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 1-800/752-5863 or write to us at PO Box 91110 Sioux Falls, SD 57109-1110. You may also request replacement cards through our website at www.svhp.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, 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. You may also have to file your own 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 NCQA 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. Primary care physicians are included in our provider directory. You may choose the physician who best meets your needs

Primary care

Your primary care physician can be a family practitioner, internist, pediatrician, general practitioner or OB/GYN. Your primary care physician will provide most of your health care, or give you a referral to see a specialist. Appropriate access for Primary Care Physicians and Hospital Provider sites is within thirty (30) miles of your city of residence. Appropriate access includes access to our providers when you have traveled outside of the service area. If you are traveling within the service area where other Plan providers are available then you must use Plan providers

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 may refer you to a specialist for needed care. However, you may also self–refer to Plan specialist providers. No referral is necessary. Appropriate access for Specialty Physicians and Hospital Provider sites is within ninety (90) miles of your city of residence. Appropriate access includes access to Plan providers when you have traveled outside of the service area. If you are traveling within the service area where other Plan providers are available then you must use Plan providers.

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, you may directly access the specialist for needed services

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 at the in-network benefit level if you choose 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 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.

Hospital care

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

If you are in the hospital when your enrollment in our Plan begins, call our Member Service department immediately at 605/328-6800 or 1-800/752-5863 (TYY 605/328-6869). 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.

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

You are ultimately responsible for obtaining Prior Approval from the Health Services Department in order to receive In-Network coverage. However, information provided by the provider’s office will also satisfy this requirement. Primary care physicians and any Participating Specialists have been given instructions on how to get the necessary authorizations for surgical procedures or hospitalizations you may need.

We determine approval for Prior Approval based on appropriateness of care and service and existence of coverage.

Services that Require Prior Approval Include:

• Inpatient hospital admissions including admissions for medical, surgical, neonatal intensive care nursery, mental health and chemical dependency services;

• Partial Hospital Program (PHP)/Day Treatment for mental health and chemical dependency services;

• Outpatient Surgeries;

• Covered dental procedures;

• Physician office site surgical center;

• Home Health, Hospice and Home IV therapy services;

• Durable Medical Equipment (rental or purchase over $200);

• Rehabilitative services; including speech, occupational and physical

therapy and one-to-one water therapy;

• Skilled nursing and sub-acute care;

• Organ transplants;

• Ambulance Services for non-emergency situations; and

• Referrals to Non-Participating Providers which are recommended by Participating Providers. Prior Approval is required for the purposes of receiving In-Network coverage only. If Prior Approval is not obtained for referrals to Non-Participating Providers, the services will be covered at the Out of Network coverage level. Prior Approval does not apply to services that are provided by Non-Participating Providers as a result of a lack of appropriate access to Participating Providers as described in Part III, Section A.

Prior Approval Process

To receive detailed instructions on the Prior Approval process for elective inpatient hospitalizations, non urgent care, pharmaceutical decisions, behavioral health, concurrent review and retrospective review (post-service) contact our Health Services Department, available between the hours of 8:00a.m. and 5:00p.m. Central Standard Time, Monday through Friday, by calling our toll-free number 1-800-805-7938 or (650)328-6807. After hours you may leave a message on the confidential voice mail of the Health Services Department and someone will return your call. You are ultimately responsible for obtaining Prior Approval from the Health Services Department. Failure to obtain Prior Approval will result in a reduction to the Out of Network benefits level. However, information provided by the physician’s office also satisfies this requirement.

Copayments

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

Example: Under High Option, your office visit copayment per visit is $20 for primary care physicians and $30 for Specialist. Under Standard Option, office visit copayments are $25 per visit.

Deductible

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them.

Example: Under High Option, deductibles only apply when you use our Point of Services (POS) benefits. There is a $500 deductible for Self enrollment and a $1,000 deductible for Self and Family enrollment. Under Standard Option, deductibles apply to both Participating providers and POS benefits. The deductible for Participating provider benefits is $500 Self enrollment and $1,000 Self and Family. The POS benefit deductible is $1,000 Self enrollment and $3,000 Self and Family.

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 thepercentage of our negotiated fee that you must pay for certain in-network and all out-of-network care. Coinsurance doesn’t begin until you meet your deductible (there is no deductible for in-network care under the High Option).

Example: Under High Option, you pay 40% of our allowance for medical office visits when you receive services from a Non-Participating Provider or you pay 20% of our negotiated fee for durable medical equipment and orthopedic appliances received by in-network providers. Under Standard Option, you pay 20% of our allowance for outpatient surgery when you receive services from Participating Providers or you pay 40% of our allowance for medical office visits when you receive services from non-Participating Providers with POS benefits.

