CALL — 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 1-800-721-2993 or (305) 575-3700 or write to us at JMH Health Plan, 1801 NW 9^th Avenue, Suite 700, Miami, FL 33136.

Where you get covered care

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

Plan providers

Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards. Health care services must be obtained through, or under the direction of your Primary Care Physician. He or she will coordinate your health care, and when medically necessary, refer you to a specialist from our network of health care providers. Your role is to always work with your Primary Care Physician for your health care needs.

We list Plan providers in the provider directory, which we update periodically.

Plan facilities

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

What you must do to get covered care

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. As a member, you must choose a Primary Care Physician (PCP) for yourself and your dependents, if any, on the date of enrollment. If you do not choose a Primary Care Physician, we will assign one to you and notify you of the assignment.

Primary care

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

If for any reason you become dissatisfied with your assigned primary care physician and/or service location, you may select a new physician and/or service location at anytime by notifying our Member Services Department at (800) 721-2993 or (305) 575-3700. The effective date of the change will be the first day of the following month. You must notify us before receiving covered services from a new Primary Care Physician.

Specialty care

Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without additional referrals. The primary care physician or the specialist may request authorization any follow-up care. Do not go to the specialist for return visits unless your primary care physician or the specialist gives you a referral. However, you may see a chiropractor, podiatrist, dermatologist and a gynecologist (one annual visit) without a referral.

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

If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care physician will use our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan or you are not satisfied with the services you are receiving from this specialist, 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 or 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 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 customer service department immediately at (800) 721-2993 or (305) 575-3700. If you are new to the FEHB Program, we will arrange for you to receive care.

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

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

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

The 92^nd day after you become a member of this Plan, whichever happens first.

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

Circumstances beyond our control

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

Services requiring our prior approval

Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from us. Your physician must obtain authorization for services such as, but not limited to: follow-up consultations by specialists, hospitalization, Growth Hormone Therapy (GHT), Home Health Service, Durable Medical Equipment, biological, injectable or intravenous drugs provided on an outpatient basis, and other comprehensive diagnostic and treatment services. 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.

Your Primary Care Physician or specialis, to whom you have been appropriately referred, is responsible for coordinating any necessary hospitalizations. Scheduled admissions require advance authorization from the JMH Health Plan. Emergency admissions require notification of the JMH Health Plan within 48 hours, or as soon thereafter as possible. Authorization occurs when we approve the admission and issue a complete authorization number to the hospital. The telephone number to call is on the back of your identification card.

Copayments

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

Example: When you see your primary care physician you pay a copayment of $10 per office visit and when you go in the hospital, you pay nothing per admission.

Deductible

We have no deductible.

Coinsurance

Coinsurance is thepercentage of our negotiated fee that you must pay for your care.

Your catastrophic protection out-of-pocket maximum

After your copayments total $1,500 per person or $3,000 per family enrollment in any calendar year, you do not have to pay any more for covered services. When the covered person has paid copayments that total the annual maximum, no further copayments shall be required by that covered person for the remainder of the calendar year. The covered person is responsible for providing documentation of the amount of copayments paid.

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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.

Plan physicians must provide or arrange your care.

We have no calendar year deductible.

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

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Professional services of physicians

In physician's office

$10 per office visit

Professional services of physicians

In an urgent care center

During a hospital stay

In a skilled nursing facility

Office medical consultations

Second surgical opinion

At home

Nothing

Nothing

Nothing

$10 per office visit

$10 per office visit

$10 per office visit

Tests, such as:

Blood tests

Urinalysis

Non-routine pap tests

Pathology

X-rays

Non-routine Mammograms

CAT Scans/MRI

Ultrasound

Electrocardiogram and EEG

Nothing

You pay

Routine screenings, such as:

Total Blood Cholesterol - once every three years

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

Routine pap test

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

$10 per office visit

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

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

From age 40 through 64, one every calendar year

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

Nothing

Routine immunizations, limited to:

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

Influenza vaccine, annually

Pneumococcal vaccine, age 65 and older

$10 per office visit

Not covered: Examinations, reports, or any other service related to requirements or documentation of heath status for employment, licenses, insurance, travel, or for educational or sports/recreational purposes.

