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 866-351-5946 or you may request replacement cards through the website at www.healthamerica.cvty.com.

Where you get covered care

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

Network providers and facilities

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 at www.healthamerica.cvty.com or you may call the plan for assistance.

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 at www.healthamerica.cvty.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. You can complete

a PCP Selection Card and mail it or you can call us.

Primary care

Your Primary Care Physician can be a family practitioner, internist or a pediatrician.

Your Primary Care Physician will provide most of your health care, or coordinate

your care 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. You do not need a referral from your primary care physician to see a participating physician for maternity or gynecological care.

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 physician will work with us to develop a treatment plan that allows you to continue seeing your specialist. Your physician will use our criteria when creating your treatment plan. The participating network provider may have to get our prior approval for certain services.

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

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

— Reduce our service area and you enroll in another FEHB Plan,

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

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

Hospital care

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

If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at (866) 351-5946. 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. The following are health care services which require precertification:

Inpatient hospital admissions

Extended Care/Skilled Nursing Facility

Outpatient surgeries

Home health care

Durable medical equipment

Out–of-network referral requests

Transplant requests

Complex diagnostic testing such as Magnetic Resonance Imaging,

Chiropractic care

Rehabilitative service

Infertility treatment

Oral surgery

Growth Hormone Therapy

Mental Health and Substance Abuse Treatment*

*You must contact ValueOptions before seeking mental health and substance abuse treatment. ValueOptions will help develop a treatment plan that you must follow. We will not cover services that ValueOptions has not approved.

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 visit and when you see your specialist, you pay $25 per visit. If you go to the emergency room you pay $100 per visit.

Deductible

A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them. The deductible amount for this plan is $1250 for self only coverage and $2500 for self and family coverage.

Traditional Medical Coverage - Your deductible must be satisfied before copayments occur.

Preventive Care Coverage - Your deductible does not apply for preventive care benefits as outlined in Section 5.1. However, you do have a copayment for covered preventive care services.

We do not pay for covered services that are subject to a deductible, until the deductible is met. You are responsible for paying your deductible. The deductible is a limit on the amount you must pay before you receive benefits. The Self and Family deductible must be satisfied by one family member or a combination of family members before we begin paying benefits.

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

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance doesn’t begin until you meet your deductible.

Example: After you have satisfied the deductible, you pay $300 copay or 50% of the cost, whichever is less, for infertility services.

Your catastrophic protection out-of-pocket maximum

Self Only: Your annual out-of-pocket maximum is $4,000.

Self and Family: Your annual out-of-pocket maximum is $8,000.

Out-of-Pocket Maximum

The out-of -pocket maximum is the amount of out-of-pocket expenses that you will pay under a Self Only or a Self and Family coverage in a plan year. Out-of-pocket maximums apply on a calendar year basis only.

Expenses applicable to out-of-pocket maximums

Only the deductible and those out-of-pocket expenses resulting from the application of copayments may be used to satisfy the out-of-pocket maximums. We will not apply expenses you incur for non-covered services, expenses that exceed our maximum benefit limitations or allowable charges.

Once you have paid your deductible and satisfied your out-of-pocket maximum, we will cover eligible medical expenses at 100%. You no longer have copayments or coinsurance for covered services.

Differences between our allowance and the bill

You must use participating providersthat are part of our network. Our participating providers agree to accept our Plan allowance. When you use a network provider, your share of covered charges will only be your deductible, coinsurance and/or copayment. Our in network physicians will not bill you for any difference between the allowed amount and the total bill.

We will not cover services from non-participating provider unless we specifically authorize such care.

Summary

Our high-deductible health plan option provides comprehensive coverage for high-cost medical events and a tax-advantaged way to help you build savings for future medical expenses.  The Plan gives you greater control over how you use your health care benefits.

When you enroll in this HDHP option, we establish either a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) for you.  Each month, we automatically pass through a portion of the total health Plan premium to your HSA based upon your eligibility as of the first day of the month. If you do not qualify for an HSA, we will establish an HRA for you, and will credit your account each month for one-twelfth of the annual HRA allocation.  

With this Plan, we cover preventive care in full and you pay only your copay.  As you receive other non-preventive medical care, you must meet the Plan’s deductible before we pay benefits according to the benefit chart on page 17.  You can choose to use funds available in your HSA to make payments toward the deductible or you can pay toward your deductible entirely out-of-pocket, allowing your savings to continue to grow.

