits You have access to alcohol and substance abuse care. These benefits are coordinated by St. Peter's Addiction Recovery Center (SPARC). CDPHP UBI members can contact SPARC directly at 1-800-427-9025. |
Limitation We may limit your benefits if you do not obtain a treatment plan. |
Section 5(f) Prescription drug benefits
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IMPORTANT |
Here are some important things to keep in mind about these benefits:
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IMPORTANT |
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There are important features you should be aware of. These include:
There are different copayments for generic and brand name prescriptions. A generic will be dispensed whenever possible. If there is no generic equivalent available, you will still be responsible for the brand name copayment.
Plan members called to active duty (or members in time of national emergency) who need to obtain prescribed medications should call our Member Services Department at 1-877-269-2134. |
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Prescription drug benefits begin on the next page
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Benefit Description |
You pay |
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We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order program:
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$10 generic/$25 preferred brand/$40 non-preferred brand for a 30-day supply. $20 generic/$50 preferred brand/$80 non-preferred brand for a 90-day supply by mail order Note: If there is no generic equivalent available, you will still have to pay the brand name copay. |
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$20 per item |
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Not covered:
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All charges. |