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 1-800-290-3657 or write to us at New West Health Services, 30 Neill Ave Helena, MT 59601

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, but it will cost you more.

Plan providers

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

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

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. www.newwesthealth.com

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. Upon enrollment you will choose a Primary care physician. You have the ability to call our member services department at 800-290-3657 to change your primary physician.

Primary care

Your primary care physician can be a family practitioner, internist, or pediatrician your primary care physician will provide most of your health care.

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

You may see any Specialist within the New West Health Services Network without a referral from you primary care physician. Your Primary care physician should be kept involved in your health care treatment.

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

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. Or those services will apply to the Point of service benefit. See page 41 for details.

If you have a chronic and disabling condition and lose access to your specialist because we:

Terminate our contract with your specialist for other than cause; or

Drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program Plan; or

Reduce our service are and you enroll in another FEHB Plan.

You may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

Hospital care

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

If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 800-290-3657. If you are new to the FEHB Program, we will arrange for you to receive care.

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

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

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

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

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

Circumstances beyond our control

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

Services requiring our prior approval

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

We call this review and approval pre-certification. Your physician must obtain pre-certification when the following are true.

Any referral for in or out patient care where the provider is not a member of NWHP’s provider network.

A member is to be confined in a hospital, mental health or chemical dependency facility, skilled nursing facility, rehabilitation facility, or other institution, whether in-network or out-of-network.

A member requires Durable Medical Equipment., prosthetic devices or Implants.

A Member requires rehabilitation or therapy.

If the services are to be provided by a Participating Provider, the Participating Provider will perform any necessary authorization process. If the services are to be provided by a Non-Participating Provider, the member is responsible to obtain pre-certification, or ensure that the Non-Participating Provider performing such services obtains the necessary pre-certification which will include the following information:

The Member’s name and group number

The attending Physician’s name, telephone number

The name address, and phone number of the facility the services are to be performed, if applicable

The exact services to be performed and justification of the medical Necessity of such services

The scheduled date for services. Authorization must be requested at least seven (7) working days prior to any In- Network scheduled service or procedure and 15 working days prior to any Out-of-Network service or procedure. If NWHP does not pre-certify a service by an Out-of Network Provider, the service will not be covered.

New West Health Services will provide verbal or written notification to the Member and the Participating Provider verifying or denying such authorization or certification. Should the Member disagree with the decision, the member may appeal pursuant to Article 9 of the Evidence of Coverage.

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 or a specialist within the network, you pay a copayment of $15 per office visit and when you go into the hospital, you pay $100 per admission

Deductible

Adeductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count toward any deductible.

The calendar year deductible is $300 per person. Under a family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $600.

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 a

another time during the year, you must begin a new deductible under your new plan.

Coinsurance

Coinsurance is thepercentage of our negotiated fee that you must pay for your care. Coinsurance doesn’t begin until you meet your deductible.

Example: In our Plan, you pay 25% of our allowance for infertility services and durable medical equipment after your deductible is met.

Your catastrophic protection out-of-pocket maximum

After your deductibles and coinsurance total $2000 per person or $4000 per family enrollment in any calendar year, you do not have to pay any more for covered services.

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

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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.

The calendar year deductible is: $300 per person ($600 per family). We added asterisks -* to show when the calendar year deductible applies.

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

$15 per office visit

$15 per visit to a specialist

Lab and x-ray services are subject to annual deductible and coinsurance if diagnostic.

Professional services of physicians

In an urgent care center

During a hospital stay

In a skilled nursing facility {plan specific}

Office medical consultations

Second surgical opinion

$25 per office visit

nothing

$15 per visit

$15 per office visit

If requested by the member:100%

If requested by NWHP: nothing

House Calls

$30 per home visit

Not covered:

Hearing aids and related services.

Reverse sterilization services.

All charges.

Tests, such as:

Blood tests

Urinalysis

Non-routine pap tests

Pathology

X-rays

Non-routine Mammograms

CAT Scans/MRI

Ultrasound

Electrocardiogram and EEG

25% coinsurance*

Routine screenings, such as:

Total Blood Cholesterol – once every three years

Colorectal Cancer Screening, including

occult blood test

Sigmoidoscopy, screening – every five years starting at age 50

Double contrast barium enema – every five years starting at age 50

Colonoscopyt screening – every ten years starting at age 50

$15 per office visit

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

$15 per office visit

Preventive care, adult - continued on next page

Routine pap test

$15 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

$15 per office visit

Routine immunizations, limited to:

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

Influenza vaccine, annually

$15 per office visit will be charged for associated visit.

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

All charges.