All charges.

Childhood immunizations recommended by the American Academy of Pediatrics

$10 per office visit

Well-child care charges for routine examinations, immunizations and care (up to age 22)

Examinations, such as:

Eye exams through age 17 to determine the need for vision correction

Ear exams through age 17 to determine the need for hearing correction

Examinations done on the day of immunizations (up to age 22)

$10 per office visit

You pay

Complete maternity (obstetrical) care, such as:

Prenatal care

Delivery

Postnatal care

Note: Here are some things to keep in mind:

You do not need to precertify your normal delivery; see page xx for other circumstances, such as extended stays for you or your baby.

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

We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.

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

$10 per office visit

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

All charges.

A range of voluntary family planning services, limited to:

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

Surgically implanted contraceptives

Injectable contraceptive drugs (such as Depo provera)

Intrauterine devices (IUDs)

Diaphragms

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

$10 per office visit

Not covered:

Reversal of voluntary surgical sterilization

Genetic counseling.

All charges.

Diagnosis and treatment of infertility such as:

Artificial insemination:

intravaginal insemination (IVI)

intracervical insemination (ICI)

intrauterine insemination (IUI)

$10 per office visit

You pay

Not covered:

Assisted reproductive technology (ART) procedures, such as:

in vitro fertilization

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

Zygote transfer

Services and supplies related to excluded ART procedures

Infertility services if one of the partners has previously undergone surgical sterilization or if one of the partners is menopausal or post menopausal

All services related to a surrogate parenting arrangement of any kind

Cost of donor sperm

Cost of donor egg

Fertility drugs

All charges.

Testing and treatment

Allergy injections

$10 per office visit

Allergy serum

Nothing

Not covered: Provocative food testing and sublingual allergy desensitization

All charges.

You pay

Chemotherapy and radiation therapy

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

Respiratory and inhalation therapy

Dialysis - hemodialysis and peritoneal dialysis

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

Growth hormone therapy (GHT)

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

Note: - We will only cover GHT when we preauthorize the treatment. Call (800) 721-2993 or (305) 575-3700 for preauthorization. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date you submit the information. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

$10 per office visit

Two consecutive months per condition per year are covered if significant improvement can be expected within the two months. Services are covered for each of the following:

qualified physical therapists and

occupational therapists

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

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is provided with same limitations listed above.

$10 per visit

Not covered:

Long-term rehabilitative therapy

Exercise programs

Massage therapy

All charges.

Up to two consecutive months per calendar year, for the services of qualified speech therapists.

$10 per visit

You pay

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

$10 per office visit

Not covered:

All other hearing testing

Hearing aids, testing and examinations for them

All charges.

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

Annual eye refraction

Eye exam to determine the need for vision correction for children through age 17 (see Preventive care, children) Annual eye refractions.

Nothing

$10 per office visit

$10 per office visit

Not covered:

Eyeglasses or contact lenses and after age 17, examinations for them

Eye exercises and orthoptics

Radial keratotomy and other refractive surgery

Eyeglasses for ocular surgery

All charges.

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

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

$10 per office visit

Not covered:

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

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

All charges.

You pay

Artificial limbs and eyes

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: 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.

Coverage for orthotic appliances is limited to leg, arm, back, and neck custom-made braces when related to a surgical procedure or when used in an attempt to avoid surgery and are necessary to carry out normal activities of daily living, excluding sports activities.

Nothing

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 unless the Plan or your Plan physician determines it is necessary because of growth or change.

All charges.

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

Standard wheelchairs;

Crutches;

Walkers;

Nebulizers;

Breast pumps

Insulin pumps.

Note: Blood glucose monitoring machines are covered under our prescription drug benefit.

$25 per episode of illness for listed durable medical equipment items.

You pay

Coverage for durable medical equipment not listed above is limited to $500 per member per calendar year.

$25 per episode of illness up to our maximum Plan benefit for durable equipment not listed.