This HDHP includes five key components: in-network preventive care; traditional in-network health care that is subject to the deductible; savings, catastrophic protection for out-of-pocket expenses, and, health education resources and account management tools.

Preventive care

You must use participating providers within our network. The Plan covers preventive care services, such as periodic health evaluations (e.g., annual physicals), screening services (e.g., mammograms), well-child care, and child and adult immunizations. We do not apply a deductible to these services. You only owe the copay as fully described in Section 5.1.  You do not have to meet the deductible before using these services.

Traditional medical care

You must use participating providers within our network. After you have paid the Plan’s deductible, we pay benefits under traditional medical care described in Section 5.2.  The Plan typically pays 100% for traditional medical care after you meet the deductible and you are only responsible for your copayment or coinsurance for covered services.  

Covered services include:

Medical services and supplies provided by physicians and other health care professionals

Surgical and anesthesia services provided by physicians and other health care professionals

Hospital services; other facility or ambulance services

Emergency services/accidents

Mental health and substance abuse benefits

Prescription drug benefits

Savings

Health Savings Accounts or Health Reimbursement Arrangements provide a means to help you pay out-of-pocket expenses (see Section 5.3 for more details).

HSA.

By law, HSAs are available to members who are not enrolled in Medicare or do not have other health insurance coverage.  In 2005, for each month you are eligible for an HSA premium pass through, we will contribute to your HSA $52.08per month for a Self-Only enrollment or $104.17 per month for a Self and Family enrollment.   In addition to our monthly contribution, you have the option to make additional tax-free contributions to your HSA, so long as total contributions do not exceed the limit established by law, which is $1,250 for Self Only enrollment and $2,500 for Self and Family enrollment. See maximum contribution information in Section 5.3. You can use funds in your HSA to help pay your health plan deductible, copayments, coinsurance,and other medical medical expenses.

Federal tax tip: There are tax advantages to fully funding your HSA as quickly as possible. Your HSA contribution payments are fully deductible on your Federal tax return. By fully funding your HSA early in the year, you have the flexibility of paying medical expenses from tax-free HSA dollars or after tax out-of-pocket dollars. If you don’t deplete your HSA and you allow the contributions and the tax-free interest to accumulate, your HSA grows more quickly for future expenses.

HSA features include:

Your HSA is administered by Corporate Benefit Services of America (CBSA)

Your contributions to the HSA are tax deductible

Your HSA earns tax-free interest

You can make tax-free withdrawals for qualified medical expenses for you, your spouse and dependents. (See IRS publication 502 for a complete list of eligible expenses.)

Your unused HSA funds and interest accumulate from year to year

It’s portable - the HSA is owned by you and is yours to keep, even when you leave Federal employment or retire

 When you need it, funds up to the actual HSA balance are available.

Important Consideration if you want to participate in a Health Care Flexible Spending Account: If you are enrolled in this HDHP with a Health Savings Account (HSA), you are not able to participate in an FSAFEDS Health Care Flexible Spending Account (HCFSA). See the Flexible Spending Account Program – FSAFEDS in Section 12.

HRA

For members who aren’t eligible for an HSA, are enrolled in Medicare or have another health plan, CBSA will administer and provide an HRA.   

In 2005, we will give you an HRA credit of $625 per year for a Self-Only enrollment and $1,250 for a Self and Family enrollment.  You can use funds in your HRA to help pay your health plan deductible and/or for certain expenses that don’t count toward the deductible. 

HRA features include:

For our HDHP option, the HRA is administered by Corporate Benefits Services of America (CBSA)

Tax-free credit can be used to pay for qualified medical expenses for you and any individuals covered by this HDHP

Unused credits carryover from year to year

HRA credit does not earn interest

HRA credit is forfeited if you leave Federal employment or switch health insurance plans.

Catastrophic protection for out-of-pocket expenses

When you use network providers, your annual maximum for out-of-pocket expenses (deductibles, coinsurance and copayments) for covered services is limited to $4,000 for self only or $8,000 for Self and Family enrollment. However, certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses once you reach your out-of-pocket maximum (such as out-of-network expenses or expenses in excess of the Plan’s allowable amount or benefit maximum). Refer to Section 4 Your catastrophic protection out-of-pocket maximum, Section 5.2 Traditional medical coverage subject to the deductible, and Section 5.4Catastrophic protection for out-of-pocket expenses for more details.

Health education resources and account management tools

Section 5.5 describes the health education resources and account management tools available to you to help you manage your health care and your health care dollars.  