Childhood immunizations recommended by the American Academy of Pediatrics

$15 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)

$15 per office visit

Complete maternity (obstetrical) care, such as:

Prenatal care

Delivery

Postnatal care

Note: Here are some things to keep in mind:

You do not need to pre-certify your normal delivery; see page 8 for other circumstances, such as extended stays for you or your baby.

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

We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment. Circumcision is covered with a surgical copay.

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

$50 Global Copay on Prenatal Care

$100 copay for hospital admission

Postnatal care is subject to $15 office visit copay.

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

All charges.

A broad range of voluntary family planning services, limited to:

Family planning counseling.

Information on birth control.

Fitting/measurement for diaphragms, IUDs and cervical caps

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

$15 per office visit

Surgical procedure for implantation of IUD's. (See Surgical procedures Section 5 (b)

Voluntary sterilization (See Surgical procedures Section 5 (b)

$100 copay

Depo-Provera injection.

25% coinsurance

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)

- Fertility Drugs

Limits

Limited infertility services to the extent pre-certified by NWHP, including testing, appropriate medical advice, and instruction in accordance with accepted medical practice.

Treatment for infertility is covered only for Members who have been diagnosed as biologically infertile in accordance with accepted medical practice.

Three artificial inseminations per Member per lifetime. If after 3 attempts per lifetime, the Member fails to conceive, no additional inseminations will be covered.

Drug therapy for infertility is limited to a 3 month course per drug per lifetime.

Note: We cover injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit.

25% coinsurance*

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 excluded ART procedures

Cost of donor sperm

Cost of donor egg

Gene manipulation therapy.

All charges.

Testing and treatment

$15 per office visit

(any lab and/or x-ray charges are subject to 25% coinsurance)*

Allergy injections

Nothing (associated office visit - $15 copay)

Allergy serum

Nothing

Not covered: Provocative food testing and sublingual allergy desensitization

All charges.

Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under Organ/Tissue Transplants on page 26.

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 the Pre-certification line at 1-800-290-5453.

25% coinsurance*

Not covered:

All charges.

For the following we cover up to two consecutive months per condition.

qualified physical therapists and

Occupational therapists.

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

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.

$15 copay per office visit

Not covered:

Long-term rehabilitative therapy

Exercise programs

All charges.

Up to two consecutive months per condition

$15 copay per office visit

Not covered:

All charges.

First hearing aid and testing only when necessitated by accidental injury

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

$15 per office visit

Not covered:

All other hearing testing

Hearing aids, testing and examinations for them

All charges.

Routine eye examinations (once per 12 months) for children through age 17

One pair eyeglasses (lenses and frames per 12 month period) for children through age 17

Note: See Preventive care, children for eye exams for children

$10 copay per examination (in network)

up to $42 per examination (out of network)

$100 copay (in network)

$100 copay (out of network)

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

25% coinsurance*

Not covered:

Eye exercises and orthoptics

Radial keratotomy and other refractive surgery

All charges.

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

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

$15 per office visit

Not covered:

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

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

All charges.

Artificial limbs and eyes; stump hose

Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy. Note: See 5(b) for coverage of the surgery to insert the device.

Must be pre-certified by NWHP

25% coinsurance*

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

All charges.

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

hospital beds;

wheelchairs;

CPAP; and

Insulin pumps.

Limits

$3000 annual benefit limit.

Must be prescribed by a Provider and pre-certified by NWHP in writing.

Member must provide proof of Medical Necessity.

The pre-certification will be for specific DME and for a specific period of time. The pre-certification will state whether purchase or rental is approved. After the initial pre-certification period of Coverage expires, continuation of Coverage is subject to written pre-certification in advance for another specified period.

Note: Call us at 1-800-290-3657 as soon as your Plan physician prescribes this equipment.

25% subject to deductible*

Not covered:

Environmental modification to home or place of residence.

Non prescribed or over the counter appliances.

Equipment for personal comfort, convenience or spare.

Penile prostheses, prostheses for cosmetic purposes, dental braces, orthotic devices for podiatric use and arch support, braces used as aids in sports and activities, corsets and other non rigid appliances.

Maintenance or replacement due to loss, theft or destruction of external prostheses.

Batteries or routine supplies needed for the operation or maintenance of the DME equipment purchased, includes, but not limited to, Oxygen tubing, CPAP and nebulizer filters.

Repair or maintenance of DME once purchased.

Breast Pump

Motorized wheelchairs

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.

Home health care must be pre-certified by NWHP

$15 per visit

Not covered:

nursing care requested by, or for the convenience of, the patient or the patient’s family;

Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative.

All charges.

Manipulation of the spine and extremities

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

Maximum of 20 visits per contract year

$15 per office visit

( lab and/or x-ray charges are subject to 25% coinsurance)*

Not covered:

All charges.

