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 1/877-280-2990 or write to us at GlobalHealth, P.O Box 1747 Oklahoma City, Oklahoma 73101-1747. You may also request replacement cards through our Web site at http://www.globalhealth.cc

Where you get covered care

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

• 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.

• 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. You may choose a primary care doctor by completing the Primary Care Doctor Selection form inside your enrollment packet.

• Primary care

Your primary care physician can be a family practitioner, internist, a pediatrician for members under the age of 18, or a general practitioner.Your primary care physician will provide most of your health care, or give you a referral to see a specialist.

If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.

• 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 must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you a referral.

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 coordinate your care with your specialist to 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, 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 other than for 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 customer service department immediately at 1/877-280-2990. 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.

Your Primary Care Physician is the person you will see first for your medical care. In most cases, your doctor will be able to take care of your medical problem. But if your Primary Care Physician believes a specialist is needed to treat your medical condition, he or she will make the referral request on your behalf. Sometimes, your Primary Care Physician may consult with other physicians who are members of a patient care team.

This team allows Primary Care Physicians to discuss special medical situations with colleagues. The team shares knowledge and experiences to recommend the course of care appropriate for you.

Your Primary Care Physician decides whether to refer you to a specialist or try other medical therapy. As the coordinator of your personal medical care, your Primary Care Physician will work with you to determine a treatment plan.

With your Primary Care Physician‘s referral, you can see a specialist. Most specialty care will be provided within your medical group. After your Primary Care Physician makes the referral, you are responsible for making the actual appointment with the specialist.

The following services require approval; they include but are not limited to:

• Hospital Stays
• All Surgery
• Any non-emergent care
• Growth Hormone Therapy (GHT)

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 $15 per office visit and when you go in the hospital, you pay $250 per day with a maximum of $750 per admission.

Deductible

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. We do not have a deductible.

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for your care.

Example: In our Plan, you pay 50% of our allowance for infertility services.

Your catastrophic protection out-of-pocket maximum

After your copayments and/or coinsurance 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. However, copayments and/or coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments and/or coinsurance for these services:

Prescription Drugs

Vision Services

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

IMPORTANT

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.

IMPORTANT

Professional services of physicians

• In physician's office

$15 per visit to your primary care physician

$25 per visit to a specialist

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

$15 per PCP visit

$25 per specialist 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 if you receive these services during your office visit; otherwise, $15 per PCP visit or $25 per specialist visit

Routine screenings, such as:

• Total Blood Cholesterol
• 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

$15 per PCP visit

$25 per specialist visit

Colonoscopy screening - every ten years starting at age 50

$15 per PCP visit

$25 per specialist visit

NOTE: If services are performed in an outpatient hospital or ambulatory surgical center the applicable facility copay will apply

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

$15 per PCP visit

Routine pap test

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

$15 per office visit

$25 per specialist 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 and over, one every calendar year

Nothing

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

You pay nothing for immunizations; PCP or specialist copays will apply to associated office visit if applicable.

• 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

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

$15 per PCP office visit

$25 per specialist 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 precertify your normal delivery; see page 27 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).

$15 for PCP initial visit only or $25 for specialist initial visit only.

NOTE: If your PCP or specialist refers you to another provider or facility for additional services, you will pay the copay applicable for the services rendered.

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.

$15 per PCP office visit

$25 per specialist 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)
• Fertility drug except for injectables

Note: We cover oral fertility drugs under the prescription drug benefit.

$15 per PCP office visit

$25 per specialist office visit

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)
• Services and supplies related to ART procedures
• Cost of donor sperm
• Cost of donor egg
• Reversal of voluntary, surgically induced sterility
• Treatment for infertility after a reversal of surgically induced sterility

All charges.

• Testing and treatment
• Allergy injections

$15 per PCP office visit

$25 per specialist office visit

NOTE: The applicable copay will be assessed for each visit to a doctor's office including visits to a nurse for an injection.

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 is limited to those transplants listed under Organ/Tissue Transplants on page 25.

• 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 the treatment is preauthorized. Call your PCP for preauthorization. We will ask you to submit information that establishes that the GHT is medically necessary. Ask your PCP to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date your PCP authorizes the treatment. 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.

$15 per PCP office visit

$25 per specialist office visit

• 60 visits per condition per year for the services of 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 for up to 3 visits per weeks for up to 3 weeks.

$25 per office visit

$25 per outpatient visit

Nothing per visit during covered inpatient admission

Not covered:

• Long-term rehabilitative therapy
• Exercise programs

All charges.

60 visits per condition per year

$25 per office visit

$25 per outpatient visit

Nothing per visit during covered inpatient admission.

• Hearing testing, examinations and necessary hearing aids for children under age 18 (see Preventive care, children)

NOTE: Hearing aids for children under the age of 18 are limited to one (1) hearing aid per ear every forty-eight (48) months, unless medically necessary. For member up to age two, four additional ear molds may be obtained per year.