Not covered:

Motorized wheel chair;

Custom wheel chairs;

Modifications to motor vehicles or homes such as wheelchair lifts or ramps;

Water therapy devices such as jacuzzis, hot tubs or whirlpools and exercise equipment;

Any equipment that is not deemed medically necessary or is an upgrade to accepted standard;

Any repairs or adjustments on equipment that is purchased for you.

All charges.

Home health services

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.

Nothing

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;

Personal comfort or convenience items such as television and telephone services;

Private duty nursing.

All charges.

Manipulation of the spine and extremities

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

$10 per office visit

Alternative treatments

No benefits

All charges.

Educational classes and programs

Coverage is limited to:

Smoking Cessation - Up to $100 for one smoking cessation program per member per lifetime, including all related expenses such as drugs.

Diabetes self management

$10 per office visit up to our benefit maximum

$10 per office visit

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

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

Plan physicians must provide or arrange your care.

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

The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5(c) for charges associated with the facility (i.e. hospital, surgical center, etc.).

YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.

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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)

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. Surgery for morbid obesity should be performed only as a last resort, when the member's health is endangered and more conservative medical measures, including prescription drugs such as appetite suppressants, have not been successful.

$10 per office visit

You pay

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

Note: The internal prosthetic device must be medically necessary to restore bodily function and require a surgical incision (as opposed to an external prosthetic device). Examples: artificial knuckles and joints, pacemakers, defibrillator, penile implants, breast implants and artificial eyes. 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.

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

Treatment of burns

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

$10 per office visit

Not covered:

Reversal of voluntary sterilization

Routine treatment of conditions of the foot; see Foot care

All charges.

Surgery to correct a functional defect

Surgery to correct a condition caused by injury or illness if:

the condition produced a major effect on the member's appearance and

the condition can reasonably be expected to be corrected by such surgery

Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes.

Nothing

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.

Nothing

Not covered:

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

Surgeries related to sex transformation

All charges.

You pay

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.

Nothing

Not covered:

Oral implants and transplants

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

All charges.

Limited to:

Cornea

Heart

Heart/lung

Kidney

Kidney/Pancreas

Liver

Lung: Single - Double

Pancreas

Allogeneic (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

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

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.

Nothing

Note: We cover related medical and hospital expenses of the donor when we cover the recipient.

Not covered:

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

Medical expenses incurred by a non-member who donates an organ or tissue to a Member will only be covered if the non-member does not have coverage for these services

Implants of artificial organs

Transplants not listed as covered

All charges.

Professional services provided in -

Hospital (inpatient)

Nothing

Professional services provided in -

Hospital outpatient department

Skilled nursing facility

Ambulatory surgical center

Office

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.

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

We have no calendar year deductible.

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

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 PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.

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Room and board, such as

Ward, semiprivate, or intensive care accommodations;

General nursing care; and

Meals and special diets.

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

Nothing

Other hospital services and supplies, such as:

Operating, recovery, maternity, and other treatment rooms

Prescribed drugs and medicines

Diagnostic laboratory tests and X-rays

Administration of blood and blood products

Blood or blood plasma, if not donated or replaced

Dressings, splints, casts, and sterile tray services

Medical supplies and equipment, including oxygen

Anesthetics, including nurse anesthetist services

Take-home items

Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home (Note: calendar year deductible applies.)

Nothing

Not covered:

Custodial or domiciliary care, basic care or housekeeping

Non-covered facilities, such as nursing homes, schools

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

Private nursing care

Services or products provided by Convalescent Homes, Homes for the Aged, or Adult Foster Care Facilities

Blood and blood derivatives not replaced by member

All charges.

Operating, recovery, and other treatment rooms

Prescribed drugs and medicines

Diagnostic laboratory tests, X-rays, and pathology services

Administration of blood, blood plasma, and other biologicals

Blood and blood plasma, if not donated or replaced

Pre-surgical testing

Dressings, casts, and sterile tray services

Medical supplies, including oxygen

Anesthetics and anesthesia service

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

Nothing

Not covered:

Custodial or domiciliary care, basic care or housekeeping

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

Private nursing care

Blood and blood derivatives not replaced by member

All charges.