No Benefit

All Charges

Not covered:

Naturopathic services

Hypnotherapy

Biofeedback

acupuncture

All charges.

Coverage is limited to:

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

Diabetes self-management

$15 per office visit

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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.

The calendar year deductible is: $300 per person ($600 per family).

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 pre-certification information shown in Section 3 to be sure which services require pre-certification and identify which surgeries require pre-certification.

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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.

$100 copay

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

$100 copay

Not covered:

Reversal of voluntary sterilization

Routine treatment of conditions of the foot; see Foot care

All charges

Surgery to correct a functional defect

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

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

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

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

All stages of breast reconstruction surgery following a mastectomy, such as:

surgery to produce a symmetrical appearance on the other breast;

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.

$100 copay

Not covered:

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

Surgeries related to sex transformation

All charges.

Oral surgical procedures, limited to:

Reduction of fractures of the jaws or facial bones;

Surgical correction of cleft lip, cleft palate or severe functional malocclusion;

Removal of stones from salivary ducts;

Excision of leukoplakia or malignancies;

Excision of cysts and incision of abscesses when done as independent procedures; and

Treatment of TMJ, including surgical and non-surgical intervention, corrective orthopedic appliances and physical therapy

Other surgical procedures that do not involve the teeth or their supporting structures.

$100 copay

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

United Resource Network (URN)

Note: We cover related medical and hospital expenses of the donor when we cover the recipient. This includes transportation to a center of excellence if applicable.

Nothing

Not covered:

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

Implants of artificial organs

Transplants not listed as covered

Experimental, Investigational, Unproven, Unusual, or Not Customary Treatments, Procedures, Devices, and/or Drugs Are Not Covered.

All charges.

Professional services provided in –

Hospital (inpatient)

Nothing

Professional services provided in –

Hospital outpatient department

Skilled nursing facility

Ambulatory surgical center

Office

$15 per office visit

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Here are some important things to remember 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.

In this section the, we added “(calendar year deductible applies)” to those benefits that the deductible applies to. The calendar year deductible is: $300 per person ($600 per family).

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 covered 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 pre-certification.

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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.

$100 copay

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

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.)

$100 copay

Not covered:

Custodial care

Non-covered facilities, such as nursing homes, schools

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

Private nursing care

Blood or blood products

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.

$100 copay

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

All charges.

Extended care benefit:Covered

Extended care rehabilitation or Convalescent care services as follows:

Only on order of the Participating PCP or other qualified professional when pre-certified in writing by NWHS;

Only when care is in lieu of a Hospital Confinement.

Note: Services include accommodations, meals, general nursing care, medical supplies and equipment ordinarily furnished by the facilities, and all prescribed drugs and biologicals

$100 per admission

Skilled nursing facility (SNF):

$100 per admission

Not covered:

custodial care

Private duty nursing

All charges.

When pre-certified, and provided by a Medicare or certified state licensed Hospice agency, services in a home or hospice facility include:

Nursing care provided by or under the supervision of a registered nurse.

Home health aide services under the supervision of a registered nurse or specialized rehabilitative therapist.

Respiratory therapy and inhalation services.

Nutrition counseling by a nutritionist or dietitian.

Individual, family and caregiver counseling.

Medical social services.

Bereavement support for Member’s family.

Continuous home care or short-term inpatient care provided in a Participating Hospice inpatient unit, Hospital, or skilled nursing facility as required for pain control or symptom management.

Medical supplies ordinarily furnished by the hospice agency, including prescription drugs and biologicals.

Respite care, limited to 5 continuous days per occurrence

Nothing

Not covered: Independent nursing, homemaker services

All charges.

Local professional ambulance service when medically appropriate

$100 Copay per encounter (ground or air)

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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.

The calendar year deductible is: $300per person ($600 per family).

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:

Dial 911 or seek medical attention as soon as possible

Emergencies within our service area:

If a member receives Medically Necessary ground or air ambulance service when the destination is an Acute Care facility, for any of the following:

Movement from the place where the Member was injured in an accident or became ill to a facility for treatment.

If appropriate Medically Necessary care is not available at a Hospital or hospice, movement to the nearest Hospital where the Medically Necessary care may be given.

When ordered by the Member’s attending Physician, movement from the Hospital to another facility or from the Member’s home for Emergency situations.

Emergencies outside our service area:

If a Member receives Medically Necessary Emergency care outside the NWHP Service Area, the Member will be entitled to reimbursement for:

Reasonable and Customary Charges for Hospital services that are Covered Services.

Reasonable and Customary Charges for professional services that are covered Benefits, including sales tax in states where such tax is allowed by law.

