Page numbers referenced within this brochure apply only to the printed brochure

Optima Health

www.optimahealth.com
757-552-7550 or 800-206-1060

2022



IMPORTANT:
  • Rates
  • Changes for 2022
  • Summary of Benefits
  • Accreditations
A Health Maintenance Organization (High Option), and a High Deductible Health Plan

This plan’s health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. See page 3 for details.  This plan is accredited.  See page 12.

Serving:  Greater Hampton Roads region of Virginia

Enrollment in this plan is limited. You must live or work in our
geographic service area to enroll. See page 14 for requirements.

Enrollment codes for this Plan:

PG1 High Option - Self Only
PG3 High Option - Self Plus One
PG2 High Option - Self and Family


PG4 High Deductible Health Plan (HDHP) – Self Only
PG6 High Deductible Health Plan (HDHP) – Self Plus One
PG5 High Deductible Health Plan (HDHP) – Self and Family

Federal Employees Health Benefits Program seal
OPM Logo








Important Notice

Important Notice from Optima Health About

Our Prescription Drug Coverage and Medicare

OPM has determined that the Optima Health’s prescription drug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all plan participants and is considered Creditable Coverage. This means you do not need to enroll in Medicare Part D and pay extra for prescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as long as you keep your FEHB coverage.

However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate benefits with Medicare.

Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program.

Please be advised

If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that is at least as good as Medicare’s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1 percent per month for every month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug coverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the next Annual Coordinated Election Period (October 15 through December 7) to enroll in Medicare Part D.

Medicare’s Low Income Benefits

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA) online at www.socialsecurity.gov, or call the SSA at 800-772-1213, (TTY:  800-325-0778). 

You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places:

  • Visit www.medicare.gov for personalized help.
  • Call 800-MEDICARE 800-633-4227, TTY 877-486-2048.



Table of Contents

(Page numbers solely appear in the printed brochure)




Introduction

This brochure describes the benefits of Optima Health under Optima Health contract (CS 2952) between Optima Health and the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law.   This plan is underwritten by Optima Health.  Customer service may be reached at 757-552-7550 or 800-206-1060 or through our website: www.optimahealth.com.  The address for Optima Health's administrative offices is:

Optima Health
4417 Corporation Lane
Virginia Beach, VA 23462

This brochure is the official statement of benefits. No verbal statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One or Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available before January 1, 2022, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2022, and changes are summarized on page 15. Rates are shown at the end of this brochure.




Plain Language

All FEHB brochures are written in plain language to make them easy to understand.  Here are some examples: 

  • Except for necessary technical terms, we use common words. For instance, "you" means the enrollee and each covered family member, "we" means Optima Health.
  • We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States Office of Personnel Management. If we use others, we tell you what they mean.
  • Our brochure and other FEHB plans’ brochures have the same format and similar descriptions to help you compare plans.



Stop Healthcare Fraud!

Fraud increases the cost of healthcare for everyone and increases your Federal Employees Health Benefits Program premium.

OPM’s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.

 Protect Yourself From Fraud– Here are some things that you can do to prevent fraud:

  • Do not give your plan identification (ID) number over the phone or to people you do not know, except for your healthcare providers, authorized health benefits plan or OPM representative.
  • Let only the appropriate medical professionals review your medical record or recommend services.
  • Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
  • Carefully review explanations of benefits (EOBs) statements that you receive from us.
  • Periodically review your claim history for accuracy to ensure we have not been billed for services you did not receive.
  • Please review your claims history periodically for accuracy to ensure services are not being billed to your accounts that were never rendered.
  • Do not ask your doctor to make false entries on certificates, bills, or records in order to get us to pay for an item or service.
  • If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
    • Call the provider and ask for an explanation. There may be an error.
    • If the provider does not resolve the matter, call us at 757-687-6326, or 866-826-5277 and explain the situation.
    • If we do not resolve the issue:

CALL - THE HEALTH CARE FRAUD HOTLINE
1-877-499-7295
OR go to www.opm.gov/our-inspector-general/hotline-to-report-fraud-waste-or-abuse/complaint-form

The online reporting form is the desired method of reporting fraud in order to ensure accuracy, and a quicker response time.

You can also write to:
United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington, DC 20415-1100

  • Do not maintain as a family member on your policy:
    • Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise);
    • Your child age 26 or over (unless they are disabled and incapable of self-support prior to age 26). 

A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

  • If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary Continuation of Coverage (TCC).
  • Fraud or intentional misrepresentation of material fact is prohibited under the Plan.  You can be prosecuted for fraud and your agency may take action against you.  Examples of fraud include falsifying a claim to obtain FEHB benefits, trying to or obtaining services or coverage for yourself or someone who is not eligible for coverage, or enrolling in the Plan when you are no longer eligible.
  • If your enrollment continues after you are no longer eligible for coverage (i.e., you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid.  You may be billed by your provider for services received.  You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums.  It is your responsibility to know when you or a family member is no longer eligible to use your health insurance coverage.



Discrimination is Against the Law

The Optima Health Plan complies with all applicable Federal civil rights laws Title VII of the Civil Rights Act of 1964.

You can also file a civil rights compliant with the Office of Personnel Management by mail at: Office of Personnel Management Healthcare and Insurance Federal Employee Insurance Operations, Attention: Assistant Director FEIO, 1900 E Street NW, Suite 3400 S, Washington, DC 20415-3610.




Preventing Medical Mistakes

Medical mistakes continue to be a significant cause of preventable deaths within the United States. While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments.  Medical mistakes and their consequences also add significantly to the overall cost of healthcare. Hospitals and healthcare providers are being held accountable for the quality of care and reduction in medical mistakes by their accrediting bodies. You can also improve the quality and safety of your own healthcare and that of your family members by learning more about and understanding your risks.  Take these simple steps:

1.  Ask questions if you have doubts or concerns.

  • Ask questions and make sure you understand the answers. 
  • Choose a doctor with whom you feel comfortable talking.
  • Take a relative or friend with you to help you take notes, ask questions, and understand answers.

2.  Keep and bring a list of all the medications you take.

  • Bring the actual medication or give your doctor and pharmacist a list of all the medication and dosage that you take, including non-prescription (over-the-counter) medications and nutritional supplements.
  • Tell your doctor and pharmacist about any drug, food, and other allergies you have, such as to latex.
  • Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your doctor or pharmacist says.
  • Make sure your medication is what the doctor ordered. Ask your pharmacist about the medication if it looks different than you expected.
  • Read the label and patient package insert when you get your medication, including all warnings and instructions.
  • Know how to use your medication. Especially note the times and conditions when your medication should and should not be taken.
  • Contact your doctor or pharmacist if you have any questions.
  • Understand both the generic and brand names of your medication. This helps ensure you do not receive double dosing from taking both a generic and a brand.  It also helps prevent you from taking a medication to which you are allergic.

3.  Get the results of any test or procedure.

  • Ask when and how you will get the results of tests or procedures. Will this be in person, by phone, mail, through the Plan or Provider's portal?
  • Do not assume the results are fine if you do not get them when expected.  Contact your healthcare provider and ask for your results.  
  • Ask what the results mean for your care.

4.  Talk to your doctor about which hospital or clinic is best for your health needs.

  • Ask your doctor about which hospital or clinic has the best care and results for your condition if you have more than one hospital or clinic to choose from to get the healthcare you need.
  • Be sure you understand the instructions you get about follow-up care when you leave the hospital or clinic.

5.  Make sure you understand what will happen if you need surgery.

  • Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.
  • Ask your doctor, "Who will manage my care when I am in the hospital?"
  • Ask your surgeon:
    • "Exactly what will you be doing?"

    • "About how long will it take?"

    •  "What will happen after surgery?"

    • "How can I expect to feel during recovery?"

  • Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reaction to anesthesia, and any medications or nutritional supplements you are taking.

Patient Safety Links

For more information on patient safety, please visit:

  • www.jointcommission.org/speakup.aspx The Joint Commission's Speak Up™ patient safety program.
  • www.jointcommission.org/topics/patient_safety.aspx The Joint Commission helps healthcare organizations to improve the quality and safety of the care they deliver. 
  • www.ahrq.gov/patients-consumers/ The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality health care providers and improve the quality of care you receive.
  • www.npsf.org The National Patient Safety Foundation has information on how to ensure safer healthcare for you and your family.
  • www.bemedwise.org/ The National Council on Patient Information and Education is dedicated to improving communication about the safe, appropriate use of medications.
  • www.leapfroggroup.org The Leapfrog Group is active in promoting safe practices in hospital care.
  • www.ahqa.org The American Health Quality Association represents organizations and healthcare professionals working to improve patient safety.

Preventable Healthcare Acquired Conditions ("Never Events")

When you enter the hospital for treatment of one medical problem, you do not expect to leave with additional injuries, infections, or other serious conditions that occur during the course of your stay. Although some of these complications may not be avoidable, patients do suffer from injuries or illnesses that could have been prevented if doctors or the hospital had taken proper precautions.  Errors in medical care that are clearly identifiable,  preventable and serious in their consequences for patients, can indicate a significant problem in the safety and credibility of a healthcare facility.   These conditions and errors are sometimes called “Never Events” or “Serious Reportable Events.”

We have a benefit payment policy that encourages hospitals to reduce the likelihood of hospital-acquired conditions such as certain infections, severe bedsores, and fractures, and to reduce medical errors that should never happen.  When such an event occurs, neither you nor your FEHB plan will incur costs to correct the medical error. 




FEHB Facts

Coverage information




TermDefinition
  • No pre-existing condition limitation
We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.
  • Minimum essential coverage (MEC)

Coverage under this plan qualifies as minimum essential coverage.  Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

  • Minimum value standard

Our health coverage meets the minimum value standard of 60% established by the ACA. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.

  • Where you can get information about enrolling in the FEHB Program

See www.opm.gov/healthcare-insurance for enrollment information as well as:

  • Information on the FEHB Program and plans available to you
  • A health plan comparison tool
  • A list of agencies that participate in Employee Express
  • A link to Employee Express
  • Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, and give you brochures for other plans and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

  • When you may change your enrollment;
  • How you can cover your family members;
  • What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire;
  • What happens when your enrollment ends;
  • When the next Open Season for enrollment begins.

We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office.  For information on your premium deductions, disability leave, pensions, etc you must also contact your employing or retirement office.

Once enrolled in your FEHB Program Plan, you should contact your carrier directly for address updates and questions about your benefit coverage.

  • Types of coverage available for you and your family

Self Only coverage is only for the enrollee.  Self Plus One coverage is for the enrollee and one eligible family member. Self and Family coverage is for the enrollee and one or more eligible family members. Family members include your spouse, and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family.  You may change your enrollment 31 days before to 60 days after that event.  The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member.  When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form.  Benefits will not be available to your spouse until you are married.  A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

Contact your carrier to obtain a Certificate of Creditable Coverage (COCC) or to add a dependent when there is already family Coverage.

Contact your employing or retirement office if you are changing from Self to Self Plus One or Self and Family or to add a newborn if you currently have a Self Only plan.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, nor will we.  Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26.

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage.  For a complete list of QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events.  If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

  • Family member coverage

Family members covered under your Self and Family enrollment are your spouse (including your spouse by valid common-law marriage if you reside in a state that recognizes common-law marriages) and children as described below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described below.

Natural children, adopted children, and stepchildren


Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday.

Foster children


Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children incapable of self-support


Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information.

Married children


Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday.

Children with or eligible for employer-provided health insurance


Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother's maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

  • Children’s Equity Act

OPM has implemented the Federal Employees Health Benefits Children’s Equity Act of 2000. This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

  • If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.
  • If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same plan; or
  • If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.

As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that doesn’t serve the area in which your children live, unless you provide documentation that you have other coverage for the children.

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child. Contact your employing office for further information.

  • When benefits and premiums start

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be paid according to the 2022 benefits of your prior plan or option.    If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2021 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage, (i.e. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid.  You may be billed for services received directly from your provider.  You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums.  It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage.

  • When you retire
When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).



When you lose benefits




TermDefinition
  • When FEHB coverage ends

You will receive an additional 31 days of coverage, for no additional premium, when:

  • Your enrollment ends, unless you cancel your enrollment, or
  • You are a family member no longer eligible for coverage.

Any person covered under the 31 day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60th day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC), or a conversion policy (a non-FEHB individual policy.)
  • Upon divorce

If you are divorced from a Federal employee or annuitant, you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get information about your coverage choices. You can also visit OPM’s website at www.opm.gov/healthcare-insurance/healthcare/plan-information/.  A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

  • Temporary Continuation of Coverage (TCC)

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). The Affordable Care Act (ACA) did not eliminate TCC or change the TCC rules.  For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, if you are a covered dependent child and you turn 26, etc.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement office or from www.opm.gov/healthcare-insurance/healthcare/plan-information/guides. It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a new kind of tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll. Finally, if you qualify for coverage under another group health plan (such as your spouse’s plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program coverage.

  • Converting to individual coverage

If you leave Federal or Tribal service, your employing office will notify you of your right to convert. You must contact us in writing within 31 days after you receive this notice.  However, if you are a family member who is losing coverage, the employing or retirement office will not notify you.  You must contact us in writing within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions.  When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 800-741-4825 or visit or website at www.optimahealth.com.

  • Health Insurance Marketplace

If you would like to purchase health insurance through the ACA’s Health Insurance Marketplace, please visit www.HealthCare.gov.  This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.




Section 1. How This Plan Works

This Plan is a health maintenance organization (HMO) plan. OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. Optima Health holds the following accreditation: National Committee for Quality Assurance (NCQA). To learn more about this plan’s accreditation, please visit the following website: www.ncqa.org.

We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. We are solely responsible for the selection of these providers in your area. Contact us for a copy of our most recent provider directory. We give you a choice of enrollment in a High Option, or a High Deductible Health Plan (HDHP).

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may have to submit claim forms.

You should join an HMO because you prefer the plan’s benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will be available and/or remain under contract with us.

General features of our High Option

We have Open Access benefits

Our HMO offers Open Access benefits. This means you can receive covered services from a participating provider without a required referral from your primary care physician or by another participating provider in the network.

How we pay providers

We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles, and non-covered services and supplies). Except for emergencies outside the service area, we will not pay for care or services from non-Plan providers unless it has been authorized by us. You are responsible for making sure that a provider is a Plan provider. If you use a non-Plan provider without our prior authorization, you may be responsible for charges.

Preventive care services

Preventive care services are generally covered with no cost-sharing and are not subject to copayments, deductibles or annual limits when received from a network provider.

Catastrophic protection

We protect you against catastrophic out-of-pocket expenses for covered services. Your annual out-of-pocket expenses for covered services, including deductibles and copayments, cannot exceed $7,300 for Self Only enrollment, and $14,700 for a Self Plus One or Self and Family.

General Features of our High Deductible Health Plan

HDHPs have higher annual deductibles and annual out-of-pocket maximum limits than other types of FEHB plans. FEHB Program HDHPs also offer health savings accounts or health reimbursement arrangements. Please see below for more information about these savings features.

Preventive care services

Preventive care services are generally covered with no cost sharing and are not subject to copayments, deductibles or annual limits when received from a network provider.

Annual deductible

The annual deductible must be met before Plan benefits are paid for care other than preventive care services.

Health Savings Account (HSA)

You are eligible for an HSA if you are enrolled in an HDHP not be covered by any other health plan that is not an HDHP (including a spouse’s health plan, excluding  specific injury insurance and accident, disability, dental care, vision care, or long-term coverage), not enrolled in Medicare, not received VA (except for veterans with a service-related disability) or Indian Health Services (IHS) benefits within the last three months, not covered by your own or your spouse’s flexible spending account (FSA), and are not claimed as a dependent on someone else’s tax return.

  • You may use the money in your HSA to pay all or a portion of the annual deductible, copayments, coinsurance, or other out-of-pocket costs that meet the IRS definition of a qualified medical expense.
  • Distributions from your HSA are tax-free for qualified medical expenses for you, your spouse, and your dependents, even if they are not covered by a HDHP.
  • You may withdraw money from your HSA for items other than qualified medical expenses, but it will be subject to income tax and, if you are under 65 years old, an additional 20% penalty tax on the amount withdrawn.
  • For each month that you are enrolled in a HDHP and eligible for an HSA, the HDHP will pass through (contribute) a portion of the health plan premium to your HSA. In addition, you (the account holder) may contribute your own money to your HSA up to an allowable amount determined by IRS rules. Your HSA dollars earn tax-free interest.
  • You may allow the contributions in your HSA to grow over time, like a savings account. The HSA is portable – you may take the HSA with you if you leave the Federal government or switch to another plan.

Health Reimbursement Arrangement (HRA)

If you are not eligible for an HSA, or become ineligible to continue an HSA, you are eligible for a Health Reimbursement Arrangement (HRA). Although an HRA is similar to an HSA, there are major differences.

  • An HRA does not earn interest.
  • An HRA is not portable if you leave the Federal government or switch to another plan.

Catastrophic protection

We protect you against catastrophic out-of-pocket expenses for covered services. The IRS limits annual out-of-pocket expenses for covered services, including deductibles and copayments, to no more than $7,000 for Self Only enrollment, and $14,800 for a Self Plus One or Self and Family. The out-of-pocket limit for this Plan may differ from the IRS limit, but cannot exceed that amount.

Health education resources and accounts management tools

We have online, interactive health and benefits information tools to help you make more informed health decisions (see page 106).

Your rights and responsibilities

OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, and our providers. OPM’s FEHB website (www.opm.gov/healthcare-insurance/) lists the specific types of information that we must make available to you. Some of the required information is listed below.

  • Optima Health is a not for profit health maintenance organization fully licensed under the laws of the Commonwealth of Virginia to arrange for the provision of health care services to its members.
  • Optima Health is one of the first HMOs in the Hampton Roads area of Virginia operating since 1984.
  • Optima Health pays providers on a fee for service basis according to a fee schedule. You may find some additional information about the Plan’s providers in this brochure in Section 3, "Where You Get Covered Care". If you would like information about the Plan’s provider network, including participating hospitals, physician education, and board certification, and whether or not physicians are accepting new patients, you may check your provider directory, or the Plan’s website at www.optimahealth.com or call Member Services at 757-552-7550 or 800-206-1060.

You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You can view the complete list of these rights and responsibilities by visiting our website at www.optimahealth.com. You can also contact us to request that we mail a copy to you.

If you want more information about us, call 757-552-7550 or 800-206-1060, or write to Optima Health, 4417 Corporation Lane, Virginia Beach, VA 23462. You may also visit our website at www.optimahealth.com/federal.

By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our website at www.optimahealth.com/federal to obtain our Notice of Privacy Practices.  You can also contact us to request that we mail a copy of the Notice.

Your medical and claims records are confidential   

We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.