Your catastrophic protection out-of-pocket maximum

Under the High Option, after your in-network copayments total $4,000 Self enrollment or $4,000 Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. Under the Standard Option, after your in-network copayments and coinsurances total $3,000 Self enrollment or $4,000 Self and 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 for these services.

Prescription drugs; and

Physician office visits.

Be sure to keep accurate records of your copayments, deductibles and coinsurance since you are responsible for informing us when you reach the maximum.

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

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

Under High Option, we have no calendar year deductible for In Network services.

Under Standard Option, the calendar year deductible for In Network services is $500 per person ($1,000 per family). The calendar year deductible applies to almost all benefits in this section. We added “(No deductible)” to show when the calendar year deductible does not apply.

Under both High and Standard Options, you must use Plan Providers in order to receive In Network benefit coverage.

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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Note: The calendar year deductible applies to almost all benefits in this Section.
We say “(No deductible)” when it does not apply

Professional services of physicians, nurse practitioners, and physician’s assistants

In physician’s office

In an urgent care center

Office medical consultations

Second surgical opinions

$20 copay per primary care visit

$30 copay per specialist visit

$25 copay primary or specialist per visit (No deductible)

During a hospital stay

In a skilled nursing facility

Nothing

Nothing

Home visits

Nothing

Nothing

You pay

Standard Option

After the calendar year deductible...

Such as:

Blood tests

Urinalysis

Non-routine pap tests

Pathology

X-rays

Non-routine Mammograms

CAT Scans/MRI

Ultrasound

Electrocardiogram and EEG

Nothing

20% of charges

Routine screenings, such as:

Total Blood Cholesterol – lipid profile between ages 18-24, once every five years between ages 25-44 and once every year ages 45 and over

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

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

Nothing

$25 copay per visit (No deductible)

Routine pap test

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

Nothing

$25 copay per visit
(No deductible)

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

Nothing

Nothing

Preventive care, adult – continued on next page

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

Nothing

Nothing

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

All charges.

All charges.

Childhood immunizations recommended by the American Academy of Pediatrics

Nothing

Nothing

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

Nothing

$20 copay per primary care visit

$30 copay per specialist visit

Nothing

$25 copay per visit
(No deductible)

Complete maternity (obstetrical) care, such as:

Prenatal care

Delivery

Postnatal care

Note: Here are some things to keep in mind:

You need to pre-approve your normal delivery due to the inability to predict admission; obstetrical admissions shall be authorized when the pregnancy is confirmed. C-sections must be pre-approved as an elective admission. See Services requiring our prior approval in Section 3.

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. Infant circumcision is covered under the maternity benefit when it is done during the mother’s inpatient hospital stay during delivery.

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

We cover 2 routine sonograms per pregnancy to determine fetal age, size or sex.

NOTE: We encourage you to participate in our Healthy Pregnancy Program; see Special Features Section.

Nothing

Nothing

A range of voluntary family planning services, limited to:

Surgically implanted contraceptives

Injectable contraceptive drugs (such as Depo provera)

Intrauterine devices (IUDs)

Diaphragms

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

$20 copay per primary care visit

$30 copay per specialist visit

20% of charges per inpatient admission

$50 per outpatient surgery

20% of all charges

Voluntary Sterilization

Note: We pay voluntary sterilization performed secondary to a Cesarean section under Surgical procedures (See Section 5(b)).

20% of charges per inpatient admission,

20% of charges

Not covered: reversal of voluntary surgical sterilization, genetic counseling or testing.

All charges.

All charges.

Diagnosis and treatment of infertility such as:

Artificial insemination:

intravaginal insemination (IVI)

intracervical insemination (ICI)

intrauterine insemination (IUI)

$30 per specialist visit

20% of charges per inpatient admission

$50 per outpatient surgery

20% of all charges

Not covered:

Assisted reproductive technology (ART) procedures, such as:

in vitro fertilization

embryo transfer, gamete (GIFT) and zygote (ZIFT)

Zygote transfer

Services and supplies related to ART procedures

Cost of donor sperm

Cost of donor egg

Fertility Drugs

Expenses related to surrogate parenting

Other preservation techniques

All charges.

All charges.

Testing and treatment

Allergy injections

$30 per specialist visit

$25 copay per visit (No deductible)

Allergy serum

Nothing

Nothing

Not covered: Provocative food testing and sublingual allergy desensitization

All charges.

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 in Section 5(b).

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 medical benefit.