$25 per office visit

Nothing for hearing aids determined to be covered for children under the age of 18

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)

$25 per visit

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

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

$25 per office visit

Not covered:

• Eyeglasses or contact lenses
• 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.

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

$15 per PCP office visit

$25 per specialist 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: 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.

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 provided less than 3 years after the last one we covered

All charges.

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

• hospital beds;
• wheelchairs; (motorized wheelchairs and scooters must be preauthorized);
• crutches;
• walkers;
• blood glucose monitors; and
• insulin pumps.

Note: Call your PCP as soon as your Plan physician prescribes this equipment to receive authorization.

Nothing

Not covered:

• Bathroom equipment such as tub seats, benches, rails and lifts
• Home modifications such as elevators or wheelchair ramps.

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 for members that are confined to an institution that is not a hospital or are homebound.
• Services include oxygen therapy, intravenous therapy and medication.

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.

All charges.

Chiropractic services limited to 20 visits per member per calendar year

• Manipulation of the spine and extremities
• Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

$25 per office visit

Not covered: Any services not specifically listed as covered

All charges.

No benefit

All charges

Coverage is limited to:

• Diabetes Nutritional Training for Diabetes
• Freedom From Smoking Medically managed Smoking Cessation
• Congestive Heart Program
• Disease Management Learn skills to help manage Diabetes, Congestive Heart Failure, Chronic Pain, and Chronic Respiratory Disease

Nothing

IMPORTANT

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.

IMPORTANT

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. These procedures must be approved in advance by the HMO.
• 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.

$15 per PCP office visit

$25 per specialist office visit

Nothing for procedures done in a facility setting

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 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.

$15 per PCP office visit

$25 per specialist office visit

Nothing if you receive these services in a facility setting

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

$15 per PCP office visit

$25 per specialist office visit

Nothing if you receive these services in a facility setting

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
• National Transplant Program (NTP) Non-experimental or non-investigational transplants are a covered benefit. Covered transplants must be ordered by your primary care physician and plan specialist doctor and approved by the Medical Director in advance of the surgery. All transplant procedures must be performed by a GlobalHealth approved transplant facility.

Limited Benefits - Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may be provided in an NCI- or NIH-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

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

All charges.

Professional services provided in -

• Hospital (inpatient)
• Hospital outpatient department
• Skilled nursing facility
• Ambulatory surgical center
• Office

Nothing

Note: When the anesthesiologist is the only provider of services such as for pain management, the specialist copay applies.

IMPORTANT

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.

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.

IMPORTANT

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.

$250 per day with a maximum of $750 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
• 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

Nothing

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

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.

$200 per visit

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

All charges.

Extended care benefit: Extended care benefit: All necessary services while confined in a skilled nursing facility limited to 100 days per calendar year when the confinement is determined to be medically appropriate by our medical director.

Nothing

Not covered: Custodial care

All charges.

Supportive and palliative care provided in the home or hospice facility for a terminally ill member is covered when directed by a Plan provider who certifies the patient is in the terminal stages of illness, with a life expectancy of approximately 6 months or less.

Nothing

Not covered: Independent nursing, homemaker services

All charges.

Ambulance service ordered or authorized by a Plan doctor

Nothing

Not covered: Ambulance services for routine transportation to receive outpatient or inpatient services.

All charges.

IMPORTANT

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.

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.

IMPORTANT

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:

When It's an Emergency

If you or someone in your family needs emergency care,

1. Go to the nearest hospital emergency room or call 911
2. Identify yourself as a GlobalHealth member by showing your ID card
3. Call your Primary Care Physician's office within 48-hours, unless it is not reasonably possible to do so. Let your doctor know you have been treated in an emergency room. Remember, the condition must be an emergency.
4. If you are admitted to the hospital, your Primary Care Physician may arrange to transfer you to a contracting hospital.
5. If you need preventive, routine or follow-up care after being treated in an emergency room, the care must be arranged or provided by your Primary Care Physician.

If You're in an Accident

If you are in an accident and are outside the service area or have no control over where you are taken following the accident, you must notify your Primary Care Physician within 48-hours, unless it was not reasonably possible to do so. There is a physician on call 24-hours a day to take your call.

Urgent Care within our service area

Urgent care is defined as medically necessary and immediately required as a result of an unforeseen illness, injury, or condition.

Urgent care is a covered benefit, subject to scheduled co-payments. Use of the emergency room for urgent care services that are not pre-authorized by your Primary Care Physician will not be covered.

1. If you need urgent medical care, call your Primary Care Physician's officeand inform them that you are a GlobalHealth member.

2. Inform your Primary Care Physician or office personnel that you have an urgent medical problem and need assistance and describe your condition or symptoms.

3. During office hours, your call will be given to your Primary Care Physician or a medical staff person who will give you instructions.