Service Area

To enroll in this Plan, you must live in or work in our service area. This is where our providers practice. Our service area in the State of Virginia:

Cities of:

Achilles, Ark, Battery Park, Bavon, Beaverlett, Bellamy, Bena, Blakes, Bohannon, Boykins, Branchville, Capron, Cardinal, Carrollton, Carrsville, Chesapeake, Claremont, Cobbs Creek, Courtland, Dendron, Diggs, Drewryville, Dutton, Elberon, Fleet, Fort Eustis, Fort Monroe, Fort Story, Foster, Franklin, Glou Point, Gloucester, Gloucester Point, Grafton, Grimstead, Gwynn, Hallieford, Hampton, Hayes, Hudgins, Isle Of Wight, Ivor, James Store, Jamestown, Lackey, Langley AFB, Lightfoot, Maryus, Mathews, Miles, Mobjack, Moon, Naval Base, Naval Weapons Station, Naxera, New Point, Newport News, Newsoms, Norfolk, Norge, North, Onemo, Ordinary, Peary, Pinero, Poquoson, Port Haywood, Portsmouth, Redart, Rescue, Schley, Seaford, Sedley, Severn, Shadow, Smithfield, Spring Grove, Suffolk, Surry, Susan, Tabb, Toano, Virginia Beach, Walters, Ware Neck, White Marsh, Wicomico, Williamsburg, Windsor, Woods Cross Roads, Yorktown, Zanoni, and Zuni.

Counties of:

Chesapeake (City), Franklin (City), Gloucester, Hampton (City), Isle Of Wight, James City, Mathews, Newport News (City), Norfolk (City), Poquoson (City), Portsmouth (City), Southampton, Suffolk (City), Surry, Virginia Beach (City), Williamsburg (City), and York.

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. We will not pay for any other healthcare services out of our service area unless the services have prior plan approval.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.




Section 2. Changes for 2022

Do not rely only on these change descriptions; this Section is not an official statement of benefits. For that, go to Section 5. Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change benefits.

Program-wide changes

• Effective in 2022, premium rates are the same for Non-Postal and Postal employees.

Change to the High Option

  • Your share of the premium rate will decrease for Self Only, Self Plus One, or Family. See Rates on Back Cover.

Change to the HDHP Option

Your share of the premium rate will decrease for Self Only, Self Plus One, or Family. See Rates on Back Cover.

Changes to the High and HDHP Option

  • The Plan has modified coverage criteria for the annual preventive screening for lung cancer with low-dose computed tomography (LDCT) in adults. See Section 5 (a), Preventive benefit.




Section 3. How You Get Care

TermDefinition

Open Access HMO

Optima Health offers Open Access to our members within the Plan’s service area identified on page 14. You can go directly to any network specialist for covered services without a referral from your primary care physician (PCP). Whether your covered services are provided by your primary care physician (for your PCP copay) or by any other participating provider in the network (for the specialist copay), you will be responsible for payment which may be in the form of a copay (flat dollar amount) or coinsurance (a percentage of covered expenses). You still must select a PCP and notify member services of your selection. If you go directly to a specialist, you are responsible for verifying that the specialist is participating in the Plan. There are three ways you can check to see if your specialty provider is in the Plan’s network. You can call Member Services, you can check your provider directory, or you can log onto the Plan’s website at www.optimahealth.com to verify that your specialty provider is in the Plan’s network. Please remember that although you do not need a referral for specialty care some services, supplies, and drugs require precertification. Please refer to Section 3 for precertification information and to make sure which services require precertification.

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 letter (for annuitants), or your electronic enrollment system (such as 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 757-552-7550 or 800-206-1060 or write to us at Optima Health, 4417 Corporation Lane, Virginia Beach, VA 23462. You may also request replacement cards through our website at www.optimahealth.com.

Where you get covered care

If you use our Plan you can receive covered services from a participating provider without a required referral from your primary care physician or by another participating provider in the network.  You will not have to file claims.

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, or you can call Member Services to find out if a hospital or other facility is a participating provider. The list is also on our web site.

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. You should receive a directory when you enroll, or you can call Member Services to request a directory. Look in the directory to find a doctor’s specialty, office location, telephone number, and notes on whether or not the doctor is accepting new patients. You may want to call the doctor to check to see if they are still participating in the Plan. You can also call Member Services, or check the Plan's web site to find out if a doctor participates in the Plan.

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 healthcare.

Primary care

Your primary care physician can be a family practitioner, internist or pediatrician. Your primary care physician will provide most of your healthcare or refer you to see a specialist.

This plan recognizes that transsexual, transgender, and gender-nonconforming members require health care delivered by healthcare providers experienced in transgender health. While gender reassignment surgery is excluded from coverage by the Plan, (benefit details found in Section 5(b)) hormone therapy providers (benefit details found in Section 5(f)) play important roles in preventive care, you should see a primary care provider familiar with your overall healthcare needs. Benefits described in this brochure are available to all members meeting medical necessity guidelines.

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 do not need a referral from your primary care physician (PCP) for specialty care from a Plan provider.

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

• If you are seeing a specialist when you enroll in our Plan, you must make sure that they participate with us. 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, 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 hospitalized when your enrollment begins

We pay for covered services from the effective date of your enrollment.  However, if you are in the hospital when your enrollment in our Plan begins, call Member Services immediately at 757-552-7550 or 800-206-1060.  If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

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 92nd 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.

  • Balance Billing Protection

FEHB Carriers must have clauses in their in-network (participating) providers agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount. If an in-network provider bills you for covered services over your normal cost share (deductible, copay, co-insurance) contact your Carrier to enforce the terms of its provider contract.

You need prior Plan approval for certain services

Since your primary care physician arranges most referrals to specialists and inpatient hospitalization, the pre-service claim approval process only applies to care shown under Other Services.

You must get prior approval for certain services.  Your benefits for Covered Services may be reduced or denied if you do not comply with the Plan's precertification requirements.

  • Inpatient hospital admission
Precertification is the process by which – prior to your inpatient hospital admission – we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition. 
  • Other Services

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

  • Transplants,
  • scheduled ambulance transport,
  • outpatient surgery and services,
  • inpatient hospitalization,
  • durable medical equipment,
  • artificial limbs,
  • prosthetic and orthopedic appliances,
  • home health care services,
  • skilled nursing facility care,
  • physical therapy, occupational therapy, speech therapy,
  • cardiac rehabilitation,
  • pulmonary rehabilitation, vascular rehabilitation, vestibular rehabilitation,
  • early intervention services,
  • clinical trials,
  • hospice services,
  • oral surgery,
  • TMJ services, 
  • mental health services,
  • growth hormone therapy,
  • maternity services, 
  • Magnetic Resonance Imaging (MRI),  Computerized Axial Tomography (CT) Scans, 
  • chemotherapy services, chemotherapy drugs and radiation therapy,
  • sleep studies performed in a facility,
  • services from non-Plan providers, and,
  • certain prescription drugs.
How to request precertification for an admission or get prior authorization for Other services

First, your physician, your hospital, you, or your representative, must call us at 757-552-7550 or 800-206-1060 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

  • enrollee’s name and Plan identification number;
  • patient’s name, birth date, identification number and phone number;
  • reason for hospitalization, proposed treatment, or surgery;
  • name and phone number of admitting physician;
  • name of hospital or facility; and
  • number of days of requested for hospital stay.
  • Non-urgent care claims

For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization.  We will make our decision within 15 days of receipt of the pre-service claim.  If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period.  Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

  • Urgent care claims

If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours.  If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim.  You will have up to 48 hours to provide the required information.  We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM.  Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 757-552-7550.  You may also call OPM’s FEHB 2 at 202-606-3818 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us at 757-552-7550 or 800-206-1060. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

  • Concurrent care claims

A concurrent care claim involves care provided over a period of time or over a number of treatments.  We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends.  If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect. 

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

  • Emergency inpatient admission
If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must telephone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital. 
  • If your treatment needs to be extended

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

Circumstances beyond our controlUnder 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.
If you disagree with our pre-service claim decision

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below.

If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8.
  • To reconsider a
    non-urgent care claim

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.  Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to

1. Precertify your hospital stay or, if applicable, arrange for the health care provider to give you the care or grant your request for prior approval for a service, drug, or supply; or

2. Ask you or your provider for more information.

You or your provider must send the information so that we receive it within 60 days of our request.  We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due.  We will base our decision on the information we already have.  We will write to you with our decision.

3. Write to you and maintain our denial.

  • To reconsider an urgent care claim

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.  Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request.  We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by telephone, electronic mail, facsimile, or other expeditious methods.
  • To file an appeal with OPM
After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure.

The Federal Flexible Spending Account Program - FSAFEDS

• Healthcare FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you and your tax dependents, including adult children (through the end of the calendar year in which they turn 26).


• FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans. This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.




Section 4. Your Costs for Covered Services

This is what you will pay out-of-pocket for covered care:




TermDefinition
Cost-sharingCost-sharing  is the general term used to refer to your out-of-pocket costs (e.g., deductible, coinsurance, and copayments) for the covered care you receive.

Copayments

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

Example: In our High Option plan, when you see your primary care physician you pay a copayment of $15 per office visit, and $50 per specialist office visit.

Deductible

A deductible 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.

  • Under the High Option, the calendar year deductible is $750 per person.  Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $750.  Under a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $1,500.  Under a Self and 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 $1,500.
  • Under the HDHP Option, the calendar year deductible is $2,000 per person.  Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $2,000.  Under a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $4,000.  Under a Self and 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 $4,000.

Note: If you change plans during Open Season, you do not have to start a new deductible under your prior 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.

If you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option.

Coinsurance

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

Example - Cost of Diabetic supplies:

  • In our High Option Plan, you pay 30% of our allowance.
  • In our HDHP Option Plan, After Deductible, you pay 20% of our allowance.

Differences between our Plan allowance and the bill

You should also see section Important Notice About Surprise Billing – Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.

Your catastrophic protection out-of-pocket maximum

With the High Option, after your (copayments and coinsurance) total $7,350 per person regardless of enrollment tier and will not exceed more than $14,700 combined per Self Plus One or $14,700 combined for Self Plus Family enrollment in any calendar year, you do not have to pay any more for covered services.

With the HDHP Option, after your (copayments and coinsurance) total $6,000 per person regardless of enrollment tier and will not exceed more than $12,000 combined per Self Plus One or $12,000 combined for Self Plus Family enrollment in any calendar year, you do not have to pay any more for covered services. However, copayments and coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments/coinsurance for these services:

  • Balance-billed charges
  • Healthcare charges this plan does not cover
  • Precertification penalties
  • Premiums

We will notify you when you reach the maximum.

Carryover

If you changed to this Plan during Open Season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan's catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan.  If you have already met your prior plan's catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan.  If you have not met this expense level in full, your old plan will first apply your covered out-of-pocket expenses until the prior year's catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan.  Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

Note:  If you change options in this Plan during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your prior plan's option to the catastrophic protection limit of your new option.

When Government facilities bill usFacilities of the Department Veterans Affairs, the Department of Defense and the Indian Health Services are entitled to seek reimbursement from us for certain services and supplies they provide to you or a family member.  They may not seek more than their governing laws allow.  You may be responsible to pay for certain services and charges. Contact the government facility directly for more information.

Important Notice About Surprise Billing – Know Your Rights

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” under certain circumstances. A surprise bill is an unexpected bill you receive from a nonparticipating health care provider, facility, or air ambulance service for healthcare. Surprise bills can happen when you receive emergency care – when you have little or no say in the facility or provider from whom you receive care. They can also happen when you receive non-emergency services at participating facilities, but you receive some care from nonparticipating providers.
Balance billing happens when you receive a bill from the nonparticipating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan.
Your health plan must comply with the NSA protections that hold you harmless from unexpected bills.




High Option Table of Contents (High Option)

See page 15 for how our benefits changed this year and page 124 for a benefits summary.




(Page numbers solely appear in the printed brochure)




Section 5. High Option Benefits (High Option)

The benefit package is described in Section 5. Make sure that you review the benefits that are available.

Section 5 is divided into subsections. Please read Important Things You Should Keep in Mind at the beginning of the subsections. Also read the general exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about the benefits, contact us at 757-552-7550 or on our website at www.optimahealth.com.




TermDefinition

Benefits:

  • $15 copayment for primary care physician office visits
  • $50 copayment for specialist office visits
  • No copayment for primary care physician office visits for preventive care
  • No referral needed to see a specialist
  • $5 copayment for Tier 1 prescription drugs
  • Protection against catostrophic costs (out of pocket maximum) is $7,350 for Self Only or $14,700 for Self Plus One or Self Plus Family enrollment per year 



Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals (Section 5 High Option )

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.
  • A facility copay applies to services that appear in this section but are performed in an ambulatory surgical center or the outpatient department of a hospital.
  • The calendar year deductible is: $750 per person ($1,500 per Self Plus One enrollment, or $1,500 per Self and Family enrollment). The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
  • 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.



Benefit Description : Diagnostic and treatment servicesHigh Option (You pay After calendar year deductible... )

Professional services of physicians

  • In physician’s office
  • Office medical consultation
  • Second surgical opinion
  • Advance care planning

$15 copayment per visit to your primary care physician (No deductible)

$50 copayment per visit to a specialist  (No deductible)

Professional services of physicians

  • During a hospital stay
  • In a skilled nursing facility

30% coinsurance of our Plan allowance

Professional services of physicians

  • In an Urgent Care Center

$50 copayment per visit (No deductible)

Benefit Description : Telehealth ServicesHigh Option (You pay After calendar year deductible... )
  • MDLIVE Virtual Office Visit

How to get started?

• Sign in to www.optimahealth.com and select Access MDLIVE, or call 866-648-3638.

• Have your Optima Health member ID number available to register. Please note that you’ll need to create an account for each covered member of your family over the age of two.

• When you want to see a doctor, you can go online to request immediate access to a provider on-call via phone or schedule a time at your convenience. You can also get connected by calling 866-648-3638.

$10 copayment per visit (No deductible)

Benefit Description : Lab, X-ray and other diagnostic testsHigh Option (You pay After calendar year deductible... )

Tests, such as:

  • Blood tests
  • Urinalysis
  • Non-routine Pap test
  • Pathology
  • X-ray
  • Non-routine mammogram
  • CT Scan
  • MRI
  • Ultrasound
  • Electrocardiogram and EEG

30% coinsurance of our Plan allowance

Benefit Description : Preventive care, adultHigh Option (You pay After calendar year deductible... )

Routine physical every year.   The following preventive services are covered at the time interval recommended at each of the links below:

  • Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/
  • Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org
    Individual counseling on prevention and reducing health risks
  • Well woman care such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of Well Women preventive care services please visit the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/
  • Routine mammogram – covered for women:
  • Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Nothing (No deductible)

Not covered:

  • Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel.
  • Immunizations, boosters, and medications for travel or work-related expenses.
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving this service.

All charges

Benefit Description : Preventive care, childrenHigh Option (You pay After calendar year deductible... )
  • Well-child visits, examinations, and immunizations other preventive recommended services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
  • To build your personalized list of preventive services go to https://health.gov/myhealthfinder 
  • Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html
  • You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Note: A complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) is available online at: www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/

HHS: www.healthcare.gov/preventive-care-benefits/

CDC: www.cdc.gov/vaccines/schedules/index.html

For additional information:

healthfinder.gov/myhealthfinder/default.aspx

Note: For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to brightfutures.aap.org/Pages/default.aspx

Nothing (No deductible)

Benefit Description : Maternity careHigh Option (You pay After calendar year deductible... )
  • Prenatal care
  • Screening for gestational diabetes for pregnant women
  • Breastfeeding support, supplies and counseling for each birth

Nothing (No deductible)

Complete maternity (obstetrical) care, such as:

  • Delivery

30% coinsurance of our Plan allowance 

  • Postnatal Care

Note: Here are some things to keep in mind:

  • You do not need to precertify your vaginal delivery; see page 18 for other circumstances, such as extended stays for you or your baby.
  • You may remain in the hospital up to 48 hours after a vaginal 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 Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
  • We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
  • Hospitalization services are covered under Section 5(c) and Surgical benefits Section 5(b).

Note: When a newborn requires definitive treatment during or after the mother’s confinement, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

$15 copayment per visit to your primary care physician (No deductible)

$50 copayment per visit to a specialist (No deductible)

Not covered:

  • Routine care and services for pregnancy outside the Plan’s service area.
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service.
All charges
Benefit Description : Family planning High Option (You pay After calendar year deductible... )

A range of voluntary family planning services, limited to:

  • Voluntary sterilization - limited to vasectomies and tubal ligations (See Section 5(b), Surgical Procedures)
  • Surgically implanted contraceptives
  • Injectable contraceptive drugs (such as Depo Provera)
  • Intrauterine devices (IUDs)
  • Diaphragms
  • Contraceptive counseling on an annual basis

Note: We cover oral contraceptives under the prescription drug benefit.  *Generic oral contraceptives are eligible for 100 percent coverage and no cost share to members.  Brand name oral contraceptives will be covered based on the plan’s formulary and the appropriate Copayment or Coinsurance will apply based on the drug tier.  Please visit www.optimahealth.com to determine member cost share for brand name oral contraceptives.

Nothing (No deductible)

Not covered:

  • Reversal of voluntary surgical sterilization
  • Genetic testing and counseling that is determined to be not medically necessary. 
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service.
All charges
Benefit Description : Infertility servicesHigh Option (You pay After calendar year deductible... )

Diagnosis and treatment of infertility

No benefit

Not covered:

  • Assisted reproductive technology (ART) procedures, such as:
    • Artificial insemination (AI)
    • Intravaginal insemination (IVI) 
    • Intracervical insemination (ICI)
    • Intrauterine insemination (IUI)
    • In vitro fertilization (IVF)
    • Embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
    • Services and supplies related to ART procedures
  • Endometrial biopsies
  • Semen analysis
  • Hysterosaloingography
  • Sims-Huhner Test (smear)
  • Diagnostic laparoscopy
  • Cost of donor sperm
  • Cost of donor egg
  • Fertility drugs
  • Reproductive material storage
  • Infertility services after voluntary sterilization

All charges

Benefit Description : Allergy careHigh Option (You pay After calendar year deductible... )
  • Testing and treatment
  • Allergy injections
  • Allergy serum

$15 copayment per visit to your primary care physician (No deductible)

$50 copayment per visit to a specialist (No deductible)

Not covered:

  • Provocative food testing and sublingual allergy desensitization
  • Food allergy ingestion testing
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service
All charges
Benefit Description : Treatment therapiesHigh Option (You pay After calendar year deductible... )
  • 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 42.

  • Respiratory and inhalation therapy

  • Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy

  • Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit.  We only cover GHT when we precertify the treatment.  We will ask you to submit information that establishes that the GHT is medically necessary.  Ask us to precertify GHT before you begin treatment.  We will only cover GHT services and related services and supplies that we determine are medically necessary.  See Other Services under You Need Prior Plan Approval for certain services on page 19.

30% coinsurance of our Plan allowance

  • Cardiac rehabilitation following a qualifying event/condition is provided for up to 90 consecutive days from the start of rehabilitation.