NOTE: We will only cover GHT when we pre-authorize the treatment. Call 1-800/805-7938 for prior approval. 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

$30 per specialist visit

20% of charges

Coverage up to 2 consecutive months per condition for the services of each of the following:

qualified physical therapists

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 (see Services requiring our Prior Approval in Section 3).

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction

$30 per outpatient visit

Nothing per visit during covered inpatient admission

20% of charges

Not covered:

Long-term rehabilitative therapy

Exercise programs

All charges.

All charges.

Coverage up to 2 consecutive months per condition by speech therapists (see Services requiring our Prior Approval in Section 3).

$30 per outpatient visit

Nothing per visit during covered inpatient admission

20% of charges

Not covered:

long term therapy

All charges.

All charges.

Hearing services (testing, treatment, and supplies)

First hearing aid(s) (unilateral or bilateral, one time only), and testing and fitting of hearing aid(s) when necessitated by accidental injury only

NOTE: Hearing services must be received within 6 months of injury.

Hearing testing for children through age 17 (see Preventive care, children)

$30 per specialist visit

$25 copay per visit (No deductible)

Not covered:

All other hearing testing

All other hearing aids

All other hearing supplies and services

All charges.

All charges.

Eyeglasses or one pair of contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts)

$20 per primary care visit

$30 per specialist visit

$25 copay per visit (No deductible)

Eye exam including refraction error to determine the need for vision correction for children through age 17 (see Preventive care, children)

$20 per primary care visit

$30 per specialist visit

$25 copay per visit (No deductible)

Not covered:

surgery for the purpose of modifying or correcting myopia, hyperopia or stigmatic error

all other vision services except as described above

All charges.

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.

$20 per primary care visit

$30 per specialist

$25 copay per visit (No deductible)

Not covered:

Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above

Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

All charges.

All charges.

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.

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy. Note: Internal prosthetic devices are paid as hospital benefits; see Section 5(c) for payment information. Insertion of the device is paid as surgery; see Section 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. (See Services requiring our prior approval in Section 3.)

20% of charges

20% of charges

Orthopedic and prosthetic devices - continued on next page

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 3 years after the last one we covered {Plan specific}

Dental appliances of any sort, including but not limited to bridges, braces, and retainers, except those for non-dental treatment of TMJ.

Wigs, scalp hair prosthesis or hair transplants

All charges.

All charges.

Rental or purchase, at our option, including repairs (repairs are limited to $750 allowable charges per year) and adjustments, of durable medical equipment prescribed by your Plan physician, such as oxygen and dialysis equipment

Under this benefit, we also cover:

standard hospital beds;

standard wheelchairs;

crutches;

walkers;

canes;

diabetes supplies including blood glucose monitors and insulin pumps;

spacers

initial casts, braces, and/or slings provided on day of treatment;

air compressor

pressure pads, mattresses, and decubitus care equipment;

apnea monitor;

sleeve compression;

home intravenous therapy supplies;

commodes;

compression hose

NOTE: We will cover motorized wheelchairs and electric beds up to, but not to exceed, the cost of standard wheelchairs or standard hospital beds. Call us at 605/328-6807 or toll free at 1-800/805-7938 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.

20% of charges

Note: You must obtain prior-authorization for supplies/equipment with a retail value of $200 or more. Failure to obtain Prior Approval will result in benefits being pad at the Point of Service benefit level.

20% of charges

Note: You must obtain prior-authorization for supplies/equipment with a retail value of $200 or more. Failure to obtain prior approval will result in benefits being pad at the Point of Service benefit level.

Durable medical equipment (DME) - continued on next page

Not covered:

Medical supplies/equipment that can be purchased over-the-counter

Household equipment/fixtures, such as air purifiers and ramps

Convenience items

Self-help items

Educational equipment

Communication aids or devices, such as speech processors

Replacement or repair of items, if the items are damaged or destroyed by your misuse, abuse or carelessness, lost, or stolen

Duplicate or similar items

Service call charges, labor charges, charges for repair estimates

Vehicle/car or van modifications including, but not limited to, hand brakes, hydraulic lifts and car carrier

All charges.

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.

NOTE: Prior approval is required; failure to get prior approval will result in payment at the point of service level. (See Services requiring our prior approval in Section 3.)

$20 copay per visit

20% of charges

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.

All charges.

Manipulation of the spine and extremities

Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy

NOTE: Office visits are limited to 20 visits per calendar year.

$20 per visit

$25 copay per visit (No deductible)

Not covered:

Vitamins, minerals, therabands, cervical pillows, traction services, and hot/cold pack application.

All charges.

All charges.

Acupuncture – by a doctor of medicine or osteopathy for anesthesia, pain relief

Sleep therapy for central of obstructive apnea when we have approved it

$30 per specialist visit

20% of charges

Not covered:

Biofeedback

All other Homeopathic or Naturopathic services

All charges.