After office hours, your Primary Care Physician's answering service will take your name and phone number. Your Primary Care Physician or an on-call physician will call you back. You will be given medical direction at that time.

Urgent Care outside our service area:

Urgent care is a covered benefit, subject to scheduled co-payments. However, use of the emergency room for urgent care services that are not pre-authorized by your Primary Care Physician will not be covered.

If you are traveling and require urgent care that cannot be delayed until you return to the GlobalHealth service area, contact your Primary Care Physician for prior authorization.

All follow-up care must be provided or arranged through your Primary Care Physician.

• 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

$15 per PCP visit

$25 per specialist visit

$100 per visit in an urgent care center or emergency room

NOTE: If admitted, the $100 ER copay is waived

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

$25 per visit at a doctor's office

$100 per visit in an urgent care center or emergency room

NOTE: If admitted, the $100 ER copay is waived

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, including air ambulance when medically appropriate. Prior approval is required.

See 5(c) for non-emergency service.

Nothing

Not covered: air ambulance without prior approval

All charges.

IMPORTANT

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

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

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.

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.

IMPORTANT

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 per visit

• Diagnostic tests

$25 per visit

• 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 treatment.

$250 per day up to a maximum of $750 per inpatient 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 of the following network authorization processes:

Behavioral health care services (e.g., treatment or care for mental disease or illness, alcohol abuse and/or substance abuse) are managed by GlobalHealth. GlobalHealth makes initial coverage determinations and coordinates referrals; any behavioral health care referrals will be made to providers affiliated with GlobalHealth, unless your needs for covered services extend beyond the capability of the affiliated providers. Emergency care is covered (See Section 5(d), Emergency services/accidents). You can receive information regarding the appropriate way to access the behavioral health care services that are covered under your specific plan by calling Member Services at 1-877/280-2990.

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

IMPORTANT

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.

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.

IMPORTANT

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

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

• Who can write your prescription. A licensed physician must write the prescription
• Where you can obtain them. you must fill your prescriptions at certain pharmacies or through our own mail order pharmacy service. There is an exception for medical emergencies and urgently needed care. If it is a medical emergency or urgently needed care, we cover prescriptions you get from doctors who are not plan providers and prescriptions that are filled at non-plan pharmacies.

We use a formulary. Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary. The Plan's formulary does not exclude medications from coverage, but requires a higher copayment for non-formulary drugs. Certain drugs require your doctor to get precertification from the Plan before they can be prescribed under the Plan. Visit our Web site at www.globalhealth.cc to review our Formulary Guide or call 1-877/280-2990.

These are the dispensing limitations. Covered prescriptiondrugs prescribed by a licensed physician obtained at a participatingPlan retail pharmacymay be dispensed for up to a 30-day supply. Members must obtain a 31-day up to a 90-day supply of covered prescription medication through mail order. In no event will the copay exceed the cost of the prescription drug. A generic equivalent will be dispensed if available, unless your physician specifically requires a brand name.

• Why use generic drugs? Generic drugs are produced and sold under their chemical names, rather than under the names of the companies that manufacture them. A generic drug is a lower cost version of a brand name drug. Some brand-name drugs have a generic equivalent and others do not.

Generic drugs cost less, but generic and brand-name drugs are the same in terms of quality and how they work. The law requires that a generic drug must contain the same amount of the same active drug ingredient as the brand-name drug. However, a generic drug may differ in certain other ways, such as its color or its flavor, the shape of the pill or tablet, and the inactive (non-drug) ingredients it contains.

As we explain below, you pay less for formulary drugs if you get a generic drug rather than a brand-name drug. TheGlobalHealthformulary list includes most generic drugs. When there is a generic drug available, theformulary list usually includes only the generic drug. GlobalHealth'splan pharmacies and mail order service fill prescriptions using generic drugs rather than brand-name drugs whenever possible.

• When you have to file a claim. Send your itemized bill to GlobalHealth, P.O. Box 1747, Oklahoma City, OK 73101-1747.

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

• Contraceptive drugs and devices

• Diabetic supplies limited to lancets, alcohol swabs, urine test strips/tablets, and blood glucose test strips

• Oral fertility drugs

Retail Pharmacy, for up to a 30-day supply per prescription or refill:

$10 per covered generic formulary drug;

$25 per covered brand name formulary drug; and

$40 per covered non-formulary (generic or brand name) drug.

Mail Order Pharmacy, for a 31-day up to a 90-day supply per prescription or refill:

$20 per covered generic formulary drug;

$50 per covered brand name formulary drug; and

$80 per covered non-formulary (generic or brand name drug).

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Injectable Fertility drugs
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
• Vitamins, nutrients and food supplements that can be purchased without a prescription
• Medical supplies such as dressings and antiseptics
• Smoking-cessation drugs and medication including, but not limited to, nicotine patches and sprays
• 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 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.

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