Reasonable and Customary Charges for transportation pre-certified by NWHP to return Member to a Participating Hospital, less the cost of Member’s normal return trip expense.

If a Member is admitted as an inpatient to a Hospital directly from the emergency room, the Emergency Copayment is waived.

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 doctor’s services

$15 copay

$25 copay

$75 copay (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 doctor’s services

$15 copay

$25 copay

$75 copay (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.

See 5(c) for non-emergency service.

$100 copay per encounter (ground or air)

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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.

In this section the, we added “(subject to deductible)” to those benefits that the deductible applies to. The calendar year deductible is: $300 per person ($600 per family).

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

25% coinsurance*

(lab and/or x-ray services subject to deductible)

Diagnostic tests

$15 per visit

(lab and/or x-ray services subject to deductible and coinsurance)

Services provided by a hospital or other facility

$100 copay per admission

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 the following authorization processes:

Please call our pre-cert line at 1-800-290-5453

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.

There is no Prescription drug 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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There are important features you should be aware of. These include:

Who can write your prescription? Prescription drugs are covered only if they are prescribed by a Physician.

Where you can obtain them. Prescription drugs must be obtained through either the Network Pharmacy Program or the Mail Service Prescription Drug Program.

We use a formulary. When accessing the Prescription benefit you will Pay $10 for Generic Drugs, $20 for Brand Drugs that are on the formulary, and $40 for brand drugs that are not on the formulary.

We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your physician may prescribe a name brand drug from a formulary list. This list of name brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost.

These are the dispensing limitations.

The Network Pharmacy Program will not provide you with drugs or medicine that exceeds a 34 day supply.

A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a name brand drug when a Federally-approved generic drug is available you will pay the 3^rd tier copay ($40)

We offer a Mail order Pharmacy program where a member can access a 90 day supply of a medication for a 2 month copay, at appropriate tier. (generic$20, brand formulary $40, brand non-formulary $80)

Plan members called to active duty (or members in time of national emergency) who need to obtain prescribed medications should call our pre-certification telephone number (1-800-290-5453) for assistance.

Prescription drugs (continued)

Why use generic drugs? Generic drugs offer a safe and economic way to meet your prescription drug needs. The generic name of a drug is its chemical name; the name brand is the name under which the manufacturer advertises and sells a drug. Under federal law, generic and name brand drugs must meet the same standards for safety, purity, strength, and effectiveness. A generic prescription costs you -- and us -- less than a name brand prescription.

When you have to file a claim. To obtain a claim form, call us at 1-800-290-5453 or access our website at www.newwesthealth.com.

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

Disposable needles and syringes for the administration of covered medications

Drugs for sexual dysfunction (see Prior authorization below)

Contraceptive drugs and devices

$10 generic

$20 brand formulary

$40 brand non-formulary

Note: If there is no generic equivalent available, you will still have to pay the brand name copay. If there is a generic available and you choose to use a brand name, your copay will be at the 3^rd tier.

Diabetic supplies such as needles, syringes, and lancets fall under the pharmacy benefit.

Coverage of appetite suppressants is limited. Member must meet medical criteria and have medications pre-approved by NWHP.

Smoking cessation drugs are limited to four months in a lifetime, and must be prior authorized by NWHP.

Sexual dysfunction drugs are limited to 6 pills per month

Fertility drugs must be prior authorized by NWHP, and are covered only until non-covered fertility services begin.

$10 generic

$20 brand formulary

$40 brand non-formulary

Note: If there is no generic equivalent available, you will still have to pay the brand name copay. If there is a generic available and you choose to use a brand name, your copay will be at the 3^rd tier.

Test strips

$20 copay

Not covered:

Drugs and supplies for cosmetic purposes

Drugs to enhance athletic performance

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

Nonprescription medicines

All charges.

24 hour nurse line

For any of your health concerns, 24 hours a day, 7 days a week, you may call 1-888-561-7137 and talk with a registered nurse who will discuss treatment options and answer your health questions.

Referral for specialist

You will NOT be required to obtain a referral to see an IN NETWORK Specialist or Chiropractor.

Out of State Benefit

New West Health Services has an agreement with Beechstreet Corporation. This arrangement provides “in-network” benefits for dependents out of the State of Montana, such as the case of a College student or when there is court ordered coverage.

High risk pregnancies

High Risk pregnancies are case managed by local patient care coordinators. Patient care coordinators are RN’s. We will refer patient to a center of excellence if appropriate.

Centers of excellence for transplants/heart surgery/etc

New West Health Services uses United Resource Network (URN) for transplants.

Travel benefit/ services overseas

New West Health Services Members are covered as if “in-network” for emergency services anywhere in the world.