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 prescription drugs

Diabetes self management from qualified providers for persons who meet plan criteria – limited to no more than two (2) comprehensive education programs per lifetime and up to eight (8) follow-up visits per year will be covered.

Nothing

Nothing

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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.

Under High Option, we have no calendar year deductible for In Network services

Under Standard Option The calendar year deductible is: $500 per person ($1000 per family). The calendar year deductible applies to almost all benefits in this Section. We added "(No deductible)" to show when the calendar year deductible does not apply.

Under both High and Standard Options, you must use Plan Providers in order to receive in-network benefit coverage.

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.).

YOU OR YOUR PHYSICIAN MUST GET PRIOR APPROVAL OF SOME SURGICAL PROCEDURES. Please refer to the prior approval information shown in Section 3 to be sure which services require prior approval and identify which surgeries require prior approval.

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Note: The calendar year deductible applies to almost all benefits in this Section. We say “(No deductible)” when it does not apply.

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)

$30 per specialist visit

$100 per day copay up to $500 per inpatient surgery or service

$50 per outpatient surgery or service

$25 copay per office visit (No deductible)

$100 per day copay up to $500 per inpatient surgery or service

20% of outpatient charges

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.

$30 per specialist visit

$100 per day copay up to $500 per inpatient surgery or service

$50 per outpatient surgery or service

$25 copay per office visit (No deductible)

$100 per day copay up to $500 per inpatient surgery or service

20% of outpatient charges

Not covered:

Reversal of voluntary sterilization

All charges.

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.

$30 per specialist visit

$100 day copay up to $500 per inpatient surgery or service

$50 per outpatient surgery or service

$25 copay per office visit (No deductible)

$100 per day copay up to $500 per inpatient surgery or service

20% of outpatient charges

Not covered:

Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, including skin tag removal, except repair of accidental injury

Surgeries related to sex transformation

All charges.

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.

Surgery to correct TMJ is covered upon radiological determination of pathology (See Services requiring our prior approval in Section 3)

$30 per specialist visit

$100 per day copay up to $500 per inpatient surgery or service

$50 per outpatient surgery or service

$25 copay per visit (No deductible)

$100 per day copay up to $500 per inpatient surgery or service

20% of outpatient charges

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.

All charges.

Limited to:

Cornea

Heart

Heart/lung

Kidney

Kidney/Pancreas

Liver

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

Nothing

Nothing

Organ/tissue transplants – continued on next page

Lung: Single – Double

Pancreas

Allogeneic (donor) bone marrow transplants

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

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. All transplants must be provided at Plan participating Center of Excellence facilities.

Nothing

20% of charges

Not covered:

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

Autologous tandem transplants

Harvesting and storage of stem cells

Transplants not listed as covered

All charges.

All charges.

Professional services provided in –

Hospital (inpatient)

Nothing

20% of charges

Hospital outpatient department

Skilled nursing facility

Ambulatory surgical center

Office

Nothing

20% of charges

Not Covered: Hypnotic Anesthesia

All charges.

All charges.

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

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

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

Under High Option, we have no calendar year deductible for In Network services.

Under Standard Option, the calendar year deductible for Participating Providers is $500 per person ($1,000 per family). The calendar year deductible applies to almost all benefits in this section. We added “(No deductible)” to show when the calendar year deductible does not apply.

Under both High and Standard Options, you must use Plan Providers in order to receive in-network benefit coverage.

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).

YOUR PHYSICIAN MUST GET PRIOR APPROVAL OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require Prior approval.

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Note: The calendar year deductible for the Standard Option applies to almost all benefits in this section. We say “(No deductible)” when it does not apply.

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.

$100 per day copay up to $500 per admission

$100 per day copay up to $500 per admission

Other hospital services and supplies, such as:

Operating, recovery, maternity, and other treatment rooms

Prescribed drugs and medicines

Diagnostic laboratory tests and X-rays

Administration of blood or blood products.

Dressings, splints, casts, and sterile tray services

Medical supplies and equipment, including oxygen

Anesthetics, including nurse anesthetist services

Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home or take home items

Nothing

Nothing

Not covered:

Custodial care

Non-covered facilities, such as nursing homes, schools

Personal comfort items (telephone, television, guest meals and beds

Private nursing care or costs associated with private rooms

Admissions to hospitals performed only for the convenience of the member, the member’s family or the member’s physician or other provider

All charges.

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

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.

$50 per visit

20% of charges

Outpatient hospital services:

Diagnostic laboratory tests, X-rays, and pathology services

Pre-surgical testing

Nothing

20% of charges

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

All charges.

