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. 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 888/674-3368.

Where you get covered care

You get care from "Plan providers" and "Plan facilities." You will only pay copayments, or coinsurance, and you will not have to file claims. If you use our point-of-service program, you can also get care from non-Plan providers, or from participating providers without a required referral, but it will cost you more. In those instances, you will have a deductible and higher coinsurance with no copayments.

Plan providers are physicians, specialists 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 website.

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 website.

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. Simply complete the primary care physician selection form and return it to us.

Your primary care physician can be a family practitioner, general 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.

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. However, you may see participating OB/GYN physicians twice a year without a referral.

Here are other things you should know about specialty 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 1-888-674-3368. 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:

Circumstances beyond our control

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

Services requiring our prior approval

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

We call this review and approval process precertification. Except for services rendered under our Point of Service benefits, your physician must obtain precertification for the following services such as:

referrals for covered services to non-participating providers

transplants

non-emergency ambulance or air ambulance transportation

physical therapy, occupational therapy, and speech therapy

drugs to treat sexual dysfunction

Your primary care physician will submit a referral to us for these services. We will establish that the appropriate criteria have been met and provide an authorization to your primary care physician and to the provider to whom you have been referred. Without the proper authorization, services may be paid at the out-of-network benefit level or not covered at all.

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 $25 per office visit.

Deductible

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count toward any deductible. The calendar year deductible is $500 per individual and $1,000 per family for in-plan benefits. A $1,500 individual and $3,000 family deductible applies to out-of-plan benefits.

Note: If you change plans during open season, you do not have to start a new deductible under your old plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan

And, if you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option.

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance doesn't begin until you meet your deductible. Coinsurance applies to all services except for office visits and emergency/urgent care services.

Example: In our Plan, you pay 20% of our allowance for all hospital related services including inpatient, outpatient and diagnostic testing, infertility services and durable medical equipment.

Your catastrophic protection out-of-pocket maximum

After your copayments and coinsurance total $3,000 per person or $6,000 per family enrollment in any calendar year, you do not have to pay any more for covered services received in-plan. However, copayments or coinsurance for the following services do not count toward your out-of-pocket maximum, and you must continue to pay copayments or coinsurance for these services:

IMPORTANT

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

IMPORTANT

Professional services of physicians

$25 per office visit

Professional services of physicians

$25 per office visit

20% of allowable charge after deductible

At home

$25 per physician visit

20% of allowable charge after deductible for home health services

Tests, such as:

Nothing if you receive these services during your office visit; otherwise, $25 per visit

20% of allowable after deductible charge for services performed at a hospital

Routine screenings, such as:

$25 per office visit

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

$25 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.

$25 per office visit

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

$25 per office visit

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

All charges.

Preventive care, adult - continued on next page

Routine immunizations, limited to:

$25 per office visit

$25 per office visit

$25 per office visit

Complete maternity (obstetrical) care, such as:

$25 per visit (initial visit only, all other routine visits, routine testing and delivery require no additional copayments)

Not covered: Non-diagnostic routine sonograms to determine fetal age, size or sex

All charges.

A range of voluntary family planning services, limited to:

$25 per office visit

20% of allowable charge after deductible (procedures performed at a hospital-inpatient or outpatient)

Not covered: reversal of voluntary surgical sterilization, genetic counseling

All charges

Diagnosis and treatment of infertility, such as:

$25 per visit (office visit)

20% of allowable charge after deductible (outpatient facility)

Not covered:

All charges.

Allergy care

Testing and treatment

Allergy injection

$25 per office visit

$5 per office visit

Allergy serum

Nothing

Not covered: Provocative food testing and sublingual allergy desensitization

All charges.

$25 per visit (office visit)

20% of allowable charge after deductible (outpatient facility)

Not covered:

All charges.

Benefits for speech and language therapy, occupational therapy ,

physical therapy and assistive technology services and devices for

dependents from birth to age three who are certified by the Department

of Mental Health, Mental Retardation and Substance Abuse Services

as eligible for services under Part H of the Individuals with Disabilities

Education Act are limited to $5,000 per member per calendar year.

$25 per office visit

$25 per visit (office visit)

20% of allowable charge after deductible (inpatient or outpatient facility)

Not covered:

All charges.

$25 per visit (office visit)

20% of allowable charge after deductible (inpatient or outpatient facility)

Not covered:

All charges.

$25 per office visit

Not covered:

All charges.

$25 per office visit

$25 per office visit

Not covered:

All charges.

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

See Orthopedic and prosthetic devices for information on podiatric shoe inserts.

$25 per office visit

Not covered:

All charges.

20% of allowable charge after deductible

Not 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. Limited to $2,000 per member per calendar year for any combination of items. Under this benefit, we also cover:

20% of allowable charge after deductible

Not covered:

All charges.

20% of allowable charge after deductible

Not covered:

All charges.

Limited to $500 per calendar year

$25 per visit

Not covered:

All charges.

Not covered:

All charges.

Coverage is limited to:

$25 per office visit