$50 copayment per specialist office visit (No deductible)

30% coinsurance of our Plan allowance, during inpatient admission

  • Pulmonary, vascular, and vestibular rehabilitation is covered for up to 90 consecutive days from the start of rehabilitation.

$50 copayment per specialist office visit (No deductible)

30% coinsurance of our Plan allowance, during inpatient admission

  • Dialysis – hemodialysis and peritoneal dialysis

$15 copayment per physician office visit (No deductible)

30% coinsurance of our Plan allowance

Applied Behavior Analysis (ABA) - Members with autism spectrum disorder

Covered Services include “diagnosis” and “treatment” of Autism Spectrum Disorder.

“Autism Spectrum Disorder” means any pervasive developmental disorder, including (i) autistic disorder, (ii) Asperger's Syndrome, (iii) Rett syndrome, (iv) childhood disintegrative disorder, or (v) Pervasive Developmental Disorder – Not Otherwise Specified, as defined in the most recent edition of The Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association.  

“Diagnosis of autism spectrum disorder” means medically necessary assessments, evaluations, or tests to diagnose whether an individual has an autism spectrum disorder.

“Treatment for autism spectrum disorder” shall be identified in a treatment plan and included the following care prescribed or ordered for an individual diagnosed with autism spectrum disorder by a licensed physician or a licensed psychologist who determines the care to be medically necessary: (i) behavioral health treatment, (ii) pharmacy care, (iii) psychiatric care, (iv) psychological care, (v) therapeutic care, and (vi) applied behavioral analysis when provided or supervised by a board certified behavioral analyst licensed by the Board of Medicine. No limit on visits.

“Applied behavioral analysis” means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior. 

$50 copayment per specialist visit (No deductible)

30% coinsurance of our Plan allowance

Not covered:

  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service

All charges

Benefit Description : Physical and occupational therapiesHigh Option (You pay After calendar year deductible... )
  • Qualified physical therapists 
  • Occupational therapists

Coverage will include 30 rehabilitative combined physical therapy and occupational therapy visits per year and 30 habilitative combined physical therapy and occupational therapy visits per year.

Note: Precertification is required. We only cover therapy when a physician:

  • orders the care;
  • identifies the specific professional skills the patient requires and the medical necessity for skilled services; and
  • indicates the length of time the services are needed.

30% coinsurance of our Plan allowance

Early Intervention Services are covered for children from birth to age three for medically necessary services limited to:

  • speech, language, occupational and physical therapy
  • assistive technology services and devices

Note: Covered services are provided to enhance functional ability without effecting a cure. Department of Mental Health, Mental Retardation, and Substance Abuse Services must certify dependents as eligible for services under Part H of the Individuals with Disabilities Act.

Note: Precertification is required. See Section 3.

 

Any applicable Copayment  or Coinsurance, depending on the type and place of treatment or service.  

Not covered:

  • Long-term rehabilitative therapy
  •  Therapies available in a school program or available through state and local funding, including sign language therapies
  • Recreation therapies, including art, dance, or  music therapies
  • Sleep therapies
  • Exercise programs, or equine therapies
  • Driver evaluations as part of occupational therapy
  • Driver training
  • Functional capacity testing needed to return to work
  • Any service or supply, unless provided in accordance with a specific treatment plan pre-authorized by the Plan
  • Therapy which is primarily educational in nature, special education, or sign language
  • Work-hardening programs
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service
All charges
Benefit Description : Speech therapy High Option (You pay After calendar year deductible... )

Speech therapy is covered for up to 30 rehabilitative speech therapy visits per year; up to 30 habilitative speech therapy visits per year for medically necessary treatment.

30% coinsurance of our Plan allowance

Not covered:

  • Speech therapy not precertified by the Plan as part of a specific treatment plan
  • Care and services from non-Plan providers unless precertifed by the Plan prior to receiving the service
All charges
Benefit Description : Hearing services (testing, treatment, and supplies)High Option (You pay After calendar year deductible... )
  • For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist

Note: For routine hearing screening performed during a child’s preventive care visit, see Section 5(a) Preventive Care, Children.

  • External hearing aids
  • Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants

Note: See Section 5(a), Orthopedic and Prosthetic Devices, for benefits for the devices.

$15 copayment per primary care physician office visit (No deductible)

$50 copayment per specialist office visit (No deductible)

Not covered:

  • All other hearing testing
  • Hearing aids, testing and examinations for them
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service
All charges
Benefit Description : Vision services (testing, treatment, and supplies)High Option (You pay After calendar year deductible... )

Preventive vision care and services are administered by EyeMed Vision Care.  The following services are covered once every 12 months: 

• Annual eye refraction including care history, visual acuity test for glasses and written lens prescription.

• Screening tests for diseases or abnormalities, including glaucoma and cataracts.

Note: You should select a EyeMed Vision Care provider and call him or her directly to schedule an appointment.  If you need help or a current list of participating providers, call EyeMed Vision Care at 866-939-3633 or visit www.optimahealth.com.  You may receive an eye exam from a non-Plan provider and receive a $30 reimbursement.

Nothing (No deductible)

  • One pair of eyeglasses or contact lenses (up to $200 allowance) to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts).   Please note that New technology, intraocular lens are excluded from coverage.

Nothing (No deductible)

  • Eye exam to determine the need for vision correction for children up to age 22 (see Preventive care, children)

Nothing per primary care physician office visit (No deductible)

$50 copayment per specialist office visit (No deductible)

Not covered:

  • Eyeglasses or contact lenses 
  • Eye exercises and orthoptics
  • Radial keratotomy and other refractive surgery
  • Any eye examination, or any corrective eyeware required by an employer as a condition as employment
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service
All charges
Benefit Description : Foot careHigh Option (You pay After calendar year deductible... )
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

$15 copayment per primary care physician office visit (No deductible)

$50 copayment per specialist office visit (No deductible)

Not covered:

  • Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the  foot, except as stated above
  • Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery) 
  • Foot orthotics of any kind including customized or non-customized shoes, boots, and inserts, except as medically necessary and approved by the Plan for members with diabetes
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service
All charges
Benefit Description : Orthopedic and prosthetic devices High Option (You pay After calendar year deductible... )
  • Artificial limbs and eyes
  • Prosthetic sleeve or sock
  • Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
  • Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
  • Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants
  • Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy.
  • Lenses following cataract removal
  • Repair and replacement

Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b) Surgical Procedures.  For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services Provided by a Hospital or Other Facility, and Ambulance Services.

30% coinsurance of our Plan allowance

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
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service
All charges
Benefit Description : Durable medical equipment (DME)High Option (You pay After calendar year deductible... )

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include:

  • Oxygen
  • Dialysis equipment
  • Hospital beds
  • Standard non-motorized wheelchairs
  • Crutches
  • Walkers
  • Colostomy, iliostomy, and tracheostomy supplies
  • Suction and urinary catheters

Note: When your Plan physician prescribes this equipment we will arrange with a healthcare provider to rent or sell you durable medical equipment at discounted rates.

30% coinsurance of our Plan allowance

  • Diabetic supplies and equipment including prescribed by a Plan physician for insulin dependent, gestational, and non-insulin dependent diabetics.

Precertification is required for insulin pumps and pump infusion sets and supplies.

Coverage includes benefits for FDA-approved equipment and supplies for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes, and non-insulin-using diabetes if prescribed by a healthcare professional legally authorized to prescribe such items.

  • Pump infusion sets and supplies, outpatient self-management training and education, and nutritional therapy are covered under the Plan’s medical benefits.
  • Insulin, needles, and syringes as well as testing supplies (test strips, lancets, lancet devices, blood glucose monitors, and control solution) are covered under the Plan’s pharmacy benefits. Diabetes testing supplies will be limited to LifeScan products, except in the case of members using an insulin pump associated with a specific, non-LifeScan meter.
    • For members who may not be using a LifeScan meter currently, there are two ways to obtain a free LifeScan meter:
      1. Order online at www.OneTouch.orderpoints.com and input the Optima Health order code 741OPT016;
      2. Call the toll-free number: 855-776-4464 and provide the order code 741OPT016

30% coinsurance of the Plan allowance


External insulin pumps

Nothing (No deductible)

Not covered:

  • Motorized wheelchairs or scooters
  • Exercise equipment
  • Air conditioners, purifiers, humidifiers, and dehumidifiers
  • Whirlpool baths
  • Convenience items, including but not limited to hypoallergenic bed linens, water purification devices, and adaptive feeding devices
  • Telephones
  • Changes made to vehicles, residences, or places of business including, but not limited to, handrails, ramps, elevators, and stair glides
  • Repair or replacement of equipment damaged through neglect or loss
  • More than one item of equipment for the same purpose
  • Disposable medical supplies, including but not limited to medical dressings, disposable diapers
  • Durable medical equipment primarily for comfort and well being of the member
  • Care and services from non-plan providers unless precertified by the Plan prior to receiving the service
All charges
Benefit Description : Home health servicesHigh Option (You pay After calendar year deductible... )
  • Home healthcare 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
  • Part-time or intermittent nursing care
  • Part-time or intermittent home health aide services
  • Surgical dressings and medical appliances

Nothing (No deductible)

  • Physical, occupational, or speech therapy

30% coinsurance of our Plan allowance

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
  • Services primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service
All charges
Benefit Description : Chiropractic High Option (You pay After calendar year deductible... )

No benefit

All charges

Benefit Description : Alternative treatmentsHigh Option (You pay After calendar year deductible... )

No benefit

All charges

Benefit Description : Educational classes and programsHigh Option (You pay After calendar year deductible... )

Coverage is provided for:

  • Diabetes self management

Note: Members should call 1-800-SENTARA for information on classes

Nothing (No deductible)

  • Counseling and education for birth control options

Nothing (No deductible)

  • Tobacco Cessation programs, including individual/group/telephone counseling, and for over the counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence (see Prescription Drugs).  

Nothing (No deductible)




Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals (High Option)

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.
  • The calendar year deductible is: $750 per person ($1,500 per Self Plus One enrollment, or $1,500 per Self and Family enrollment). The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
  • 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 services listed below are for the charges billed by a physician or other healthcare professional for your surgical care. See Section 5(c) for charges associated with a facility (i.e. hospital, surgical center, etc.).

YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR ALL SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3.




Benefit Description : Surgical proceduresHigh Option (You pay After calendar year deductible....)

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 (bariatric surgery) -- a condition in which an individual weighs 100 pounds or 100% over their normal weight according to current underwriting standards; eligible members must be age 18 or over.
  • Insertion of internal prosthetic devices. See 5(a) – Orthopedic and prosthetic devices for device coverage information
  • Voluntary sterilization (e.g., vasectomy)
  • Treatment of burns

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

30% coinsurance of our Plan allowance

Not covered:

  • Reversal of voluntary sterilization
  • Surgery related to gender reassignment
  • Routine treatment of conditions of the foot; see Foot care
  • Surgery primarily for cosmetic purposes
  • Any surgical services, other than emergent, which have not been pre-authorized by the Plan.
  • Any surgical services determined not medically necessary by the Plan.
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service
All charges
Benefit Description : Reconstructive surgery High Option (You pay After calendar year deductible....)
  • 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; and webbed fingers and toes.
  • All stages of breast reconstruction surgery following a mastectomy, such as:
    • surgery to produce a symmetrical appearance of breasts;
    • treatment of any physical complications, such as lymphedemas;
    • breast prostheses and surgical bras and replacements (see Prosthetic devices

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

30% coinsurance of our Plan allowance

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 gender reassignment
  • Any surgical services, other than emergent, which have not been precertified by the Plan
  • Any surgical services determined not medically necessary by the Plan
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service
All charges
Benefit Description : Oral and maxillofacial surgery High Option (You pay After calendar year deductible....)

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.

30% coinsurance of our Plan allowance

Not covered:

  • Oral implants and transplants
  • Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service.
All charges
Benefit Description : Organ/tissue transplantsHigh Option (You pay After calendar year deductible....)

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. See Other services under You need prior Plan approval for certain services on page 19.

  • Cornea
  • Heart
  • Heart/lung
  • Intestinal transplants
    • Isolated small intestine
    • Small intestine with the liver
    • Small intestine with multiple organs, such as the liver, stomach, and pancreas
  • Kidney
  • Kidney-pancreas
  • Liver
  • Lung: single/bilateral/lobar
  • Pancreas
  • Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Other services in Section 3 for prior authorization procedures.

  • Autologous tandem transplants for
    • AL Amyloidosis
    • Multiple myeloma (de novo and treated)
    • Recurrent germ cell tumors (including testicular cancer)

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below.

  • Allogeneic transplants for
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Acute myeloid leukemia
    • Advanced Myeloproliferative Disorders (MPDs)
    • Amyloidosis
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Hemoglobinopathy
    • Infantile malignant osteopetrosis
    • Kostmann’s syndrome
    • Leukocyte adhesion deficiencies
    • Marrow failure and related disorders (i.e., Fanconi’s, PNH, Pure Red Cell Aplasia)
    • Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
    • Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s syndrome, Sanfillippo’s syndrome, Maroteaux-Lamy syndrome variants)
    • Myelodysplasia/Myelodysplastic syndromes
    • Paroxysmal Nocturnal Hemoglobinuria
    • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
    • Severe combined immunodeficiency
    • Severe or very severe aplastic anemia
    • Sickle cell anemia
  • Autologous transplants for
    • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
    • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Amyloidosis
    • Breast Cancer
    • Epithelial Ovarian Cancer
    • Ewing’s sarcoma
    • Multiple myeloma
    • Medulloblastoma
    • Testicular, Mediastinal, Retroperitoneal, and ovarian germ cell tumors

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan. 

Refer to Other services in Section 3 for prior authorization procedures:

  • Allogeneic transplants for
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Acute myeloid leukemia
    • Advanced Myeloproliferative Disorders (MPDs)
    • Amyloidosis
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Hemoglobinopathy
    • Marrow failure and related disorders (i.e., Fanconi’s, PNH, Pure Red Cell Aplasia)
    • Myelodysplasia/Myelodysplastic syndromes
    • Paroxysmal Nocturnal Hemoglobinuria
    • Severe combined immunodeficiency
    • Severe or very severe aplastic anemia
  • Autologous transplants for
    • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
    • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Amyloidosis
    • Neuroblastoma

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of health approved clinical trial or a Plan-designated center of excellence if approved by the Plan’s medical director in accordance with the Plan’s protocols. 

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, x-rays and scans, and hospitalization related to treating the patient’s condition) if it is not provided by the clinical trial.  Section 9 has additional information on costs related to clinical trials.  We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

  • Allogeneic transplants for
    • Advanced Hodgkin’s lymphoma
    • Advanced non-Hodgkin’s lymphoma
    • Chronic inflammatory demyelination polyneuropathy (CIDP)
    • Sickle Cell anemia
  • Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning or RIC) for
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Advanced Hodgkin’s lymphoma
    • Advanced non-Hodgkin’s lymphoma
    • Breast cancer
    • Chronic lymphocytic leukemia
    • Chronic myelogenous leukemia
    • Colon cancer
    • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
    • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
    • Multiple myeloma
    • Myeloproliferative disorders (MSDs)
    • Myelodysplasia/Myelodysplastic Syndromes
    • Non-small cell lung cancer
    • Ovarian cancer
    • Prostate cancer
    • Renal cell carcinoma
    • Sarcomas
    • Sickle cell anemia
  • Autologous transplants for
    • Advanced Childhood kidney cancers
    • Advanced Ewing sarcoma
    • Aggressive non-Hodgkin lymphomas
    • Breast Cancer
    • Childhood rhabdomyosarcoma
    • Chronic myelogenous leukemia
    • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
    • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
    • Epithelial Ovarian Cancer
    • Mantle Cell (Non-Hodgkin lymphoma)

National Transplant Program (NTP)

Note: We cover related medical and hospital expenses of the donor when we cover the recipient.  We cover donor testing for the actual solid organ donor or up to four bone marrow/stem cell transplant donors in addition to the testing of family members.

30% coinsurance of our Plan allowance

Not covered:

  • Donor screening tests and donor search expenses, except as shown above
  • Implants of artificial organs
  • Transplants not listed as covered 
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service.
All charges
Benefit Description : AnesthesiaHigh Option (You pay After calendar year deductible....)

Professional services provided in –

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

30% coinsurance of our Plan allowance

Not covered:

  • Anesthesia related to Gender Reassignment Surgery
All charges



Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services (High Option)

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.
  • In this Section, unlike Sections 5(a) and 5(b), the calendar year deductible applies to only a few benefits. We added “(calendar year deductible applies)” when it applies. The calendar year deductible is: $750 per person ($1,500 per Self Plus One enrollment, or $1,500 per Self and Family enrollment).
  • 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 FOR 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.



Benefit Description : Inpatient hospitalHigh Option (You pay After calendar year deductible...)

Room and board, such as

  • Ward, semiprivate, or intensive care accommodations
  • General nursing care
  • 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.

30% coinsurance of our Plan allowance

Other hospital services and supplies, such as:

  • Operating, recovery, maternity, and other treatment rooms
  • Prescribed drugs and medications
  • Diagnostic laboratory tests and X-rays
  • Administration of blood and blood products
  • Blood or blood plasma, if not donated or replaced
  • Presurgical testing
  • 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
  • Hospitalization and anesthesia for dental procedures as determined medically necessary by a Plan physician for members under age five, severely disabled or with a medical condition requiring hospitalization for dental procedures.

30% coinsurance of our Plan allowance

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
  • The cost of securing the services of blood donors
  • Professional dental services
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service
All charges
Benefit Description : Outpatient hospital or ambulatory surgical centerHigh Option (You pay After calendar year deductible...)
  • Operating, recovery, and other treatment rooms
  • Prescribed drugs and medications
  • 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.

30% coinsurance of our Plan allowance

Not covered:

  • Blood and blood derivatives not replaced by the member
  • Professional dental services and procedures
  • Care and services from non-Plan providers unless precertification by the Plan prior to receiving the service
All charges
Benefit Description : Extended care benefits/Skilled nursing care facility benefitsHigh Option (You pay After calendar year deductible...)

Extended care benefit/Skilled nursing facility :

The Plan provides a comprehensive range of benefits up to 100 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan. All necessary services are covered including:

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

30% coinsurance of our Plan allowance

Not covered:

  • Custodial care
  • Rest cures
  • Domiciliary or convalescent care
  • Personal comfort items such as telephone, and television
  • Blood and blood derivatives not replaced by the member
  • Care and services from non-Plan providers unless precertification by the Plan prior to receiving services
All charges
Benefit Description : Hospice careHigh Option (You pay After calendar year deductible...)

A coordinated program of home and inpatient care under the direction of a Plan doctor for the patient who is in the terminal stages of illness with a life expectancy of six months or less that includes:

  • Palliative Care
  • Supportive physical, psychological, and psychosocial services

Note: Palliative care is treatment to control pain, relieve other symptoms and focus on the special needs of the patient.