Skilled nursing facility (SNF): We provide a comprehensive range of benefits for up to 60 post-hospital days per calendar year when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor, and approved by the Plan. All necessary services are covered, including:

Bed, board, and general nursing care;

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

Nothing

Not covered:

Custodial or domiciliary care, basic care or housekeeping

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

Private nursing care

Blood and blood derivatives not replaced by member

All charges.

We provide supportive and palliative care for a terminally ill member in the home or hospice facility. Services included:

Inpatient and outpatient care;

Family counseling

These services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six months or less.

Nothing

Not covered:

Custodial or domiciliary care, basic care or housekeeping

Independent nursing, homemaker services

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

Private nursing care

Skilled nursing services provided on a twenty-four (24) hour basis in the home

All charges.

Local professional ambulance service when medically appropriate

Nothing

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

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

We have no calendar year deductible.

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

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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:

The procedure the covered person should follow for emergency care, as defined in this section, depends on whether the treatment is rendered inside or outside the service area.

Emergencies within our service area:You are covered for treatment when a true emergency exists. If you are in doubt of the seriousness of the medical condition and have time to call your Primary Care Physician, you should do so. If your physician feels that the problem requires immediate attention, he or she will direct your treatment. Please note: Emergency health services rendered by a non-participating provider within our service area are covered. Also service will be covered if they are rendered by a non-participating provider because an emergency prevents you from receiving services from a participating provider.

Emergencies outside our service area: In case of an emergency when you are out of the Plan's service area, we provide coverage for necessary emergency care. If your problem is too serious, and prevents you from returning to the service area, you may go to the closest urgent or emergency care facility. Emergency admissions require notification of the JMH Health Plan within 24 hours, or as soon thereafter as possible. You may call the JMH Health Plan 24 hours a day at the number on the back of your JMH Health Plan identification card. Please call the Plan within 24 hours if it is reasonable to do so after an emergency in order to confirm coverage, ensure proper follow-up care and assure payment for covered services.

Note: We reserve the right not to pay for non-emergency treatment received at emergency facilities. If you are hospitalized at an out-of-network hospital, you may be transferred to an in-network hospital as soon as it is medically appropriate in the opinion of the attending physician. Should you, or your designee, refuse a transfer to an in-network hospital, continued care provided to you at an out-of-network shall not constitute covered services and shall no longer be the financial responsibility of Us. Follow-up visits shall be provided by participating providers, your Primary Care Physician will coordinate your follow-up care

Emergency care at a doctor's office

Emergency care at an urgent care center

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

$10 per office visit

$25 per visit

$50 per visit (waived if admitted)

Not covered: Elective care or non-emergency care

All charges.

Emergency care at a doctor's office

Emergency care at an urgent care center

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

$10 per office visit

$25 per visit

$50 per visit (waived if admitted)

Not covered:

Elective care or non-emergency care

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

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

All charges.

Professional ambulance service when medically appropriate.

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

Nothing

Not covered: Air ambulance

All charges.

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

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

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

We have no calendar year deductible.

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

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

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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.

Professional services, including individual or group therapy by providers such as psychiatrists, psychologists, or clinical social workers

Medication management

$10 per visit

Diagnostic tests

Nothing

Services provided by a hospital or other facility

Services in approved alternative care settings such as partial hospitalization, half-way house, residential treatment, full-day hospitalization, facility based intensive outpatient

Nothing

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.

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following network authorization processes:

You must call University of Miami Behavioral Health (UMBH) at (800) 294-8642. You do not need a referral from your primary care physician or approval from us. UMBH is a managed behavioral health care firm with over 500 providers in our service area. A UMBH provider will evaluate you and develop a treatment plan. Once the treatment plan has been approved, you must follow it. If you need inpatient care, your UMBH provider will arrange it for you. Call UMBH for the participating providers in your area.

Limitation We may limit your benefits if you do not obtain a treatment plan.

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

We cover prescribed drugs and medications, as described in the chart beginning on the next page.

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

We have no calendar year deductible.

YOUR PHYSICIAN MUST GET PRIOR AUTHORIZATION FOR SOME PRESCRIPTION DRUGS. Please refer to the precertification information shown in Section 3 to be sure which prescription drugs require prior authorization.