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

Preventive care services listed in this Section are not subject to the deductible. You only owe your copay for covered preventive care services.

You must use providers that are part of our network.

For all other covered expenses, please see Section 5.2 –Traditional Medical Coverage

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.

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Professional services, such as:

Routine physical examinations

Routine screenings

Routine immunizations such as:

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

– Influenza vaccines, annually, age 50 and over at physicians discretion for those determined to be high risk.

– Pneumococcal vaccine, age 65 and over

Wellness programs

$15 per office visit to your Primary Care Physician or

$25 per office visit copay to a Specialist

Routine screenings, such as:

Blood test

Urinalysis

Nothing

Total Blood Cholesterol-once every three years

Colorectal Cancer Screening, including

– Fecal occult blood test

Nothing if you receive these services during yoru office visit; otherwise,

$15 per office visit to your Primary Care Physician or

$25 per office visit copay to a Specialist

– Sigmoidoscopy screening – every 5 years starting at age 50

Nothing

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

Nothing

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

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

– One per calendar year age 40 and above

Nothing

Routine pap test

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

Not covered:

Physical exams required for obtaining or continuing employment or insurance, or travel.

Immunizations, boosters, and medications for travel.

All charges.

Professional services, such as:

Well-child visits for routine examinations, immunizations and care ( through age 22)

Childhood immunizations recommended by the American Academy of Pediatrics

Examinations, such as:

Eye exam through age 17 to determine the need for vision correction.

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

$15 office visit copay for Primary Care Physician

$25 office visit copay for Specialist

Not covered:

Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel.

Immunizations, boosters, and medications for travel.

All charges.

Annual eye refraction

All ages

$15 per office visit to a participating vision provider.

Not covered:

Eyeglasses or contact lenses

Eye exercises and orthoptics

Radial Keratotomy and other refractive surgery

All charges.

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Here are some important things you should keep in mind about your 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.

You must use providers that are part of our network.

Services described in this section are subject to the deductible. The deductible is $1,250 for self only or $2,500 for Self and Family enrollment. The family deductible can be satisfied by one or more family members. The deductible applies to almost all benefits in Section 5.2. You must satisfy your deductible before we pay for Traditional Medical Coverage.

Preventive care services are not subject to the deductible. Please refer to Section 5.1 for information on preventive care services.

Under Traditional Medical Coverage, you are responsible for the copayment and/or coinsurance for a covered service after you satisfy the deductible.

You are protected by an annual catastrophic maximum on out-of-pocket expenses for covered services. After your coinsurance, copayments and deductibles total $4,000 for self or $8,000 for Self and Family enrollment in any calendar year, you do not have to pay any more for covered services from network providers. However, certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses once you reach your out-of-pocket maximum (such as expenses in excess of the Plan’s benefit maximum, or if you use out-of-network providers, amounts in excess of the Plan allowance). In-network benefits apply only when you use a network provider. This plan does not include out of network coverage.

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

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You must satisfy your deductible before your Traditional Medical Coverage begins. The Self and Family deductible must be satisfied by one family member or a combination of family members. The deductible applies to almost all benefits in this Section. In the You pay column, we say "No deductible" when it does not apply. When you receive covered services from network providers, you are responsible for paying the allowable charges until you meet the deductible.

100% of allowable charges until you meet the deductible of $1,250 for self only or $2,500 for Self and Family enrollment. You may choose to pay deductible expenses from your HSA or HRA, or you can pay for them out-of-pocket.

After you meet the deductible, we pay the allowable charge (less your copayment) until you meet the annual catastrophic out-of-pocket maximum.

After you meet the deductible, you pay the indicated copayments and/or coinsurance for covered services. You may choose to pay the copayments or coinsurance from your HSA or HRA, or you can pay for them out-of-pocket.

Professional services of physicians

In physician’s office

Office medical consultations

Second surgical opinion

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

Professional services of physicians

In an urgent care center

During a hospital stay

In a skilled nursing facility

Nothing

At home

$15 per visit from your Primary Care Physician

$25 per visit from a Specialist

Tests, such as:

Blood tests

Urinalysis

Non-routine pap tests

Pathology

Non-routine mammograms

Nothing

X-rays

CT Scans/MRI

Ultrasound, (including prenatal ultrasound)

Electrocardiogram and EEG

$25 copay per visit

Not covered:

Physical examinations required for, obtaining, or continuing employment or insurance, attending schools or camp, or travel

All charges.