30% coinsurance of our Plan allowance

Advance Care Planning

30% coinsurance of our Plan allowance

Not covered:

  • Independent nursing
  • Homemaker services   
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service
All charges
Benefit Description : AmbulanceHigh Option (You pay After calendar year deductible...)
Local professional ambulance service when medically appropriate$50 copayment per trip



Section 5(d). Emergency Services/Accidents (High Option)

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: $750 per person ($1,500 per Self Plus One enrollment, or $1,500 per Self and Family enrollment). The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
  • 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.



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:

  • If the situation is life threatening, call 911 or go to the nearest hospital.
  • If at all possible, call your primary care physician (PCP) or the After Hours Nurse Triage Program at the number on your Plan ID card.

Emergencies within our service area:

If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e.g., the 911 telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member should notify the Plan within 48 hours unless it is not reasonably possible to do so. It is your responsibility to ensure that the Plan has been timely notified.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If you are hospitalized in non-Plan facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition. The Plan will pay reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers. You must have any follow-up care recommended by non-Plan providers approved by the Plan and you must receive all follow-up care from Plan providers.

For urgent or emergency mental health or substance abuse services, call Optima Behavioral Health Services Inc., at 757-552-7174 or 800-648-8420. The Psychiatric Emergency Response Service is available 24 hours a day, seven days per week to respond to clinical psychiatric and substance abuse emergencies.

Emergencies outside our service area:

Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member should notify the Plan within 48 hours unless it is not reasonably possible to do so. It is your responsibility to ensure that the Plan has been timely notified.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If you are hospitalized in non-Plan facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.

You must have any follow-up care recommended by non-Plan providers approved by the Plan. You must receive all follow-up care from Plan providers.

With your authorization, the Plan will pay benefits directly to non-Plan providers of your emergency care upon receipt of their claims for covered services. Physicians should submit their claims on a HCFA 1500 claim form. If you are required to pay for the services, submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID card.

Payment will be sent to you (or the provider if you did not pay the bill), unless the claim is denied. If it is denied, you will receive notice of decision, including the reasons for the denial and the provisions of the contract on which denial was based. If you disagree with the Plan’s decision, you may request reconsideration in accordance with the disputed claims procedure.




Benefit Description : Emergency within our service areaHigh Option (You pay After calendar year deductible...)

Emergency care at a doctor’s office

$15 copayment per primary care physician office visit (No deductible)

$50 copayment per specialist office visit (No deductible)

Emergency care at an urgent care center

$50 copayment per visit (No deductible)

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

30% coinsurance of our Plan allowance

Benefit Description : Emergency outside our service areaHigh Option (You pay After calendar year deductible...)

Emergency care at a doctor’s office

$15 copayment per primary care physician office visit, no deductible

$50 copayment per specialist office visit, no deductible

Emergency care at an urgent care center

$50 copayment per visit, no deductible

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

30% coinsurance of our Plan allowance

Not covered:

  • Elective care or non-emergency care and follow-up care recommended by non-Plan providers that has not been approved by the Plan or provided by Plan providers
  • 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
Benefit Description : AmbulanceHigh Option (You pay After calendar year deductible...)

Professional ambulance service when medically appropriate

Note: See Section5(c) for non-emergency service.

$50 copayment each way



Section 5(e). Mental Health and Substance Use Disorder Benefits (High Option)

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: $750 per person ($1,500 per Self Plus One enrollment, or $1,500 per Self and Family enrollment). The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
  • 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.
  • We will provide medical review criteria or reasons for treatment plan denials to enrollees, members or providers upon request or as otherwise required.
  • 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.



Benefit Description : Professional servicesHigh Option (You pay After calendar year deductible... )

When part of a treatment plan we approve, we cover professional services by licensed professional mental health and substance misuse disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists.

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders.  Services include:

  • Diagnostic evaluation
  • Crisis intervention and stabilization for acute episodes
  • Medication evaluation and management  (pharmacotherapy)
  • Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
  • Treatment and counseling (including individual or group therapy visits)
  • Diagnosis and treatment of substance use disorders, including detoxification, treatment and counseling
  • Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
  • Electroconvulsive therapy

$15 copayment per office visit copay (No deductible)

30% coinsurance of our Plan allowance

Benefit Description : DiagnosticsHigh Option (You pay After calendar year deductible... )
  • Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment practitioner
  • Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility
  • Inpatient diagnostic tests provided and billed by a hospital or other covered facility
  • MRI, CT Scans and PET Scans

30% coinsurance of our Plan allowance

Benefit Description : Inpatient hospital or other covered facilityHigh Option (You pay After calendar year deductible... )

Inpatient services provided and billed by a hospital or other covered facility

  • Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services

30% coinsurance of our Plan allowance per admission

Benefit Description : Outpatient hospital or other covered facilityHigh Option (You pay After calendar year deductible... )

Outpatient services provided and billed by a hospital or other covered facility

  • Services in approved treatment programs, such as partial hospitalization, full-day hospitalization, or facility-based intensive outpatient treatment

30% coinsurance of our Plan allowance

Benefit Description : Not coveredHigh Option (You pay After calendar year deductible... )
  • Residential Treatment
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the services.

All charges



Section 5(f). Prescription Drug Benefits (High Option)

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.
  • 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.
  • Members must make sure their prescribers obtain prior approval/authorizations for certain prescription drugs and supplies before coverage applies.  Prior approval/authorizations must be renewed periodically.
  • Federal law prevents the pharmacy from accepting unused medications.
  • 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.



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

  • Who can write your prescription.  A licensed physician or dentist, and in states allowing it, licensed /certified providers with prescriptive authority prescribing within their scope of practice.
  • Where you can obtain them. You may fill the prescription at a Plan pharmacy, or a non-Plan pharmacy that has agreed to accept our reimbursement as payment in full. Specialty drugs must be filled through our Specialty mail order vendor, Proprium Pharmacy.  You may also use our mail order program for maintenance medications.
  • We use a closed formulary. That means the Plan includes coverage for a specific list of drugs and medications determined by our Pharmacy and Therapeutics Committee. Drugs that are not included on the Standard formulary will not be covered. Please use the following link to see a list of drugs on the Standard formulary: http://public.optimahealth.com/Lists/OptimaFormsLibrary/form-doc-drug-list-standard-formulary.pdf.   Your physician is responsible for obtaining precertification.  Optima’s Pharmacy and Therapeutics Committee places covered drugs into the following Tiers: 
    • Selected Generic (Tier 1): includes commonly prescribed generic drugs.  Other drugs may be included in Tier 1 if the Plan recognizes they show documented long-term decreases in illness.
    • Selected Brand & Other Generic (Tier 2) includes brand-name drugs, and some generic drugs with higher costs than Tier 1 generics, that are considered by the Plan to be standard therapy. 
    • Non-Selected Brand/Other (Tier 3) includes brand name drugs not included by the Plan on Tier 1 or Tier 2.  These may include single source brand name drugs that do not have a generic equivalent or a therapeutic equivalent.  Drugs on this tier may be higher in cost than equivalent drugs, or drugs determined to be no more effective than equivalent drugs on lower tiers.
    • Specialty Drugs (Tier 4)  includes Specialty Drugs that have unique uses and are generally prescribed for people with complex or ongoing medical conditions.  Specialty Drugs typically require special dosing, administration, and additional education and support from a health care professional.  
  • Coverage of Specialty Drugs:  Specialty Drugs are only available through Proprium Pharmacy at 757-553-3568 or 855-553-3568 (toll free).  Specialty Drugs include the following:
    • Medications that treat certain patient populations including those with rare diseases;
    • Medications that require close medical and pharmacy management and monitoring;
    • Medications that require special handling and/or storage;
    • Medications derived from biotechnology and/or blood derived drugs or small molecules; and
    • Medications that can be delivered via injection, infusion, inhalation, or oral administration. 

Your Specialty Drug will be delivered to your home address.  If you have a question or need to find out if your drug is considered a Specialty Drug please call Member Services at the number on Your Optima ID Card .  You can also log onto www.optimahealth.com/federal for a list of Specialty Drugs.

  • These are the dispensing limitations.  Prescription drugs dispensed at a Plan pharmacy will be dispensed for up to a 31-day supply. We will permit and apply a prorated daily cost sharing rate to prescription drugs for the purpose of synchronizing medications. Prescriptions will be dispensed by a Plan pharmacy for a partial supply if the prescribing provider or pharmacist determines the fill or refill to be in the best interest of the Member, and the Member requests or agrees to a partial supply.  You may receive up to a 90-day supply of a prescribed maintenance medication through our mail-order program or at one of our retail pharmacies. Specialty drugs are limited to a 31-day supply.  

You may use the Plan’s mail order prescription drug benefit for Tier 1, 2 or 3 drugs and purchase a 90 day supply of maintenance drugs, for two prescription drug copayments. If you have a question about the mail order prescription drug program, or if you want to find out if your prescription is available through the program, you may call OptumRx Home Delivery at 844-672-2307, 24 hours a day, 7 days a week. You may also write to OptumRx, P.O. Box 2975, Mission, KS 66201.   

If you are called to active duty, or in time of national or other emergency please call Member Services for assistance in obtaining a medium term supply of your prescription drugs. 

  • 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, or a higher costing generic, when a Federally-approved generic drug is available, and your physician has not specified Dispense as Written for the name brand drug, you have to pay the difference in cost between the name brand drug and the generic in addition to your copayment. The Plan limits the quantities of drugs you will receive for your copayment. Please read the information below to determine what you will receive for your prescription drug copay. If you have any questions about your prescription drug benefit please call Member Services.
  • 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 brand name is the name under which the manufacturer advertises and sells a drug. Under federal law, generic and brand name drugs must meet the same standards for safety, purity, strength, and effectiveness. A generic prescription costs you -and us- less than a brand name prescription.
  • When have to file a claim. Members will be reimbursed for outpatient prescription drugs obtained from other than a Plan-participating pharmacy (or a non-Plan pharmacy that has agreed to accept reimbursement as payment in full for their services at rates applicable to Plan participating pharmacies) when:
    • Ordered in connection with an out-of-area emergency
    • Ordered by a Plan provider for immediate use because of a medical necessity and because no Plan –participating pharmacy was open for business at the time
    • Reimbursement will be limited to a quantity sufficient to treat the acute phase of the illness.



Benefit Description : Covered medications and suppliesHigh Option (You Pay)

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 medications (including those administered during a non-covered admission or in a non-covered facility) that by Federal law of the United States require a physician's prescription for their purchase, except those listed as Not covered.

  • Rescue and maintenance inhalers
  • Insulin
  • Drugs for sexual dysfunction (limited to four pills per month)
  • Drugs to treat gender dysphoria
  • Intravenous fluids and medication for home use

Note: Injectable contraceptive drugs are covered under Family Planning Section 5(a).

Retail Pharmacy:

$5 copayment per Tier 1 Drug

$45 copayment per Tier 2 Drug

50% coinsurance per Tier 3 Drug

Mail Order (90 day supply of Maintenance Drugs):

$10 copayment per Tier 1 Drug

$90 copayment per Tier 2 Drug

50% coinsurance per Tier 3 Drug

Specialty Drugs are only available through Proprium Pharmacy (limited to a 31 day supply):

50% coinsurance per Tier 4 Specialty Drug

Diabetic supplies limited to:

  • Disposable needles and syringes for the administration of covered medications

Applicable copayment or coinsurance

  • Test strips, lancet devices and lancets
  • Blood glucose monitors and control solution

Nothing (No deductible)

  • Women's contraceptive drugs and devices, including the morning after pill
  • Tobacco eCessation medications

Note:  The above over-the-counter drugs and devices approved by the FDA require a written prescription by an approved plan provider.  Some restrictions apply.

Nothing (No deductible)

Preventive care medications to promote better health as recommended by ACA.

The following are covered:

  • Aspirin (81 mg) for men age 45-79 and women age 55-79 and women of childbearing age
  • Folic acid supplements for women of childbearing age 400 & 800 mcg
  • Liquid iron supplements for children age 0-2 years
  • Vitamin D supplements (prescription strength) (400 & 1000 units) for members 65 or older
  • Bowel Evacuant drugs
  • Tamoxifen and Raloxefin for women
  • Generic and over-the-counter tobacco cessation medications
  • Fluoride tablets, solution (not toothpaste, rinses) for children age 0-7

Note: Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a healthcare professional and filled by a network pharmacy. These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browserecommendations

Nothing (No deductible)

Not covered:

  • Drugs and supplies for cosmetic purposes
  • Drugs to enhance athletic performance
  • Fertility drugs
  • Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
  • Nonprescription medications
  • Vitamins, nutrients and food supplements even if a physician prescribes or administers them (except Vitamin D, as stated above)
  • Over-the-counter medications, except as noted above
  • Appetite suppressants or other weight management medications
  • Medical supplies such as dressings and antiseptics
  • Immunization agents, biological sera, blood or blood products

 

All charges




Section 5(g). Dental Benefits (High Option)

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
  • If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your FEHB Plan will be First/Primary payor of any Benefit payments and your FEDVIP Plan is secondary to your FEHB Plan. See Section 9 Coordinating benefits with other coverage.
  • Care must be received by Plan providers only.
  • The calendar year deductible is: $750 per person ($1,500 per Self Plus One enrollment, or $1,500 per Self and Family enrollment). The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
  • We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. See Section 5(c) for inpatient hospital benefits and coverage for hospitalization and anesthesia for dental procedures. We do not cover the dental procedure unless it is described below.
  • 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.



Benefit : Accidental injury benefitHigh Option (You Pay After calendar year deductible...)

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth.  The need for these services must result from an accidental injury.

30% coinsurance of our Plan allowance

Benefit : Dental benefitsHigh Option (You Pay After calendar year deductible...)

We have no other dental benefits.

All charges



Section 5(h). Wellness and Other Special Features (High Option)

TermDefinition

Flexible benefits option

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

  • We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue.
  • Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
  • By approving an alternative benefit, we do not guarantee you will get it in the future.
  • The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
  • If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
  • Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8).

24 hour nurse line

For any of your health concerns, 24 hours a day, 7 days a week, you may call and talk with a registered nurse who will discuss treatment options and answer your health questions. When you call the Nurse Triage Program have your Plan ID card handy, and describe your medical situation in as much detail as possible. Please remember that the Nurse Triage Program professional cannot diagnose medical conditions or write prescriptions. You can call the 24 Hours Nurse Triage Program at 757-552-7250 or 800-394-2237.

Services for deaf and hearing impaired

TDD number: 757-552-7120 or 800-225-7784

High risk pregnancies

A Plan Care Manager will assist with a treatment plan prescribed by your OB/GYN physician.

Wellness Tools - My Life My Plan Connection

Through a partnership with WebMD, we offer our members flexible programs, expert guidance, and inspiration to take charge of their own health—whether they are continuing healthy behaviors, or making a change to improve their health. It all begins when the member completes a Personal Health Assessment—and creates the foundation for their Health Record and coaching program. Our health-coaching partner, WebMD, offers a comprehensive online activities tool, known as the Digital Health Assistant (DHA). The DHA delivers a personalized, interactive, and motivational experience to help members take action and sustain healthy behaviors in a fun way.




HDHP Table of Contents (HDHP)

(Page numbers solely appear in the printed brochure)




Section 5. High Deductible Health Plan Overview (HDHP)

This Plan offers a High Deductible Health Plan (HDHP). The HDHP benefit package is described in this Section.  Make sure that you review the benefits carefully.

HDHP Section 5, which describes the HDHP benefits, is divided into subsections.  Please read Important things you should keep in mind about these benefits at the beginning of each subsection.  Also read the general exclusions in Section 6; they apply to benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about HDHP benefits, contact us at 757-552-7550 or 800-206-1060 or on our website at www.optimahealth.com/federal.

Our HDHP option provides traditional healthcare coverage 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, we establish either a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) for you. We automatically pass through a portion of the total health Plan premium to your HSA or credit an equal amount to your HRA based upon your eligibility on a monthly basis.

With this Plan, in-network preventive care is covered in full. As you receive other non-preventive medical care, you must meet the Plan’s deductible before we pay benefits according to the benefits described on page 74. 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 medical and dental preventive care; traditional medical coverage healthcare that is subject to the deductible; savings; catastrophic protection for out-of-pocket expenses; and health education resources and account management tools, such as online, interactive health and benefits information tools to help you make more informed health decisions.




TermDefinition
  • Preventive care

The Plan covers preventive care services, such as periodic health evaluations (e.g., routine physicals), screening services (e.g., routine mammograms), well-child care, routine child and adult immunizations, and preventive prescription drugs, such as tobacco cessation medications. These services are covered at 100% if you use a network provider. The services are described in Section 5, Preventive Care. You do not have to meet the deductible before using these services. This does not reduce your HRA nor do you need to use your HSA for in-network preventive care.

Traditional medical coverage 

After you have paid the Plan’s deductible ($2,000 for Self Only enrollment, $4,000 for Self Plus One enrollment and $4,000 for Self and Family enrollment), we pay benefits under Traditional medical coverage described in Section 5. The Plan typically pays 80% for in-network care.

Covered services include:

  • Medical services and supplies provided by physicians and other healthcare professionals
  • Surgical and anesthesia services provided by physicians and other healthcare professionals
  • Hospital services; other facility or ambulance services
  • Emergency services/accidents
  • Mental health and substance use benefits
  • Prescription drug benefits
  • Special features

Savings

Health Savings Accounts or Health Reimbursement Arrangements provide a means to help you pay out-of-pocket expenses (see page 65 for more details).

Health Savings Accounts (HSAs)

By law, HSAs are available to members who are not enrolled in Medicare, cannot be claimed as a dependent on someone else’s tax return, have not received VA (except for service-connected disability) and/or Indian Health Services (IHS) benefits within the last three months, or do not have other health insurance coverage other than another High Deductible Health Plan. In 2022, for each month you are eligible for a HSA premium pass through, we will contribute to your HSA $75.00 per month for a Self Only enrollment or $150.00 per month for a Self Plus One or 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 $3,650 for Self Only enrollment and $7,300 for Self Plus One or Self and Family enrollment for 2022. The IRS allows you to contribute up to $1,000 in catch-up contributions for 2022, if you are age 55 or older. See maximum contribution information on page 66. You can use funds in your HSA to help pay your health plan deductible. You own your HSA, so the funds can go with you if you change plans or employment.

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 qualified 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:

  • Health Equity will provide a debit card and is the custodian for the HSA accounts.
  • You may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions (i.e., Employee Express, MyPay, etc.)
  • Your HSA earns tax-free interest or any investment gains through a choice of voluntary investment options.
  • 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.) A link to this publication can also be found at www.optimahealth.com/federal.
  • 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 Healthcare Flexible Spending Account (HCFSA): If you are enrolled in this HDHP with a Health Savings Account (HSA), and start or become covered by a Healthcare Flexible Spending Account (HCFSA) (such as FSAFEDS offers – see Section 11), this HDHP cannot continue to contribute to your HSA. Similarly, you cannot contribute to an HSA if your spouse enrolls in an HCFSA. Instead, when you inform us of your coverage in an HCFSA, we will establish an HRA for you.