All charges.

All necessary services ordered by a Plan doctor are covered, including:

Unlimited days

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

Care must be received from a state licensed nursing facility

$100 per day copay up to $500 per admission

$100 per day copay up to $500 per admission

Not covered:

Custodial care

Convalescent care

Intermediate level or domiciliary care

Residential care

Rest cures or services to assist in activities of daily living

All charges.

All charges.

You pay -

Standard Option

After the calendar year deductible...

Admission to a hospice facility, hospital, or skilled nursing facility for room and board, supplies and services for pain management and other acute/chronic symptom management

Part-time or intermittent nursing care by an RN, LPN, LVN or home health aide for patient care for up to 8 hours a day

Social services

Psychological and dietary counseling

Physical or occupational therapy

Consultation and case management services by a participating practitioner

Medical supplies and drugs prescribed by a participating practitioner

Nothing

20% of charges

Not covered: Independent nursing, homemaker services

All charges.

All charges.

Local professional ground and/or air ambulance service when medically necessary and plan approved hospital transfers.

$50 copay

20% of charges

Not covered:

Transfers to hospitals performed only for the convenience of the member, the member’s family or the member’s physician or other provider.

Non-emergency services and/or travel, unless pre-approved and arranged by us.

All charges.

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.

Under High Option, we have no calendar year deductible for In Network services.

Under Standard Option, the calendar year deductible for Participating Providers is $500 per person ($1,000 per family). The calendar year deductible applies to almost all benefits in this section. We added “(No deductible)” to show when the calendar year deductible does not apply.

Under both High and Standard Options, you must use Plan Providers in order to receive in-network benefit coverage.

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:

In the event of an Emergency Medical Condition, go to the closest emergency room, or call 911 for assistance. We will cover Emergency Services whether you are in or out of the Service Area. Sioux Valley Health Plan offers world-wide emergency coverage. Prior approval for treatment of Emergency Medical Conditions is not required. You should have someone telephone us at 1-800/805-7938 (TYY 605/328-6869) as soon as reasonably possible. Inpatient or outpatient emergency services that are furnished by any qualified Provider and needed to evaluate or stabilize an Emergency Medical Condition are covered.

Emergencies within our service area: If you have an Emergency Medical Condition within the Service Area, you should contact your PCP and the Plan after an emergency so that we can arrange for your follow-up care.

Emergencies outside our service area: If you have an Emergency Medical Condition while out of the Service Area, we prefer that you return to the Service Area to receive care through Plan Participating Providers after you have been treated for your condition. However, services will be covered out of the Service Area as long as the care required continues to meet the definition for either Emergency Services or Urgently Needed Services.

Whether you are inside or outside of our service area, $100 copay for Emergency or Urgent services applies. However, this copay is waived if you are admitted to a hospital as a result of the emergency visit.

Post-Stabilization Care

We also provide coverage for services needed to ensure that you remain stabilized (or, in certain instances, to improve or resolve your condition) if:

We provide prior approval for such services; or

Emergency services/accidents - continued on next page

The services were not pre-approved by us, but were administered within 1 hour of a request from the Provider for prior approval of additional post-stabilization care; or

We do not respond within one (1) hour to a request for prior approval from a Non-Contracting Medical Provider or Facility (or we could not be contacted for prior approval).

Coverage for Post-Stabilization Care is effective until:

You are discharged; or

A Contracting Medical Provider with privileges at the hospital in which you are treated arrives and assumes responsibility for your care; or

The Non-Contracting Medical Provider and Sioux Valley Health Plan agree to other arrangements; or

A Contracting Medical Provider assumes responsibility for your care through transfer.

Remember, if you receive services from Non-Contracting Medical Providers without Prior approval, except for Emergency Services, Urgently Needed Services, or out-of-area renal dialysis, SiouxValley Health Plan will pay for those services at the Out-of-Network benefit level.

Refunds for Emergency, Urgently Needed, or Out-of-Area Dialysis Services Paid by Members:

Providers should submit bills to us for payment. However, if you paid for any Emergency Services, Urgently Needed Services, or Out-of-Area Renal Dialysis services obtained from Non-Contracting Medical Providers, you should submit your bills us to Sioux Valley Health Plan for payment. Bills should be submitted to the following address:

Sioux Valley Health Plan, PO Box 91110, Sioux Falls, SD 57109-1110. If you have questions about any bills, contact the SVHP Member Service Department at 1-800/752-5863 or 605/328-6800. The TTY # is 605/328-6869. (The hours of operation for these numbers are 8:00a.m. until 5:00p.m. Central Standard Time, Monday through Friday.)