Complete maternity (obstetrical) care, such as:

Prenatal care

Delivery

Postnatal care

Note: Here are some things to keep in mind:

You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will cover an extended 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.

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

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

Note: You pay the office visit copay for your first visit only. We waive the office visit copay after your initial maternity care visit.

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

All charges.

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

Surgically implanted contraceptives

Injectable contraceptive drugs

Intrauterine devices (IUDs)

Diaphragm fitting

Note: We cover oral contraceptives (including diaphragms and injectables under the prescription drug benefit.

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

Voluntary Sterilization

$50 per vasectomy

$100 per tubal ligation

Not covered: reversal of voluntary surgical sterilization and genetic counseling

All charges.

Diagnosis and treatment of infertility such as:

Artificial insemination:

– intravaginal insemination (IVI)

– intracervical insemination (ICI)

– intrauterine insemination (IUI)gs

$300 copay or 50% of the cost of the service, whichever is less

Not covered:

Fertility Drugs

Assisted reproductive technology (ART) procedures, such as:

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

– In vitro fertilization

Services and supplies related to excluded ART procedures

Cost of donor sperm

Cost of donor egg

All charges.

Testing and treatment

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

Allergy injection

Allergy serum

Nothing

Not covered: provocative food testing and sublingual allergy desensitization

All charges.

Treatment therapies

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 and determine that it is medically necessary. Your doctor will need to submit medical information to support that GHT is medically necessary. You must obtain authorization for GHT before you begin treatment because we only cover GHT services from the date we determine it is medically necessary. We do not cover GHT or related services and supplies if we determine it isn’t medically necessary. See Services requiring our prior approval in Section 3.

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

Up to two consecutive months per condition 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 and if significant improvement can be expected within two consecutive months.

Cardiac rehabilitation is limited to treatment for therapy conditions that in the judgement of a participating physician and the Medical Director are subject to significant improvement through short-term therapy. We only cover one course of cardiac rehabilitation treatment per episode.

$15 per visit from your Primary Care Physician or

$25 per visit from a Specialist

Nothing per visit if the services are provided by a participating physical therapist

Nothing per visit during a covered inpatient hospital admission.

Not covered:

long-term rehabilitative therapy or rehabilitative therapy beyond two consecutive months per condition

Exercise programs

All charges.

Up to two consecutive months per condition for the services provided by a qualified speech therapist

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

Hearing testing (one per contract year)

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

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

Nothing

Not covered:

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 the "Not Covered" section under Orthopedic and prosthetic devices for information on podiatric shoe inserts.

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

Not covered:

Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and smilar 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

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

Internal prosthetic devices, such as artificial joints, limbs, pacemakers, and surgically implanted breast implant following mastectomy, when authorized in accordance with the plan’s policies and procedures. Note: See 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 when rheumatoid arthritis, ankylosing spondylitis, or disseminated lupus erythmatosus.

Note: You must receive our preauthorization. Call us at (866) 351-5946 as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call

Nothing

Not covered:

Orthopedic and corrective shoes

Arch supports

Foot orthotics (except for diabetics)

Heel pads and heel cups

Corsets, trusses, elastic stockings, support hose, and other supportive devices

Cochlear implant devices

Replacement due to neglect

Any dental care involved with the treatment of tempormandibular joint (TMJ) pain dysfunction syndrome or joint disorders

Dental prosthesis

Lumbar supports

Wigs

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; base model necessary to cover your needs

crutches;

walkers;

Diabetes equipment such as blood glucose monitors, insulin infusion devices and orthotics

Note: You must receive our preauthorization. Call us at (866) 351-5946 as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

Nothing

Not covered:

Disposable items such as incontinent pads, catheters, irrigation kits, electrodes, ace bandages, elastic stockings and dressings

Equipment which serves for comfort or convenience functions or is primarily for the convenience of a person caring for a member

Air conditioners

Corrective appliances that do not require prescription specifications or are used primarily for recreational sports

Humidifiers

Electric air cleaners

Exercise or fitness equipment

Elevators

Hot tubs

Hoyer lifts

Shower/bath bench

Routine servicing, e.g., testing, cleaning, regulating and checking of equipment

Special clothing of any type

Hearing devices of any type

Replacement due to neglect

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.

Nothing

Not covered:

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

Services primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication

Homemaker services

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

Services or supplies furnished by a person who is the spouse or relative of member or by non home health provider

All charges.