Health Reimbursement Arrangements (HRA)

If you are not eligible for a HSA, for example you are enrolled in Medicare, Tricare or have another health plan, we will administer and provide an HRA instead. You must notify us that you are ineligible for an HSA. If we determine that you are ineligible for an HSA, we will notify you by letter and provide an HRA for you.

In 2022, we will give you an HRA credit of $900 per year for a Self Only enrollment, $1,800 for a Self Plus One enrollment and $1,800 per year for a Self and Family enrollment. These amounts will be credited on a monthly basis and prorated if you join the health plan or become ineligible for an HSA within the plan year. Your HRA will be used to help pay for covered services that apply towards your health plan deductible.

HRA features include:

  • For our HDHP option, the HRA is administered by Health Equity.
  • HRA credit (prorated from your effective date to the end of the plan year) is available on a monthly basis.
  • Tax-free credit can be used to pay for qualified medical or prescription expenses within your deductible for you and any individuals covered by this HDHP.
  • Unused credits will not carryover from year to year.
  • HRA credit does not earn interest.
  • HRA credit is forfeited if you leave the FEHB Program or switch health insurance plans.
  • An HRA does not affect your ability to participate in an FSAFEDS Healthcare Flexible Spending Account (HCFSA). However, you must meet FSAFEDS eligibility requirements.

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 $6,000 for Self Only, $12,000 for Self Plus One or $12,000 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 expenses in excess of the Plan’s allowable amount or benefit maximum). Refer to Section 4 Your Catastrophic Protection Out-of-Pocket Maximum and HDHP Section 5 Traditional Medical Coverage Subject to the Deductible for more details.

Health education resources and account management tools

HDHP Section 5(i) describes the health education resources and account management tools available to you to help you manage your healthcare and your healthcare dollars.




Section 5. Savings - HSAs and HRAs (HDHP)

Feature ComparisonHealth Savings Account (HSA)Health Reimbursement Arrangement (HRA) Provided when you are ineligible for a HSA

Administrator

The Plan will establish an HSA for you with Health Equity (an administrator, trustee or custodian as defined by Federal tax code and approved by IRS).

Health Equity
15 West Scenic Pointe Dr., Suite 100
Draper, UT 84020
866-346-5800
www.healthequity.com

Health Equity is the HRA fiduciary for this Plan.

Health Equity
15 West Scenic Pointe Dr., Suite 100
Draper, UT 84020
866-346-5800
www.healthequity.com

Fees

There is no HSA set-up fee.

The administrative fee is covered in the premium while the member is covered under the HDHP.

Members will be subject to the administrative fee if they are enrolled but no longer eligible for contributions into the HSA and/or are enrolled in the HSA.

None

Eligibility

You must:

  • Enroll in this High Deductible Health Plan (HDHP).
  • Not currently receiving VA benefits or services unless they are due to a service-connected disability.
  • Have no other health insurance coverage (does not apply to another HDHP plan, specific injury, accident, disability, dental, vision, or long term care coverage).
  • Not be enrolled in Medicare.
  • Not be enrolled in Tricare.
  • Not be claimed as a dependent on someone else’s tax return.
  • Not have received Indian Health Service (IHS) benefits in the last three months.

You must enroll in this HDHP.

If you enroll in a HDHP during open season or in the month of January, your HRA will be funded on a monthly basis after premium has been received. If you enroll outside of Open Season or other than the month of January, the funding of your HRA will be prorated based on each full month in which you are enrolled in a HDHP.

Funding

If you are eligible for HSA contributions, a portion of your monthly health plan premium is deposited to your HSA each month.
Premium pass through contributions are based on the effective date of your enrollment in the HDHP.

Note: If your effective date in the HDHP is after the 1st of the month, the earliest your HSA will be established is the 1st of the following month.

In addition, you may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions (i.e., Employee Express, MyPay, etc.).
You may contribute to your HSA by submitting a contribution coupon or setting up an electronic funds transfer from your checking or savings account up to the maximum allowed. The deadline for HSA contributions is April 15 following the year for which contributions are made. When making contributions for a previous tax year, use the Tax Year Designation Change for Contributions to HSA form. You can obtain additional HSA forms by logging into the Optima Health website at www.optimahealth.com.

Eligibility for the annual credit will be determined on the first day of the month and will be prorated for length of enrollment. HRA contributions, a portion of your monthly health plan premium is deposited to your HRA each month.

  • Self Only enrollment

For 2022, a monthly premium pass through of $75.00 will be made by the HDHP directly into your HSA each month.

For 2022, a monthly premium pass through of $75.00 will be made by the HDHP directly into your HRA each month.

  • Self Plus One enrollment

For 2022, a monthly premium pass through of $150.00 will be made by the HDHP directly into your HSA each month.

For 2022, a monthly premium pass through of $150.00 will be made by the HDHP directly into your HRA each month.

  • Self and Family enrollment

For 2022, a monthly premium pass through of $150.00 will be made by the HDHP directly into your HSA each month.

For 2022, a monthly premium pass through of $150.00 will be made by the HDHP directly into your HRA each month.

Contributions/credits

The maximum that can be contributed to your HSA is an annual combination of the HDHP premium pass through and enrollee contribution funds, which when combined, do not exceed the annual statutory dollar maximum, which is $3,650 for Self Only coverage, $7,300 for Self Plus One coverage and $7,300 for Self and Family coverage for 2022.  If you are age 55 or older, the IRS permits you to make additional “catch-up” contributions to your HSA. The allowable catch-up contribution is $1,000. Contributions must stop once an individual is enrolled in Medicare. Additional details are available on the U.S. Department of Treasury website at  www.treasury.gov/resource-center/faqs/Taxes/ Pages/Health-Savings-Accounts.aspx

If you enroll during Open Season, you are eligible to fund your account up to the maximum contribution limit set by the IRS.
Note: Annual premium pass through contributions will be forfeited if you do not open an HSA by 12/31 of that plan year.

You are eligible to fund your account up to the maximum contribution limit set by the IRS, even if you have partial year coverage as long as you maintain your HDHP enrollment for 12 months following the last month of the year of your first year of eligibility. To determine the amount you may contribute, take the IRS limit and subtract the amount the Plan will contribute to your account for the year.

If you do not meet the 12 month requirement, the maximum contribution amount is reduced by 1/12 for any month you were ineligible to contribute to an HSA. If you exceed the maximum contribution amount, a portion of your tax reduction is lost and a 10% penalty is imposed. There is an exception for death or disability.

You may rollover funds you have in other HSAs to this HDHP HSA (rollover funds do not affect your annual maximum contribution under this HDHP).

You are able to make a one-time, tax-free, irrevocable, trustee-to-trustee rollover from your IRA to your HSA. The amount that may be rolled over from an IRA to an HSA is limited to the amount of your maximum annual HSA contribution limit for the year in which the rollover is made. Any amount you rollover from an IRA will count towards your annual HSA contribution limit so you will need to make sure that the amount you transfer from your IRA combined with your other HSA contributions for the year do not exceed the annual HSA contribution limit.

HSAs earn tax-free interest (does not affect your annual maximum contribution).

Catch-up contribution discussed on page 70.

HRA credits will be made monthly and are subject to proration based on the effective date of enrollment. The HRA does not earn interest. You cannot contribute to the HRA.

  • Self Only enrollment

You may make a voluntary annual maximum contribution of $2,750.

Note: Additional deposits by the Plan into your HSA can impact the amount you can contribute for the year. Please review IRS guidelines or discuss with your accountant.

You cannot contribute to the HRA.

  • Self Plus One enrollment

You may make a voluntary annual maximum contribution of $5,500.

Note: Additional deposits by the Plan into your HSA can impact the amount you can contribute for the year. Please review IRS guidelines or discuss with your accountant.

You cannot contribute to the HRA.

  • Self and Family enrollment

You may make a voluntary annual maximum contribution of $5,500.

Note: Additional deposits by the Plan into your HSA can impact the amount you can contribute for the year. Please review IRS guidelines or discuss with your accountant.

You cannot contribute to the HRA.

Access Funds

You can access your HSA by the following methods:

  • Debit Card – The Health Equity HSA Visa debit card  must be activated in order to have access to HSA Funds, customer service and online information.
  • The online employee portal.  From the portal, you will be linked to the Health Equity.  If there is money available in your HSS, claims may be paid to a provider from the HSA as claims are submitted to Optima Health.
  • Direct Deposit for HSA Reimbursement - Reimbursements can now be sent electronically to personal checking or savings accounts. You can access this feature from the employee portal.

For covered medical expenses under the deductible of your HDHP, claims will be paid automatically by your HRA when claims are submitted to Optima Health, if there is money available in your HRA.

You may also be reimbursed from the HRA for prescriptions covered within the deductible period, if there is money available in your HRA.

Distributions/withdrawals

  • Medical

You can pay the out-of-pocket expenses for yourself, your spouse or your dependents (even if they are not covered by the HDHP) from the funds available in your HSA.

Your HSA is established the first of the month following the effective date of your enrollment in this HDHP. For most Federal enrollees (those not paid on a monthly basis), the HDHP becomes effective the first pay period in January 2022. If the HDHP is effective on a date other than the first of the month, the earliest date medical expenses will be allowable is the first of the next month.

If you incur a medical expense between your HDHP effective date but before your HSA is effective, you will not be able to use your HSA to reimburse yourself for those expenses.

Note: Plan contributions are typically deposited around the middle of each month.

See IRS Publication 502 for a list of eligible medical expenses.

You can pay the out-of-pocket expenses for qualified medical expenses for individuals covered under the HDHP.

  • Non-medical

If you are under age 65, withdrawal of funds for non-medical expenses will create a 20% income tax penalty in addition to any other income taxes you may owe on the withdrawn funds.

When you turn age 65, distributions can be used for any reason without being subject to the 20% penalty, however they will be subject to ordinary income tax.

Not applicable – distributions will not be made for anything other than qualified medical and prescription expenses within the deductible.

Availability of funds

Funds are not available for withdrawal until all the following steps are completed:

  • Your enrollment in this HDHP is effective (effective date is determined by your agency in accord with the event permitting the enrollment change).
  • The HDHP receives record of your enrollment and initially establishes your HSA account with the fiduciary by providing information it must furnish and by contributing the minimum amount required to establish an HSA.
  • The fiduciary sends you HSA paperwork for you to complete and the fiduciary receives the completed paperwork back from you.

  • Your enrollment in this HDHP is effective (effective date is determined by your agency in accord with the event permitting the enrollment change).
  • A monthly amount will be deposited into your HRA, based on your enrollment tier.

Account owner

FEHB enrollee

Optima Health

Portable

You can take this account with you when you change plans, separate or retire.

If you do not enroll in another HDHP, you can no longer contribute to your HSA.

If you retire and remain in this HDHP, you may continue to use and accumulate credits in your HRA.

If you terminate employment or change health plans, only eligible expenses incurred while covered under the HDHP will be eligible for reimbursement subject to timely filing requirements. Unused funds are forfeited.

Annual rollover

Yes, accumulates without a maximum cap.

No.




TermDefinition

If you have a HSA

  • Contributions

All contributions are aggregated and cannot exceed the maximum contribution amount set by the IRS. You may contribute your own money to your account through payroll deductions, or through Electronic Fund Transfer deposits that are withdrawn from your personal bank accounts, or you may make lump sum contributions at any time, in any amount not to exceed an annual maximum limit. If you contribute, you can claim the total amount you contributed for the year as a tax deduction when you file your income taxes. Your own HSA contributions are either tax-deductible or pre-tax (if made by payroll deduction). You receive tax advantages in any case. To determine the amount you may contribute, subtract the amount the Plan will contribute to your account for the year from the maximum contribution amount set by the IRS. You have until April 15 of the following year to make HSA contributions for the current year.

If you newly enroll in a HDHP during Open Season and your effective date is after January 1st or you otherwise have partial year coverage, you are eligible to fund your account up to the maximum contribution limit set by the IRS as long as you maintain your HDHP enrollment for 12 months following the last month of the year of your first year of eligibility. If you do not meet this requirement, a portion of your tax reduction is lost and a 10% penalty is imposed. There is an exception for death or disability.

  • Catch-up contributions

If you are age 55 or older, the IRS permits you to make additional “catch-up” contributions to your HSA. The allowable catch-up contribution is $1,000. Contributions must stop once an individual is enrolled in Medicare. Additional details are available on the U.S. Department of Treasury website at www.treasury.gov/resource-center/faqs/Taxes/Pages/Health-Savings-Accounts.aspx.

  • Investment Options

Participation in voluntary investment options are entirely optional and Health Equity will not be acting in the capacity of a registered investment advisor for the HSA.

Account holders who exceed the minimum required balance of $2,000 in their HSA cash account, will have a number of different investment options to choose from in 2022 that will be offered by different organizations that have been selected by Health Equity in these investment options may fluctuate up or down and will not be insured by the FDIC or other government agencies.

Health Equity will make available HSA investment options to account holders who exceed the minimum required balance of $2,000 in their HSA cash account. (Investment options are subject to change).

  • If you die

If you have not named a beneficiary and you are married, your HSA becomes your spouse’s; otherwise, your HSA becomes part of your taxable estate.

  • Qualified expenses

You can pay for “qualified medical expenses,” as defined by IRS Code 213(d).  These expenses include, but are not limited to, medical plan deductibles, diagnostic services covered by your plan, long-term care premiums, health insurance premiums if you are receiving Federal unemployment compensation, physician prescribed over-the-counter drugs, LASIK surgery, and some nursing services.

When you enroll in Medicare, you can use the account to pay Medicare premiums or to purchase health insurance other than a Medigap policy. You may not, however, continue to make contributions to your HSA once you are enrolled in Medicare.

For a detailed list of IRS-allowable expenses, request a copy of IRS Publication 502 by calling 800-829-3676, or visit the IRS website at www.irs.gov and click on “Forms and Publications.” Note: Although physician prescribed over-the-counter drugs are not listed in the publication, they are reimbursable from your HSA. Also, insurance premiums are reimbursable under limited circumstances.

  • Non-qualified expenses

You may withdraw money from your HSA for items other than qualified health expenses, but it will be subject to income tax and if you are under 65 years old, an additional 20% penalty tax on the amount withdrawn.

  • Tracking your HSA balance

You can view account activity such as the “premium pass through,” withdrawals, and interest earned on your account, as well as account balances online on the MyOptima portal. You can also request a paper monthly activity statement at an additional charge - $1.00 per month.

  • Minimum reimbursements from your HSA

There is no minimum withdrawal or distribution amount.

If you have a HRA

  • Why a HRA is established

If you don't qualify for an HSA when you enroll in this HDHP, or later become ineligible for an HSA, we will establish an HRA for you. If you are enrolled in Medicare, you are ineligible for an HSA and we will establish an HRA for you. You must tell us if you are or become ineligible to contribute to an HSA.

  • How a HRA differs

Please review the chart beginning on page 65 which details the differences between an HRA and HSA. The major differences are:

  • you cannot make contributions to an HRA
  • funds are forfeited if you leave the HDHP
  • an HRA does not earn interest
  • HRAs can only pay for qualified medical and prescription expenses which apply to your deductible for individuals covered by the HDHP.  FEHB law does not permit qualified medical expenses to include services, drugs or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest.



Section 5. Preventive Care (HDHP)

Important things you should keep in mind about these benefits:

  • Preventive care services listed in this Section are not subject to the deductible.
  • You must use providers that are part of our network.
  • For all other covered expenses, please see Section 5 – Traditional Medical Coverage Subject to the Deductible.



Preventive Care : Preventive care, adultHDHP Option (You pay )

Routine physical every year. The following preventive services are covered at the time interval recommended at each of the links below:

  • Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules
  • Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org
  • Individual counseling on prevention and reducing health risks
  • Well woman care such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of Well Women preventive care services please visit the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/
  • Routine mammogram – covered for women:
  • Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.

Nothing

Not covered:

  • Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel.
  • Immunizations, boosters, and medications for travel or work-related expenses.
  • Care and services from non-Plan providers unless pre-authorized by the Plan prior to receiving this service.

All charges

Preventive Care : Preventive care, childrenHDHP Option (You pay )

• Well-child visits, examinations, and immunizations other preventive recommended services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org


• Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html


• You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

Nothing

Not covered:

  • Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel.
  • Immunizations, boosters, and medications for travel or work-related expenses.
  • Care and services from non-Plan providers unless pre-authorized by the Plan prior to receiving this service.

All charges




Section 5. Traditional Medical Coverage Subject to the Deductible

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.
  • In-network preventive care is covered at 100% (see page 72) and is not subject to the calendar year deductible.
  • The deductible is $2,000 per person ($4,000 per Self Plus One enrollment, or $4,000 per Self and Family enrollment). The family deductible can be satisfied by one or more family members. The deductible applies to almost all benefits under Traditional medical coverage. You must pay your deductible before your Traditional medical coverage may begin.
  • Under Traditional medical coverage, you are responsible for your coinsurance and copayments for covered expenses.
  • When you use network providers, you are protected by an annual catastrophic maximum on out-of-pocket expenses for covered services. After your coinsurance, copayments and deductibles total $6,000 per person, $12,000 per Self Plus One enrollment or $12,000 per 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, Balance-billed charges, Healthcare charges this plan does not cover, Precertification penalties, or Premiums).
  • In-network benefits apply only when you use a network provider. You must use a network provider, except in emergent situations. 
  • 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.



Benefit Description : Deductible before Traditional medical coverage beginsHDHP Option (You pay )

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 $2,000 per person, $4,000 per Self Plus One enrollment or $4,000 per Self and Family enrollment.

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

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




Section 5(a). Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals (HDHP)

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.
  • The deductible is $2,000 for Self Only enrollment, $4,000 per Self Plus One enrollment, or $4,000 for a Self and Family enrollment). each calendar year. The Self Plus One and Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this Section unless we indicate differently.
  • After you have satisfied your deductible, coverage begins for traditional medical services.
  • Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions.
  • 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.



Benefit Description : Diagnostic and treatment servicesHDHP Option (You pay After the calendar year deductible…)

Professional services of physicians

  • In physician’s office
  • In an urgent care center
  • During a hospital stay
  • In a skilled nursing facility
  • Office medical consultations
  • Second surgical opinion
  • Advance care planning

20% coinsurance of our Plan allowance 

Benefit Description : Telehealth ServicesHDHP Option (You pay After the calendar year deductible…)
  • MDLIVE Virtual Office Visit

How to get started?

  • Sign in to www.optimahealth.com and select Access MDLIVE, or call 866-648-3638.
  • Have your Optima Health member ID number available to register. Please note that you’ll need to create an account for each covered member of your family over the age of two.
  • When you want to see a doctor, you can go online to request immediate access to a provider on-call via phone or schedule a time at your convenience. You can also get connected by calling 866-648-3638.