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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There are important features you should be aware of. These include:

Who can write your prescription. A plan physician or licensed dentist authorized to prescribe drugs within the scope of his or her license must write the prescription.

Where you can obtain them. You must fill the prescription at a plan pharmacy, or by mail for a maintenance medication.

We have an open formulary. The prescription drug co-payments for generic and brand name, are shown below. To order a prescription drug brochure, call 1-888-243-6250.

These are the dispensing limitations. A generic equivalent will be dispensed when available.  If you (or your physician) request a brand name product when a generic is available, you will pay the cost difference between the generic and brand name product in addition to the applicable brand co-payment. Retail pharmacy prescriptions are limited to 30 days per prescription. Mail order prescriptions are a benefit option for defined maintenance medications as needed for chronic or long term health conditions. It is best to get an initial prescription filled at your retail pharmacy and then ask your physician for an additional prescription for a 90 day supply of your medication to be ordered through the mail order pharmacy. You pay two times the co-payment for generic drugs or 50% of the cost per brand name up to a maximum of $200 plus the cost difference if you or your doctor requests a brand name when a generic equivalent is available. 

Members called to active military duty in a time of national or other emergency who need to obtain a greater-than-normal supply of prescribed medications should call our Member Services Department at (305) 575-3640.

Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expensive brand-name drugs. They must contain the same active ingredients and must be equivalent in strength and dosage to the original brand-name product. Generics cost less than the equivalent brand-name product. The U.S. Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same standards of quality and strength as brand-name drugs.

You can save money by using generic drugs. However, you and your physician have the option to request a name-brand if a generic option is available. Using the most cost-effective medication saves money.

When you do have to file a claim. Our members may occasionally receive bills for health care services. This may occur for a number of reasons, such as computer errors or out-of-area emergency treatment. If you receive a bill or statement, or are requesting reimbursement, mail the bills to us within 90 days of the date of service. Please be sure that the bill contains the following information.

Patient name

Subscriber number and the patients two-digit relationship code as shown on your identification card

Amount billed

Amount paid

Description of service and procedure codes

Diagnosis and diagnosis codes

Location of service

Date of Service

Address the envelop as follows:

JMH Health Plan

Attention: Claims Department

1801 NW 9^th Avenue, Suite 700

Miami, FL 33136

If you need further assistance, or have questions, pleas call our Member Services Department at (800) 721-2993.

We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order program:

Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except those listed as Not covered.

Insulin and FDA approved glucose strips and tablets, and chemstrip test tapes

Disposable needles and syringes for the administration of covered medications

Blood glucose monitoring machines

Drugs for sexual dysfunction

Oral contraceptive drugs [contraceptive devices and diaphragms are covered under medical services, see section 5 (a)]

Growth hormone

Retail Pharmacy

$5 per generic

50% of the cost per brand name up to a maximum of $100.

Mail Order (up to a 90 day supply)

$10 per generic

50% of the cost per brand name up to a maximum of $200.

Note: If there is no generic equivalent available, you will still have to pay the brand name copay.

Not covered:

Drugs and supplies for cosmetic purposes

Drugs to enhance athletic performance

Fertility drugs

Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies

Vitamins, nutrients and food supplements even if a physician prescribes or administers them

Prescription refills in excess of the number specified by the physician or dispensed more than one year from the date of the original order of the physician or other participating provider authorized to prescribe drugs within the scope of his or her license

Any portion of a prescription or refill that exceeds 30 days unless specified above

Nonprescription medicines

All charges.

Flexible benefits option

Under the flexible benefits option, we determine the most effective way to provide services.

We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative benefit.

Alternative benefits are subject to our ongoing review.

By approving an alternative benefit, we cannot guarantee you will get it in the future.

The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits.

Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.

High risk pregnancies

A case manager is assigned upon notification of a high risk pregnancy. The physician, member, and case manger develop a treatment plan specific to the member's medical needs.

Centers of excellence for Trauma Facilities, Burn Center, and Transplant Services

The following is a Center of excellence available when appropriately referred:

University of Miami/Jackson Memorial Medical Center, Miami, FL