Medical Foods and Nutritional Therapy

Services for nutritional formulas as Medically Necessary for the therapeutic treatment of phenylketonuria, branched-chain ketonuria, galactosemia and homocystinuria as administered under the direction of a Participating Provider

Elemental Formula: Prior authorization is required. Covered services according to Plan guidelines for formulas made up of single amino acids and simple sugars and if the following requirements are met:

– You must require nutritional therapy to sustain life (that is, to meet 505 of your daily nutritional requirements) and adequate nutrition must not be possible with dietary adjustment and/ or oral supplements

– Your Physician must see you within thirty (30) days prior to initial Prior Authorization and any subsequent re-Authorization.

Nothing

Not covered:

Food or food supplements, vitamins or other nutritional and over-the –counter electrolyte supplements except as specified above.

All charges.

Chiropractic

Up to 15 visits per member per calendar year for

Manipulation of the spine and extremities or

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

$25 per office visit to a Specialist

Not covered: Visits that exceed 15 per calendar year

All charges.

Alternative Treatments

Biofeedback when approved in conjunction with an approved pain management program or for the treatment of urinary and or fecal incontinence

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

Not covered:

Naturopathic services

Acupuncture

Hypnotherapy

Biofeedback not shown as covered

All charges.

Educational classes and programs

Outpatient diabetes self-management training and education (including nutritional therapy) for persons with diabetes, when prescribed by a Plan Physician. Coverage includes:

visits medically necessary upon the diagnosis of diabetes;

visits where a Plan physician identifies and diagnoses a significant change in the patient’s symptoms or conditions that necessitates changes in a patient’s self-management; and

visits where a licensed physician identifies that a new medication or therapeutic process relating to the person’s treatment or diabetes management is medically necessary.

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

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

The deductible is $1,250 under Self Only and $2,500 under Self and Family. After you have satisfied the deductible, you traditional medical coverage begins.

You must use providers that are part of our participating provider network.

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 PRECERTIFICATION FOR SOME SURGICAL PROCEDURES. Please refer to the prior approval information in Section 3 to be sure which services require our prior approval.

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 or Body Mass Index (BMI) is greater than 40.

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

Treatment of Burns

Circumcisions for male newborns

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

Nothing

Voluntary sterilization

$50 copay for vasectomy and

$100 for tubal ligation

Not covered:

Reversal of voluntary sterilization

Routine treatment of conditions of the foot; see Foot care.

Cosmetic procedures

All charges.

Reconstructive surgery

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.

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.

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.

Excision of lesions of the mandible, mouth , lip, or tongue

Incision of accessory sinuses, mouth, salivary glands or duct;

Manipulation of dislocations of the jaw

Reconstruction or repair of the mouth or lips necessary to correct functional impairment caused by congenital condition and birth abnormalities;

Treatment of tumors

Extractions of impacted third molars when partially or totally covered by bone

Nothing

Not covered:

Oral implants and transplants

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

Orthodontia

Treatment of TMJ if dental related

Orthognathic or prognathic surgery when it is performed only to improve the appearance of a functioning structure

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

Note: Transplant services must be performed at a participating Center of Excellence. We approve and designate where all transplants must be performed including hospitals for specific transplant procedures. If you would like to know about a specific facility, please contact Member Services.

Note: We cover related medical and hospital expenses of the donor when the expenses are not covered by the donor’s insurance and when the transplant recipient is a HealthAmerica member approved for transplant services.

Nothing

Not covered:

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

Donor expenses related to donating organs or tissue to a non-member recipient

Implants of artificial organs

Experimental or investigational transplants

Transplants not listed as covered

All charges.

Professional services provided in –

Hospital (inpatient)

Hospital outpatient department

Skilled nursing facility

Ambulatory surgical center

Nothing

Professional services provided in –

Office

$15 per office visit to your Primary Care Physician

$25 per office visit to a Specialist

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

The deductible is $1,250 for Self Only enrollment and $2,500 for Self and Family enrollment. After you have satisfied your deductible, your Traditional Medical Coverage begins.

You must use providers that are part of our participating provider network.

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 10 about coordinating benefits with other coverage, including with Medicare.

YOUR NETWORK PHYSICIAN WILL PRECERTIFY YOUR HOSPITAL STAY. Please refer to the prior approval information in Section 3 to be sure which services require our prior approval.

Room and board, such as

Ward, semiprivate, or intensive care accommodations;

General nursing care; and

Meals and special diets.

Note: We will cover a private room when it is medically necessary. 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

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

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 nurse care

All charges