$10 copayment

Benefit Description : Lab, X-ray and other diagnostic testsHDHP Option (You pay After the calendar year deductible…)

Tests, such as:

  • Blood tests
  • Urinalysis
  • Non-routine pap test
  • Pathology
  • X-rays
  • Non-routine mammogram
  • CT Scans/MRI
  • Ultrasound
  • Electrocardiogram and EEG

20% coinsurance of our Plan allowance

Benefit Description : Maternity careHDHP Option (You pay After the calendar year deductible…)

Complete maternity (obstetrical) care, such as:

  • Screening for gestational diabetes for pregnant women
  • Breastfeeding support, supplies and counseling for each birth

Nothing (No deductible)

  • Prenatal care
  • Delivery
  • Postnatal care

20% coinsurance of our Plan allowance

Note: Here are some things to keep in mind:

  • You do not need to precertify your vaginal delivery; see page 18 for other circumstances, such as extended stays for you or your baby.
  • You may remain in the hospital up to 48 hours after a vaginal 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 Plus One or a Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
  • We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
  • Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

Note: When a newborn requires definitive treatment during or after the mother’s confinement, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

20% coinsurance of our Plan allowance

Not covered:

  • Routine care and services for pregnancy outside the Plan’s service area
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service

All charges

Benefit Description : Family planningHDHP Option (You pay After the calendar year deductible…)

A range of voluntary family planning services, limited to:

  • Voluntary sterilization - limited to vasectomies and tubal ligations (See Section 5(b), Surgical Procedures)
  • Surgically implanted contraceptives
  • Injectable contraceptive drugs (such as Depo provera)
  • Intrauterine devices (IUDs)
  • Diaphragms

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

Nothing (No deductible)

Contraceptive counseling on an annual basis

Note: We cover oral contraceptives under the prescription drug benefit.    *Generic oral contraceptives are eligible for 100 percent coverage and no cost share to members. Brand name oral contraceptives will be covered based on the plan’s formulary and the appropriate Copayment or Coinsurance will apply based on the drug tier. Please visit www.optimahealth.com to determine member cost share for brand name oral contraceptives.

Nothing (No deductible)

Not covered:

  • Reversal of voluntary surgical sterilization

  • Genetic testing and counseling that is determined to be not medically necessary

  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service

All charges

Benefit Description : Infertility services HDHP Option (You pay After the calendar year deductible…)

Diagnosis and treatment of infertility 

All charges

Not covered:

  • Assisted reproductive technology (ART) procedures, such as:
    • Artificial insemination (AI)
    • Intravaginal insemination (IVI)
    • Intracervical insemination
    • (ICI)Intrauterine insemination (IUI)
    • In vitro fertilization (IVF)
    • Embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
    • Services and supplies related to ART procedures
  • Endometrial biopsies
  • Semen analysis
  • Hysterosaloingography
  • Sims-Huhner Test (smear)
  • Diagnostic laparoscopy
  • Cost of donor sperm
  • Cost of donor egg
  • Fertility drugs
  • Reproductive material storage
  • Infertility services after voluntary sterilization

All charges

Benefit Description : Allergy careHDHP Option (You pay After the calendar year deductible…)
  • Testing and treatment
  • Allergy injections
  • Allergy serum

20% coinsurance of our Plan allowance

Not covered:

  • Provocative food testing and sublingual allergy desensitization
  • Food allergy ingestion testing
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service

All charges

Benefit Description : Treatment therapiesHDHP Option (You pay After the calendar year deductible…)
  • 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 87.

  • Respiratory and inhalation therapy
  • Cardiac rehabilitation following qualifying event/condition is provided for up to 90 consecutive days from the start of rehabilitation.
  • 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 only cover GHT when we precertify the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to precertify GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Other Services under You Need Prior Plan Approval for Certain Services on page 19.

20% coinsurance of our Plan allowance

Applied Behavior Analysis (ABA) - Members with autism spectrum disorder

Covered Services include “diagnosis” and “treatment” of Autism Spectrum Disorder.

“Autism Spectrum Disorder” means any pervasive developmental disorder, including (i) autistic disorder, (ii) Asperger's Syndrome, (iii) Rett syndrome, (iv) childhood disintegrative disorder, or (v) Pervasive Developmental Disorder – Not Otherwise Specified, as defined in the most recent edition of The Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association.

“Diagnosis of autism spectrum disorder” means medically necessary assessments, evaluations, or tests to diagnose whether an individual has an autism spectrum disorder.

“Treatment for autism spectrum disorder” shall be identified in a treatment plan and included the following care prescribed or ordered for an individual diagnosed with autism spectrum disorder by a licensed physician or a licensed psychologist who determines the care to be medically necessary: (i) behavioral health treatment, (ii) pharmacy care, (iii) psychiatric care, (iv) psychological care, (v) therapeutic care, and (vi) applied behavioral analysis when provided or supervised by a board certified behavioral analyst licensed by the Board of Medicine. No limit on visits.

“Applied behavioral analysis” means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior. 

20% coinsurance of our Plan allowance

Early Intervention Services are covered for children from birth to age three for medically necessary services limited to:

  • speech, language, occupational and physical therapy
  • assistive technology services and devices

Note: Covered services are provided to enhance functional ability without effecting a cure. Department of Mental Health, Mental Retardation, and Substance Abuse Services must certify dependents as eligible for services under Part H of the Individuals with Disabilities Act.

Note: Precertifcation is required.

20% coinsurance of our Plan allowance

Benefit Description : Physical and occupational therapies HDHP Option (You pay After the calendar year deductible…)
  • Qualified physical therapists
  • Occupational therapists

Coverage will include 30 rehabilitative combined physical therapy and occupational therapy visits per year and 30 habilitative combined physical therapy and occupational therapy visits per year.

Note: Precertification is required. We only cover therapy when a physician:

  • orders the care;
  • identifies the specific professional skills the patient requires and the medical necessity for skilled services; and
  • indicates the length of time the services are needed.

20% coinsurance of our Plan allowance

Not covered:

  • Long-term rehabilitative therapy
  • Therapies available in a school program or available through state and local funding, including sign language therapies
  • Recreation therapies, including art, dance, or music therapies
  • Sleep therapies
  • Exercise programs, or equine therapies
  • Driver evaluations as part of occupational therapy
  • Driver training
  • Functional capacity testing needed to return to work
  • Any service or supply, unless provided in accordance with a specific treatment plan pre-authorized by the Plan
  • Therapy which is primarily educational in nature, special education, or sign language
  • Work-hardening programs
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service

All charges

Benefit Description : Speech therapy HDHP Option (You pay After the calendar year deductible…)

Up to 30 rehabilitative speech therapy visits per year, and up to 30 habilitative speech therapy visits per year.

Note: Precertification is required.

20% coinsurance of our Plan allowance

Benefit Description : Hearing services (testing, treatment, and supplies)HDHP Option (You pay After the calendar year deductible…)
  • For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist

Note: For routine hearing screening performed during a child’s preventive care visit, see Section 5(a) Preventive care, children.

20% coinsurance of our Plan allowance

Benefit Description : Vision services (testing, treatment, and supplies)HDHP Option (You pay After the calendar year deductible…)

Preventive vision care and services are administered by EyeMed Vision Care. The following services are covered once every 12 months:

  • Annual eye refraction including care history, visual acuity test for glasses and written lens prescription.
  • Screening tests for diseases or abnormalities, including glaucoma and cataracts.

Note: You should select a EyeMed Vision Care provider and call him or her directly to schedule an appointment. If you need help or a current list of participating providers, call EyeMed Vision Care at 866-939-3633 or visit www.optimahealth.com. You may receive an eye exam from a non-Plan provider and receive a $30 reimbursement.

Nothing (No deductible)

  • One pair of eyeglasses or contact lenses (up to $200 allowance) to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts). Please note that New technology, intraocular lens are excluded from coverage.

20% coinsurance of our Plan allowance

  • Eye exam to determine the need for vision correction for children up to age 22 (see Preventive care, children)

Nothing (No deductible)

Not covered:

  • Eyeglasses or contact lenses
  • Eye exercises and orthoptics
  • Radial keratotomy and other refractive surgery
  • Any eye examination, or any corrective eyeware required by an employer as a condition as employment
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service

All charges

Benefit Description : Foot care HDHP Option (You pay After the calendar year deductible…)

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

20% coinsurance of our Plan allowance

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)
  • Foot orthotics of any kind including customized or non-customized shoes, boots, and inserts, except as medically necessary and approved by the Plan for members with diabetes
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service

All charges

Benefit Description : Orthopedic and prosthetic devices HDHP Option (You pay After the calendar year deductible…)
  • Artificial limbs and eyes
  • Prosthetic sleeve or sock
  • Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
  • Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
  • Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants
  • Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy.
  • Lenses following cataract removal
  • Repair and replacement

Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b) Surgical Procedures. For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services Provided by a Hospital or Other Facility, and Ambulance Services.

20% coinsurance of our Plan allowance

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
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service

All charges

Benefit Description : Durable medical equipment (DME)HDHP Option (You pay After the calendar year deductible…)

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include:

  • Oxygen
  • Dialysis equipment
  • Hospital beds
  • Standard non-motorized wheelchairs
  • Crutches
  • Walkers
  • Colostomy, iliostomy, and tracheostomy supplies
  • Suction and urinary catheters

Note: When 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.

20% coinsurance of our Plan allowance

  • Diabetic Treatment:
    • Precertification is required for insulin pumps and pump infusion sets and supplies. Coverage includes benefits for FDA-approved equipment, supplies, and in-person outpatient self-management training and education—including medical nutrition therapy—for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes, and non-insulin-using diabetes if prescribed by a healthcare professional legally authorized to prescribe such items.
    • Insulin pumps, pump infusion sets and supplies, testing supplies (test strips, lancets, lancet devices, blood glucose monitors, and control solution), and outpatient self-management training and education and nutritional therapy are covered under the Plan’s medical benefits.
    • Insulin, needles, and syringes are covered under the Plan’s pharmacy benefits.

      To arrange for prescribed supplies to be delivered to their home, members may call one of the following providers, who are authorized to provide members who have diabetes with a new meter every 24 months at no cost to the member. Only these vendors can issue free meters:

      Home Care Delivered at 800-867-4412; or
      EdgePark Medical Supplies at 888-394-5375.

      Note:  Members may purchase covered diabetic testing supplies (not meters) from other sources and then submit receipts to have these costs applied to their plan.

20% coinsurance of our Plan allowable charge

Not covered:

  • Motorized wheelchairs or scooters
  • Exercise equipment
  • Air conditioners, purifiers, humidifiers, and dehumidifiers
  • Whirlpool baths
  • Convenience items, including but not limited to hypoallergenic bed linens, water purification devices, and adaptive feeding devices
  • Telephones
  • Changes made to vehicles, residences, or places of business including, but not limited to, handrails, ramps, elevators, and stair glides
  • Repair or replacement of equipment damaged through neglect or loss
  • More than one item of equipment for the same purpose
  • Disposable medical supplies, including but not limited to medical dressings, disposable diapers
  • Durable medical equipment primarily for comfort and well-being of the member
  • Care and services from non-plan providers unless precertified by the Plan prior to receiving the service

All charges

Benefit Description : Home health servicesHDHP Option (You pay After the calendar year deductible…)
  • Home healthcare 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
  • Part-time or intermittent nursing care
  • Part-time or intermittent home health aide services
  • Surgical dressings and medical appliances
  • Physical, occupational, or speech therapy

20% coinsurance of our Plan allowance

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;
  • Services primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication;
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service.

All charges

Benefit Description : Chiropractic HDHP Option (You pay After the calendar year deductible…)

No benefit

All charges

Benefit Description : Alternative treatments HDHP Option (You pay After the calendar year deductible…)

No benefit

All charges

Benefit Description : Educational classes and programsHDHP Option (You pay After the calendar year deductible…)

Coverage is provided for:

  • Diabetes self management

Note: Members should call 1-800-SENTARA for information on classes.

Nothing (No deductible)

  • Counseling and education for birth control options

Nothing (No deductible)

  • Tobacco Cessation programs, including individual/group/telephone counseling, and for over the counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence (see Prescription Drugs).

Nothing (No deductible)




Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals (HDHP)

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.
  • The deductible is $2,000 for Self Only enrollment, $4,000 per Self Plus One enrollment, and $4,000 Self and Family enrollment each calendar year. The Self Plus One and Self and Family deductible can be satisfied by one or more family members. The deductible applies to almost all benefits in this Section.
  • After you have satisfied your deductible, your Traditional medical coverage begins.
  • Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions.
  • The services listed below are for the charges billed by a physician or other healthcare professional for your surgical care. See Section 5(c) for charges associated with a facility (i.e. hospital, surgical center, etc.).
  • YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR 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.



Benefit Description : Surgical proceduresHDHP Option (You pay After calendar year deductible....)

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 (bariatric surgery) -- a condition in which an individual weighs 100 pounds or 100% over their normal weight according to current underwriting standards; eligible members must be age 18 or over.
  • Insertion of internal prosthetic devices. See 5(a) – Orthopedic and Prosthetic Devices for device coverage information
  • Voluntary sterilization (e.g., 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.

20% coinsurance of our Plan allowance

Not covered:

  • Reversal of voluntary sterilization
  • Surgery related to gender reassignment
  • Routine treatment of conditions of the foot; see Foot care
  • Surgery primarily for cosmetic purposes
  • Any surgical services, other than emergent, which have not been pre-authorized by the Plan.
  • Any surgical services determined not medically necessary by the Plan.
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service

All charges

Benefit Description : Reconstructive surgery HDHP Option (You pay After calendar year deductible....)
  • 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; and webbed fingers and 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.

20% coinsurance of our Plan allowance

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 gender reassignment
  • Any surgical services, other than emergent, which have not been precertified by the Plan.
  • Any surgical services determined not medically necessary by the Plan.
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service.

All charges

Benefit Description : Oral and maxillofacial surgeryHDHP Option (You pay After calendar year deductible....)

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.

20% coinsurance of our Plan allowance

Not covered:

  • Oral implants and transplants
  • Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service

All charges

Benefit Description : Organ/tissue transplantsHDHP Option (You pay After calendar year deductible....)

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. See Other Services under You Need Prior Plan Approval for Certain Services on page 19.

  • Cornea
  • Heart
  • Heart/lung
  • Intestinal transplants
    • Isolated small intestine
    • Small intestine with the liver
    • Small intestine with multiple organs, such as the liver, stomach, and pancreas
  • Kidney
  • Kidney-pancreas
  • Liver
  • Lung: single/bilateral/lobar
  • Pancreas
  • Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Other Services in Section 3 for prior authorization procedures.

  • Autologous tandem transplants for
    • AL Amyloidosis
    • Multiple myeloma (de novo and treated)
    • Recurrent germ cell tumors (including testicular cancer)

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below.

  • Allogeneic transplants for
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Acute myeloid leukemia
    • Advanced Myeloproliferative Disorders (MPDs)
    • Amyloidosis
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Hemoglobinopathy
    • Infantile malignant osteopetrosis
    • Kostmann’s syndrome
    • Leukocyte adhesion deficiencies
    • Marrow failure and related disorders (i.e., Fanconi’s, PNH, Pure Red Cell Aplasia)
    • Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
    • Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s syndrome, Sanfillippo’s syndrome, Maroteaux-Lamy syndrome variants)
    • Myelodysplasia/Myelodysplastic syndromes
    • Paroxysmal Nocturnal Hemoglobinuria
    • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
    • Severe combined immunodeficiency
    • Severe or very severe aplastic anemia
    • Sickle cell anemia
  • Autologous transplants for
    • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
    • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Amyloidosis
    • Breast Cancer
    • Epithelial Ovarian Cancer
    • Ewing’s sarcoma
    • Multiple myeloma
    • Medulloblastoma
    • Testicular, Mediastinal, Retroperitoneal, and ovarian germ cell tumors

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan.

Refer to Other Services in Section 3 for precertification procedures:

  • Allogeneic transplants for
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Acute myeloid leukemia
    • Advanced Myeloproliferative Disorders (MPDs)
    • Amyloidosis
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Hemoglobinopathy
    • Marrow failure and related disorders (i.e., Fanconi’s, PNH, Pure Red Cell Aplasia)
    • Myelodysplasia/Myelodysplastic syndromes
    • Paroxysmal Nocturnal Hemoglobinuria
    • Severe combined immunodeficiency
    • Severe or very severe aplastic anemia 
  • Autologous transplants for
    • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
    • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Amyloidosis
    • Neuroblastoma

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of health approved clinical trial or a Plan-designated center of excellence if approved by the Plan’s medical director in accordance with the Plan’s protocols.

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient’s condition) if it is not provided by the clinical trial. Section 9 has additional information on costs related to clinical trials. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

  • Allogeneic transplants for
    • Advanced Hodgkin’s lymphoma
    • Advanced non-Hodgkin’s lymphoma
    • Chronic inflammatory demyelination polyneuropathy (CIDP)
    • Sickle Cell anemia
  • Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning or RIC) for
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Advanced Hodgkin’s lymphoma
    • Advanced non-Hodgkin’s lymphoma
    • Breast cancer
    • Chronic lymphocytic leukemia
    • Chronic myelogenous leukemia
    • Colon cancer
    • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
    • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
    • Multiple myeloma
    • Myeloproliferative disorders (MSDs)
    • Myelodysplasia/Myelodysplastic Syndromes
    • Non-small cell lung cancer
    • Ovarian cancer
    • Prostate cancer
    • Renal cell carcinoma
    • Sarcomas
    • Sickle cell anemia
  • Autologous transplants for
    • Advanced Childhood kidney cancers
    • Advanced Ewing sarcoma
    • Aggressive non-Hodgkin lymphomas
    • Breast Cancer
    • Childhood rhabdomyosarcoma
    • Chronic myelogenous leukemia
    • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
    • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
    • Epithelial Ovarian Cancer
    • Mantle Cell (Non-Hodgkin lymphoma)

National Transplant Program (NTP)

Note: We cover related medical and hospital expenses of the donor when we cover the recipient. We cover donor testing for the actual solid organ donor or up to four bone marrow/stem cell transplant donors in addition to the testing of family members.

20% coinsurance of our Plan allowance

Not covered:

  • Donor screening tests and donor search expenses, except as shown above
  • Implants of artificial organs
  • Transplants not listed as covered
  • Care and services from non-Plan providers unless precertified

All charges

Benefit Description : Anesthesia HDHP Option (You pay After calendar year deductible....)

Professional services provided in –

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

20% coinsurance of our Plan allowance

Not covered:

  • Anesthesia related to Gender Reassignment Surgery

All charges




Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services (HDHP)

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.
  • The calendar year deductible is $2,000 per person regardless of enrollment tier and will not exceed more than $2,000 combined per Self Plus One or $4,000 combined for Self Plus Family. 
  • 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 FOR HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.




Benefit Description : Inpatient hospitalHDHP Option (You pay After calendar year deductible...)

Room and board, such as:

  • Ward, semiprivate, or intensive care accommodations
  • General nursing care
  • 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.

20% coinsurance of our Plan allowance

Other hospital services and supplies, such as:

  • Operating, recovery, maternity, and other treatment rooms
  • Prescribed drugs and medications
  • Diagnostic laboratory tests and x-rays
  • Administration of blood and blood products
  • Blood or blood plasma, if not donated or replaced
  • Presurgical testing
  • 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
  • Hospitalization and anesthesia for dental procedures as determined medically necessary by a Plan physician for members under age five, severely disabled or with a medical condition requiring hospitalization for dental procedures.

20% coinsurance of our Plan allowance

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
  • The cost of securing the services of blood donors
  • Professional dental services
  • Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service

All charges

Benefit Description : Outpatient hospital or ambulatory surgical centerHDHP Option (You pay After calendar year deductible...)

Operating, recovery, and other treatment rooms

  • Prescribed drugs and medications
  • 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.

20% coinsurance of our Plan allowance

Not covered:

  • Blood and blood derivatives not replaced by the member
  • Professional dental services and procedures
  • Care and services from non-Plan providers unless pre-authorized by the Plan prior to receiving the service

All charges

Benefit Description : Extended care benefits/Skilled nursing care facility benefitsHDHP Option (You pay After calendar year deductible...)

Extended care benefit/Skilled nursing care facility:

The Plan provides a comprehensive range of benefits up to 100 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan. All necessary services are covered including:

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

20% coinsurance of our Plan allowance

Not covered:

  • Custodial care
  • Rest cures
  • Domiciliary or convalescent care
  • Personal comfort items such as telephone, and television
  • Blood and blood derivatives not replaced by the member
  • Care and services from non-Plan providers unless pre-authorized by the Plan prior to receiving services

All charges

Benefit Description : Hospice careHDHP Option (You pay After calendar year deductible...)

A coordinated program of home and inpatient care under the direction of a Plan doctor for the patient who is in the terminal stages of illness with a life expectancy of six months or less that includes:

  • Palliative Care
  • Supportive physical, psychological, and psychosocial services

Note: Palliative care is treatment to control pain, relieve other symptoms and focus on the special needs of the patient.

20% coinsurance of our Plan allowance

Not covered:

  • Independent nursing
  • Homemaker services
  • Care and services from non-Plan providers unless pre-authorized by the Plan prior to receiving the service

All charges

Benefit Description : AmbulanceHDHP Option (You pay After calendar year deductible...)

Local professional ambulance service when medically appropriate

20% coinsurance of our Plan allowance




Section 5(d). Emergency Services/Accidents (HDHP)

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.
  • The deductible is $2,000 for Self Only enrollment, $4,000 per Self Plus One enrollment and $4,000 Self and Family enrollment each calendar year. The Self and Family and Self Plus One deductibles can be satisfied by one or more family members. The deductible applies to all benefits in this Section.
  • After you have satisfied your deductible, your Traditional medical coverage begins.
  • Under your Traditional medical coverage, you will be responsible for your coinsurance amounts and copayments for eligible medical expenses and prescriptions.
  • 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.



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:

  • If the situation is life threatening, call 911 or go to the nearest hospital.
  • If at all possible, call your primary care physician (PCP) or the After Hours Nurse Triage Program at the number on your Plan ID card.

Emergencies within our service area:

If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e.g., the 911 telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member should notify the Plan within 48 hours unless it is not reasonably possible to do so. It is your responsibility to ensure that the Plan has been timely notified.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If you are hospitalized in non-Plan facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition. The Plan will pay reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers. You must have any follow-up care recommended by non-Plan providers approved by the Plan and you must receive all follow-up care from Plan providers.

For urgent or emergency mental health or substance abuse services, call Optima Behavioral Health Services Inc., at 757-552-7174 or 800-648-8420. The Psychiatric Emergency Response Service is available 24 hours a day, seven days per week to respond to clinical psychiatric and substance abuse emergencies.

Emergencies outside our service area:

Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member should notify the Plan within 48 hours unless it is not reasonably possible to do so. It is your responsibility to ensure that the Plan has been timely notified.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If you are hospitalized in non-Plan facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.

You must have any follow-up care recommended by non-Plan providers approved by the Plan. You must receive all follow-up care from Plan providers.

With your authorization, the Plan will pay benefits directly to non-Plan providers of your emergency care upon receipt of their claims for covered services. Physicians should submit their claims on a HCFA 1500 claim form. If you are required to pay for the services, submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID card.

Payment will be sent to you (or the provider if you did not pay the bill), unless the claim is denied. If it is denied, you will receive notice of decision, including the reasons for the denial and the provisions of the contract on which denial was based. If you disagree with the Plan’s decision, you may request reconsideration in accordance with the disputed claims procedure.




Benefit Description : Emergency within our service areaHDHP Option (You pay After calendar year deductible)
  • Emergency care at a doctor’s office
  • Emergency care at an urgent care center
  • Emergency care as an outpatient in a hospital, including doctors’ services

20% coinsurance of our Plan allowance

Benefit Description : Emergency outside our service areaHDHP Option (You pay After calendar year deductible)
  • Emergency care at a doctor’s office
  • Emergency care at an urgent care center
  • Emergency care as an outpatient in a hospital, including doctors’ services

20% coinsurance of our Plan allowance

Benefit Description : AmbulanceHDHP Option (You pay After calendar year deductible)

Professional ambulance service when medically appropriate

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

20% coinsurance of our Plan allowance




Section 5(e). Mental Health and Substance Use Disorder Benefits (HDHP)

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.
  • The calendar year deductible is $2,000 per person ($4,000 per Self Plus One enrollment, or $4,000 per Self and Family enrollment). The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
  • 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.
  • We will provide medical review criteria or reasons for treatment plan denials to enrollees, members or providers upon request or as otherwise required.
  • 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.



Benefit Description : Professional servicesHDHP Option (You pay After calendar year deductible...)

We cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists.

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders. Services include:

  • Diagnostic evaluation
  • Crisis intervention and stabilization for acute episodes
  • Medication evaluation and management (pharmacotherapy)
  • Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
  • Treatment and counseling (including individual or group therapy visits)
  • Diagnosis and treatment of substance abuse disorder, including detoxification, treatment and counseling
  • Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
  • Electroconvulsive therapy

20% coinsurance of our Plan allowance

Benefit Description : DiagnosticsHDHP Option (You pay After calendar year deductible...)
  • Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment practitioner
  • Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility
  • Inpatient diagnostic tests provided and billed by a hospital or other covered facility
  • MRI, CAT Scans and PET Scans

20% coinsurance of our Plan allowance

Benefit Description : Inpatient hospital or other covered facilityHDHP Option (You pay After calendar year deductible...)

Inpatient services provided and billed by a hospital or other covered facility

  • Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services

20% coinsurance of our Plan allowance

Benefit Description : Outpatient hospital or other covered facilityHDHP Option (You pay After calendar year deductible...)

Outpatient services provided and billed by a hospital or other covered facility

  • Services such as partial hospitalization, half-way house, full-day hospitalization, or facility-based intensive outpatient treatment

20% coinsurance of our Plan allowance

Benefit Description : Not coveredHDHP Option (You pay After calendar year deductible...)

Not covered:

  • Residential treatment
  • Care and services from non-Plan providers unless pre-authorized by the Plan prior to receiving the services.

All charges




Section 5(f). Prescription Drug Benefits (HDHP)

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.
  • 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.
  • Federal law prevents the pharmacy from accepting unused medications.
  • Members must make sure their prescribers obtain prior approval/authorizations for certain prescription drugs and supplies before coverage applies. Prior approval/authorizations must be renewed periodically.
  • The deductible is $2,000 for Self Only enrollment, $4,000 per Self Plus One enrollment and $4,000 Self and Family enrollment each calendar year. The Self and Family and Self Plus One deductibles can be satisfied by one or more family members. The deductible applies to all benefits in this Section.
  • After you have satisfied your deductible, your Traditional medical coverage begins.
  • Under your Traditional medical coverage, you will be responsible for your coinsurance amounts for eligible medical expenses or copayments for eligible prescriptions.
  • 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.



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

  • Who can write your prescription.  A licensed physician or dentist, and in states allowing it, licensed certified providers with prescriptive authority within their scope of practice must prescribe your medication.
  • Where you can obtain them. You may fill the prescription at a Plan pharmacy, or a non-Plan pharmacy that has agreed to accept our reimbursement as payment in full. Specialty drugs must be filled through our Specialty mail order vendor, Proprium Pharmacy.  You may also use our mail order program for maintenance medications.
  • We use a closed formulary. That means the Plan includes coverage for a specific list of drugs and medications determined by our Pharmacy and Therapeutics Committee. Drugs that are not included on the Standard formulary will not be covered. Please use the following link to see a list of drugs on the Standard formulary: http://public.optimahealth.com/Lists/OptimaFormsLibrary/form-doc-drug-list-standard-formulary.pdf. Your physician is responsible for obtaining precertification. Optima’s Pharmacy and Therapeutics Committee places covered drugs into the following Tiers: 
    • Selected Generic (Tier 1): includes commonly prescribed generic drugs.  Other drugs may be included in Tier 1 if the Plan recognizes they show documented long-term decreases in illness.
    • Selected Brand & Other Generic (Tier 2): includes brand-name drugs, and some generic drugs with higher costs than Tier 1 generics, that are considered by the Plan to be standard therapy. 
    • Non-Selected Brand/Other (Tier 3): includes brand name drugs not included by the Plan on Tier 1 or Tier 2.  These may include single source brand name drugs that do not have a generic equivalent or a therapeutic equivalent.  Drugs on this tier may be higher in cost than equivalent drugs, or drugs determined to be no more effective than equivalent drugs on lower tiers.
    • Specialty Drugs (Tier 4): includes Specialty Drugs that have unique uses and are generally prescribed for people with complex or ongoing medical conditions.  Specialty Drugs typically require special dosing, administration, and additional education and support from a health care professional.  
  • Coverage of Specialty Drugs:  Specialty Drugs are only available through Proprium Pharmacy at 757-553-3568 or 855-553-3568 (toll free).  Specialty Drugs include the following:
    • Medications that treat certain patient populations including those with rare diseases;
    • Medications that require close medical and pharmacy management and monitoring;
    • Medications that require special handling and/or storage;
    • Medications derived from biotechnology and/or blood derived drugs or small molecules; and
    • Medications that can be delivered via injection, infusion, inhalation, or oral administration. 

Your Specialty Drug will be delivered to your home address.  If you have a question or need to find out if your drug is considered a Specialty Drug please call Member Services at the number on your Optima ID Card .  You can also log onto www.optimahealth.com/federal for a list of Specialty Drugs.

These are the dispensing limitations. Prescription drugs dispensed at a Plan pharmacy will be dispensed for up to a 31-day supply. We will permit and apply a prorated daily cost sharing rate to prescription drugs for the purpose of synchronizing medications. Prescriptions will be dispensed by a Plan pharmacy for a partial supply if the prescribing provider or pharmacist determines the fill or refill to be in the best interest of the Member, and the Member requests or agrees to a partial supply. You may receive up to a 90-day supply of a prescribed maintenance medication through our mail-order program or at one of our retail pharmacies. Specialty drugs are limited to a 31-day supply.

You may use the Plan’s mail order prescription drug benefit for Tier 1, 2 or 3 drugs and purchase a 90 day supply of maintenance drugs, for two prescription drug copayments. If you have a question about the mail order prescription drug program, or if you want to find out if your prescription is available through the program, you may call OptumRx Home Delivery at 844-672-2307, 24 hours a day, 7 days a week. You may also write to OptumRx, P.O. Box 2975, Mission, KS 66201.  

If you are called to active duty, or in time of national or other emergency please call Member Services for assistance in obtaining a medium term supply of your prescription drugs. 

  • 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, or a higher costing generic, when a Federally-approved generic drug is available, and your physician has not specified Dispense as Written for the name brand drug, you have to pay the difference in cost between the name brand drug and the generic in addition to your copayment. The Plan limits the quantities of drugs you will receive for your copayment. Please read the information below to determine what you will receive for your prescription drug copay. If you have any questions about your prescription drug benefit please call Member Services.
  • 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 brand name is the name under which the manufacturer advertises and sells a drug. Under federal law, generic and brand name drugs must meet the same standards for safety, purity, strength, and effectiveness. A generic prescription costs you -and us- less than a brand name prescription.
  • When have to file a claim. Members will be reimbursed for outpatient prescription drugs obtained from other than a Plan-participating pharmacy (or a non-Plan pharmacy that has agreed to accept reimbursement as payment in full for their services at rates applicable to Plan participating pharmacies) when:
    • Ordered in connection with an out-of-area emergency
    • Ordered by a Plan provider for immediate use because of a medical necessity and because no Plan–participating pharmacy was open for business at the time
    • Reimbursement will be limited to a quantity sufficient to treat the acute phase of the illness.



Benefit Description : Covered medications and suppliesHDHP Option (You pay After calendar year deductible...)

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 medications (including those administered during a non-covered admission or in a non-covered facility) that by Federal law of the United States require a physician's prescription for their purchase, except those listed as Not covered.
  • Rescue and maintenance inhalers
  • Insulin
  • Drugs for sexual dysfunction (limited to four pills per month)
  • Drugs to treat gender dysphoria
  • Intravenous fluids and medication for home use

Note: Injectable contraceptive drugs are covered under Family Planning Section 5(a).

Retail Pharmacy:

$15 copayment per Tier 1 Drug

$50 copayment per Tier 2 Drug

20% coinsurance not to exceed $85 copayment per Tier 3 Drug

Mail Order (90 day supply of Maintenance Drugs):

$30 copayment per Tier 1 Drug

$100 copayment per Tier 2 Drug

20% coinsurance not to exceed $170 copayment per Tier 3 Drug

Specialty Drugs are only available through Proprium Pharmacy (limited to a 31 day supply):

20% coinsurance per Tier 4 Specialty Drug

Diabetic supplies limited to:

  • Disposable needles and syringes for the administration of covered medications

Note: Some diabetic supplies are covered by our medical benefit (see Section 5(a) Durable Medical Equipment, page 82.)

20% coinsurance of our Plan allowance

  • Women's contraceptive drugs and devices
  • Tobacco/E-cigarette cessation drugs

Note:  The above over-the-counter drugs and devices approved by the FDA require written prescription by an approved Plan provider.  Some restrictions apply.

Nothing (No deductible)

Benefit Description : Preventive medicationsHDHP Option (You pay After calendar year deductible...)

Preventive care medications to promote better health as recommended by ACA and as defined by the IRS.

The following are covered:

  • Aspirin (81 mg) for men age 45-79 and women age 55-79 and women of childbearing age
  • Folic acid supplements for women of childbearing age 400 & 800 mcg
  • Liquid iron supplements for children age 0-2 years
  • Vitamin D supplements (prescription strength) (400 & 1000 units) for members 65 or older
  • Bowel Evacuant drugs
  • Tamoxifen and Raloxefin for women
  • Generic and over-the-counter tobacco cessation medications
  • Fluoride tablets, solution (not toothpaste, rinses) for children age 0-7

Note: Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a healthcare professional and filled by a network pharmacy. These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browserecommendations

Nothing (No deductible)

Not covered:

  • Drugs and supplies for cosmetic purposes
  • Drugs to enhance athletic performance
  • Fertility drugs
  • Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
  • Vitamins, nutrients and food supplements even if a physician prescribes or administers them (except Vitamin D, as stated above)
  • Over-the-counter medications, except as noted above
  • Appetite suppressants or other weight management medications
  • Medical supplies such as dressings and antiseptics
  • Immunization agents, biological sera, blood or blood products

All charges




Section 5(g). Dental Benefits (HDHP)

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.
  • If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your FEHB Plan will be First/Primary payor of any Benefit payments and your FEDVIP Plan is secondary to your FEHB Plan. See Section 9 Coordinating benefits with other coverage.
  • Plan dentists must provide or arrange your care.
  • The deductible is $2,000 for Self Only enrollment, $4,000 per Self Plus One enrollment and $4,000 Self and Family enrollment each calendar year. The Self and Family and Self Plus One deductibles can be satisfied by one or more family members. The deductible applies to all benefits in this Section.
  • After you have satisfied your deductible, your Traditional medical coverage begins.
  • Under your Traditional medical coverage, you will be responsible for your coinsurance amounts and copayments for eligible medical expenses and prescriptions.
  • We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. See Section 5(c) for inpatient hospital benefits. We do not cover the dental procedure unless it is described below.
  • 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.



Benefit Description : Accidental injury benefitHDHP Option (You pay After calendar year deductible...)

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury.

20% coinsurance of Plan allowance

Benefit Description : Dental benefitsHDHP Option (You pay After calendar year deductible...)

We have no other dental benefits

All charges




Section 5(h). Wellness and Other Special Features

TermDefinition
Flexible benefits option

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

  • We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue.
  • Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
  • By approving an alternative benefit, we do not guarantee you will get it in the future.
  • The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
  • If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
  • Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.  However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8).

24 hour nurse line

For any of your health concerns, 24 hours a day, 7 days a week, you may call and talk with a registered nurse who will discuss treatment options and answer your health questions. When you call the Nurse Triage Program have your Plan ID card handy, and describe your medical situation in as much detail as possible. Please remember that the Nurse Triage Program professional cannot diagnose medical conditions or write prescriptions. You can call the 24 Hours Nurse Triage Program at 757-552-7250 or 800-394-2237.

Services for deaf and hearing impairedTDD number: 757-552-7120 or 800-225-7784
High risk pregnancies A Plan Care Manager will assist with a treatment plan prescribed by your OB/GYN physician.

Wellness Tools - My Life My Plan Connection

Through a partnership with WebMD, we offer our members flexible programs, expert guidance, and inspiration to take charge of their own health—whether they are continuing healthy behaviors, or making a change to improve their health.  It all begins when the member completes a Personal Health Assessment—and creates the foundation for their Health Record and coaching program.  Our health-coaching partner, WebMD, offers a comprehensive online activities tool, known as the Digital Health Assistant (DHA).  The DHA delivers a personalized, interactive, and motivational experience to help members take action and sustain healthy behaviors in a fun way.




Section 5(i). Health Education Resources and Account Management Tools (HDHP)

TermDefinition

Health education resources

We publish an e-newsletter to keep you informed on a variety of issues related to your good health. Visit our website at www.optimahealth.com/members/updates/ for the latest edition, or to view past newsletters.

Visit our on our website at www.optimahealth.com/members for information on:

  • General health topics
  • Links to healthcare news
  • Cancer and other specific diseases
  • Drugs/medication interactions
  • Kids’ health
  • Patient safety information
  • Several helpful website links

Account management tools

For each HSA and HRA account holder, we maintain a complete claims payment history online through your MyOptima member portal at www.optimahealth.com/members

Your balance will also be shown on your explanation of benefits (EOB) form.

You will receive an EOB after every claim.

If you have an HSA:

  • You will receive a statement outlining your account balance and activity for the month.  You may choose to receive a printed statement to be mailed to you, at an additional cost.
  • You may also access your account on-line through your MyOptima member portal at www.optimahealth.com/members

If you have an HRA:

Consumer choice information

As a member of this HDHP, you must use a Plan provider.  Directories are available online at www.optimahealth.com/find-doctors-drugs-and-facilities.

Pricing information for medical care is available through your Treatment Cost Calculator in your MyOptima member portal at www.optimahealth.com.

Pricing information for prescription drugs is available at www.optimahealth.com    Select Optima FEHB from the drop down box.

Link to online pharmacy through your MyOptima member portal at www.optimahealth.com/members.

Educational materials on the topics of HSAs, HRAs and HDHPs are available at www.optimahealth.com/members/manage-plans/optima-equity-resources.




Non-FEHB Benefits Available to Plan Members

"Staying Healthy", an award-winning collection of nutrition, fitness, tobacco cessation and screening programs. Health Coaches and online resources are part of "Staying Healthy."  You can find more information on these programs at www.optimahealth.com/members/health-and-wellness/prevention-and-wellness/.

Health and Fitness Center Discounts:

  • Gym Network 360:  Optima Health members have access to premier fitness, weight loss, and wellness brands at discounted pricing with Gym Network 360 from GlobalFit. You must sign in to access the shopping platform to browse for services and activate your discount.

Complementary Alternative Treatments:
For more information about the complementary alternative treatments listed below, call toll-free 877-327-2746.

  • Acupuncture: Up to 25% discount for acupuncture exams and treatment.
  • Chiropractic Care: Up to 25% discount for routine chiropractic care.
  • Massage Therapy: Up to 25% discount for massage therapy.
  • Physical Therapy: Up to 25% discount for physical therapy.
  • Occupational Therapy: Up to 25% discount for occupational therapy.
  • Podiatry: Up to 25% discount for podiatry services.

Search for a participating provider near you (one-time registration is required at Choosehealthy.com)

Learn more about all of the "Saving More" Complementary Alternative Treatment programs:

  • Hearing Extras:
    • Reduced pricing for hearing care services, including functional testing, hearing aid evaluation, fitting, programming, training and up to 50% discount (from manufacturer’s suggested retail) for a hearing aid.
    • For additional information, call toll-free 866-956-5400 or visit the Epic Hearing Web site.
    • Learn more about the Saving More Hearing Care programs
  • Vision Extras:
    • For additional information about savings offered by EyeMed Vision Care call toll-free 888-610-2268 or visit the EyeMed Vision Care Web site.
    • Vision Extras: Significant savings on routine eye exams, lenses and frames, contact lenses.
    • Laser Vision: Up to 15% discount on the cost of laser vision surgery.
    • Learn more about the "Saving More" Vision Care programs

Important Points to Remember:

  • The savings brought to you as part of the Optima Health Member Discount Program do not affect your premiums and are not covered benefits of your Plan.
  • Discounts may not be used in conjunction with any other discount, rider, or benefit.
  • You will be responsible for applicable taxes.



Section 6. General Exclusions –Services, Drugs and Supplies We Do Not Cover

The exclusions in this section apply to all benefits.  There may be other exclusions and limitations listed in Section 5 of this brochure.  Although we may list a specific service as a benefit, we will not cover it unless it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition.  For information on obtaining prior approval for specific services, such as transplants, see Section 3 When You Need Prior Plan Approval for Certain Services.

We do not cover the following:

  • Care by non-plan providers except for authorized referrals or emergencies (see Emergency services/accidents);
  • Services, drugs, or supplies you receive while you are not enrolled in this Plan;
  • Services, drugs, or supplies not medically necessary;
  • Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;
  • Experimental or investigational procedures, treatments, drugs or devices (see specifics regarding transplants);
  • Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest;
  • Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program;
  • Services, drugs, or supplies you receive without charge while in active military service;
  • Services or supplies furnished by yourself, immediate relatives or household members, such as spouse, parents, children, brothers or sisters by blood, marriage or adoption;
  • Services or supplies we are prohibited from covering under the law.



Section 7. Filing a Claim for Covered Services

This Section primarily deals with post-service claims (claims for services, drugs or supplies you have already received).  See Section 3 for information on pre-service claims procedures (services, drugs or supplies requiring prior Plan approval), including urgent care claims procedures. When you see Plan providers, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims.  Just present your identification card and pay your copayment, or coinsurance. 

You will only need to file a claim when you receive emergency services from non-plan providers.  Sometimes these providers bill us directly.  Check with the provider. 

If you need to file the claim, here is the process:




TermDefinition

Medical and hospital benefits

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, contact us at 757-552-7550 or 800-206-1060, or at our Web site at www.optimahealth.com.

When you must file a claim – such as for services you receive outside the Plan’s service area – submit it on the CMS-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

  • Covered member’s name, date of birth, address, phone number and ID number
  • Name and address of the provider or facility that provided the service or supply
  • Dates you received the services or supplies
  • Diagnosis
  • Type of each service or supply
  • The charge for each service or supply
  • A copy of the explanation of benefits, payments, or denial from any primary payor – such as the Medicare Summary Notice (MSN)
  • Receipts, if you paid for your services

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills. 

Submit your claims to:       

Claims
P.O. Box 5028
Troy, MI 48007-5028

Other supplies or services

For EyeMed Vision Care non-Plan provider or out-of-network provider claims, please send your health plan name, your name, member ID number, current address, telephone number and your itemized statement. Claims must be submitted within six months of the time services are received.

Submit your claims to:     

EyeMed Vision Care
Attn: OON Claims
P.O. Box 8504
Mason, OH 45040-7111

Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.
Post-service claims procedures

We will notify you of our decision within 30 days after we receive your post-service claim.  If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 30-day period.  Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.

Authorized Representative

You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us.  For urgent care claims, we will permit a healthcare professional with knowledge of your medical condition to act as your authorized representative without your express consent.  For the purposes of this section, we are also referring to your authorized representative when we refer to you.

Notice Requirements

If you live in a county where at least 10 percent of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language. You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as telephone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the healthcare provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes.




Section 8. The Disputed Claims Process

You may appeal directly to the Office of Personnel Management (OPM) if we do not follow required claims processes.  For more information or to make an inquiry about situations in which you are entitled to immediately appeal to OPM, including additional requirements not listed in Sections 3, 7 and 8 of this brochure, please call your plan's customer service representative at the phone number found on your enrollment card, plan brochure, or plan website.

Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your post-service claim (a claim where services, drugs or supplies have already been provided).  In Section 3 If You Disagree With Our Pre-service Claim Decision, we describe the process you need to follow if you have a claim for services, referrals, drugs or supplies that must have prior Plan approval, such as inpatient hospital admissions.

To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan documents under our control relating to your claim, including those that involve any expert review(s) of your claim.  To make your request, please contact our Customer Service Department by writing Optima Health, 4417 Corporation Lane, Virginia Beach, VA 23462 or calling 800-206-1060.

Our reconsideration will take into account all comments, documents, records, and other information submitted by you relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.

When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical necessity, experimental/investigational), we will consult with a healthcare professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who was not involved in making the initial decision.

Our reconsideration will not take in account the initial decision.  The review will not be conducted by the same person, or their subordinate, who made the initial decision. 

We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support the denial of benefits.




StepDescription
1

Ask us in writing to reconsider our initial decision. You must:

a) Write to us within 6 months from the date of our decision; and

b) Send your request to us at: Optima Health Appeals Department, 4417 Corporation Lane, Virginia Beach, VA 23462; and

c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

e) Include your e-mail address (optional for member), if you would like to receive our decision via email.  Please note that by giving us your email, we may be able to provide our decision more quickly.

 We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision.  We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date.  However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration.  You may respond to that new evidence or rationale at the OPM review stage described in step 4.

2

In the case of a post-service claim, we have 30 days from the date we receive your request to:

a)  Pay the claim or  

b)  Write to you and maintain our denial or.

c)  Ask you or your provider for more information

You or your provider must send the information so that we receive it within 60 days of our request.  We will then decide within 30 more days.

If we do not receive the information within 60 days we will decide within 30 days of the date the information was due.  We will base our decision on the information we already have.  We will write to you with our decision.

3

 If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:

  • 90 days after the date of our letter upholding our initial decision; or
  • 120 days after you first wrote to us -- if we did not answer that request in some way within 30 days; or
  • 120 days after we asked for additional information.

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 2, 1900 E Street, NW, Washington, DC 20415-3620.

Send OPM the following information:

  • A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
  • Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
  • Copies of all letters you sent to us about the claim;
  • Copies of all letters we sent to you about the claim; and
  • Your daytime phone number and the best time to call.
  • Your email address, if you would like to receive OPM’s decision via email.  Please note that by providing your email address, you may receive OPM’s decision more quickly.

Note:  If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note:  You are the only person who has a right to file a disputed claim with OPM.  Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request.  However, for urgent care claims, a health care professional with knowledge of your medical condition may act as your authorized representative without your express consent.

Note:  The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

4

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct.  OPM will send you a final decision within 60 days.  There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to sue.  If you decide to file a lawsuit, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval.  This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision.  This information will become part of the court record.

You may not file a lawsuit until you have completed the disputed claims process.  Further, Federal law governs your lawsuit, benefits, and payment of benefits.  The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision.  You may recover only the amount of benefits in dispute.

Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 757-552-7550 or 800-206-1060.  We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal.  You may call OPM’s FEHB 2 at 202-606-3818 between 8 a.m. and 5 p.m. Eastern Time.

Please remember that we do not make decisions about plan eligibility issues. For example, we do not determine whether you or a dependent is covered under this plan.You must raise eligibility issues with your Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant or the Office of Workers' Compensation Programs if you are receiving Workers' Compensation benefits

 




Section 9. Coordinating Benefits with Medicare and Other Coverage

TermDefinition

When you have other health coverage

You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays healthcare expenses without regard to fault. This is called “double coverage.”

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines.   For more information on NAIC rules regarding the coordinating of benefits, visit our website at www.optimahealth.com/federal.

When we are the primary payor, we will pay the benefits described in this brochure.

When we are the secondary payor, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance.

TRICARE and CHAMPVA

TRICARE is the healthcare program for eligible dependents of military persons, and retirees of the military.  TRICARE includes the CHAMPUS program.  CHAMPVA provides health coverage to disabled Veterans and their eligible dependents.  IF TRICARE or CHAMPVA and this Plan cover you, we pay first.  See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium.  (OPM does not contribute to any applicable plan premiums.)  For information on suspending your FEHB enrollment, contact your retirement office.  If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under TRICARE or CHAMPVA.

Workers' Compensation

We do not cover services that:

  • You (or a covered family member) need because of a workplace-related illness or injury that the Office of Workers’ Compensation Programs (OWCP) or a similar Federal or State agency determines they must provide; or
  • OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care.
Medicaid

When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these State programs, eliminating your FEHB premium.  For information on suspending your FEHB enrollment, contact your retirement office.  If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the State program.
When other Government agencies are responsible for your careWe do not cover services and supplies when a local, State, or Federal government agency directly or indirectly pays for them.
When others are responsible for your injuries

Our right to pursue and receive subrogation and reimbursement recoveries is a condition of, and a limitation on, the nature of benefits or benefit payments and on the provision of benefits under our coverage.

If you have received benefits or benefit payments as a result of an injury or illness and you or your representatives, heirs, administrators, successors, or assignees receive payment from any party that may be liable, a third party’s insurance policies, your own insurance policies, or a workers’ compensation program or policy, you must reimburse us out of that payment.  Our right of reimbursement extends to any payment received by settlement, judgment, or otherwise.

We are entitled to reimbursement to the extent of the benefits we have paid or provided in connection with your injury or illness.  However, we will cover the cost of treatment that exceeds the amount of the payment you received.

Reimbursement to us out of the payment shall take first priority (before any of the rights of any other parties are honored) and is not impacted by how the judgment, settlement, or other recovery is characterized, designated, or apportioned.  Our right of reimbursement is not subject to reduction based on attorney fees or costs under the “common fund” doctrine and is fully enforceable regardless of whether you are “made whole” or fully compensated for the full amount of damages claimed.

We may, at our option, choose to exercise our right of subrogation and pursue a recovery from any liable party as successor to your rights.

If you do pursue a claim or case related to your injury or illness, you must promptly notify us and cooperate with our reimbursement or subrogation efforts.

When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) coverage

Some FEHB plans already cover some dental and vision services.  When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage.  FEDVIP coverage pays secondary to that coverage.  When you enroll in a dental and/or vision plan on BENEFEDS.com or by phone at 877-888-3337 (TTY 877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.

Clinical trials

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application. 

If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:

  • Routine care costs – costs for routine services such as doctor visits, lab tests, x-rays and scans, and hospitalizations related to treating the patient’s condition, whether the patient is in a clinical trial or is receiving standard therapy.
  • Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care.
  • Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes.  These costs are generally covered by the clinical trials.  This plan does not cover these costs.
When you have Medicare

What is Medicare?

For more detailed information on “What is Medicare?” and “Should I Enroll in Medicare?” please contact Medicare at 1-800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048) or at www.medicare.gov.

  • The Original Medicare Plan (Part A or Part B)

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share. Some things are not covered under Original Medicare, such as prescription drugs (but coverage through private prescription drug plans will be available starting in 2006).

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary. This is true whether or not they accept Medicare.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.
• Claims process when you have the Original Medicare Plan– You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payor, we process the claim first.

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. You will not need to do anything. To find out if you need to do something to file your claim, call us at 757-552-7550 or 800-206-1060 or see our website at www.optimahealth.com.

We waive some costs if the Original Medicare Plan is your primary payor – We will waive some out-of-pocket costs as follows:

• Medical services and supplies provided by physicians and other healthcare professionals.

Please review the following table as it illustrates your cost share if you are enrolled in Medicare Part B. If you purchase Medicare Part B, your provider is in our network and participates in Medicare, then we waive some costs because Medicare will be the primary payor.

Benefit Description: Deductible
Medical Cost Without Medicare: 
$750 per Member
Medical Cost with Medicare Part A and B: 
Medicare Part A: $1,260 per benefit period, Medicare Part B: $147

Benefit Description: Primary Care Physician
Medical Cost Without Medicare: 
$15 Copayment
Medical Cost with Medicare Part A and B: 
After Part A deductible, 20% coinsurance of Medicare allowed amount

Benefit Description: Specialist
Medical Cost Without Medicare: 
$50 Copayment
Medical Cost with Medicare Part A and B: 
After Part A deductible, 20% coinsurance of Medicare allowed amount

Benefit Description: Inpatient Hospital
Medical Cost Without Medicare:
 30% Coinsurance of our Plan allowance
Medical Cost with Medicare Part A and B: 
$1,260 deductible for each benefit period, Days 1-60: $0 coinsurance for each benefit period, Days 61-90: $315 coinsurance per day of each benefit period, Days 91 and beyond: $630 coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime)

Benefit Description: Outpatient Hospital
Medical Cost Without Medicare: 
30% Coinsurance of our Plan allowance
Medical Cost with Medicare Part A and B: 
After Part A deductible, 20% coinsurance of Medicare allowed amount

Benefit Description: Rx
Medical Cost Without Medicare: 
Tier 1 - $5, Tier 2 - $45, Tier 3 – 50% Coinsurance, Tier 4  - Specialty (30 day supply) – 50% Coinsurance
Medical Cost with Medicare Part A and B: Part D benefit varies by plan

Benefit Description: Rx – Mail Order (90 day supply)
Medical Cost Without Medicare: 
2x retail copay (No mail order for Tier 4 drugs)
Medical Cost with Medicare Part A and B: Part D benefit varies by plan

  • Tell us about your Medicare coverage
You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask.  You must also tell us about other coverage you or your covered family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare.
  • Medicare Advantage (Part C)

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 1-800-MEDICARE (800-633-4227) (TTY 877-486-2048) or at www.medicare.gov.

If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and another plan’s Medicare Advantage plan:  You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers).  However, we will not waive any of our copayments, coinsurance, or deductibles. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan:  If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage plan premium). For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.

  • Medicare prescription drug coverage (Part D)

When we are the primary payor, we process the claim first. If you enroll in Medicare Part D and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan.




Primary Payor Chart

A. When you – or your covered spouse are age 65 or over and have Medicare and you...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have FEHB coverage on your own as an active employee
2) Have FEHB coverage on your own as an annuitant or through your spouse who is an annuitant
3) Have FEHB through your spouse who is an active employee
4) Are a reemployed annuitant with the Federal government and your position is excluded from the FEHB (your employing office will know if this is the case) and you are not covered under FEHB through your spouse under #3 above
5) Are a reemployed annuitant with the Federal government and your position is not excluded from the FEHB (your employing office will know if this is the case) and...
  • You have FEHB coverage on your own or through your spouse who is also an active employee
  • You have FEHB coverage through your spouse who is an annuitant
6) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge) and you are not covered under FEHB through your spouse under #3 above
7) Are enrolled in Part B only, regardless of your employment status ✓ for Part B services ✓ for other services
8) Are a Federal employee receiving Workers' Compensation ✓ *
9) Are a Federal employee receiving disability benefits for six months or more


B. When you or a covered family member...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have Medicare solely based on end stage renal disease (ESRD) and..
  • It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)
  • It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD
2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and...
  • This Plan was the primary payor before eligibility due to ESRD (for 30-month coordination period)
  • Medicare was the primary payor before eligibility due to ESRD
3) Have Temporary Continuation of Coverage(TCC) and...
  • Medicare based on age and disability
  • Medicare based on ESRD (for the 30-month coordination period)
  • Medicare based on ESRD (after the 30-month coordination period)


C. When either you or a covered family member are eligible for Medicare solely due to disability and you...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have FEHB coverage on your own as an active employee or through a family member who is an active employee
2) Have FEHB coverage on your own as an annuitant or through a family member who is an annuitant
D. When you are covered under the FEHB Spouse Equity provision as a former spouse

*Workers' Compensation is primary for claims related to your condition under Workers’ Compensation.




Section 10. Definitions of Terms We Use in This Brochure

TermDefinition
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.

Catastrophic limit

The maximum amount that an insured person will have to pay for covered expenses under the plan, usually within the plan effective dates.

  • The High Option catastrophic limit is $7,350 for Self Only, $14,700 for Self Plus One or $14,700 for Self and Family enrollment.
  • The HDHP Option catastrophic limit is $6,000 for Self Only, $12,000 for Self Plus One or $12,000 for Self and Family enrollment.
Clinical Trials Cost Categories

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application. 

If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:

  • Routine care costs – costs for routine services such as doctor visits, lab tests, x-rays and scans, and hospitalizations related to treating the patient’s condition whether the patient is in a clinical trial or is receiving standard therapy
  • Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care
  • Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes are generally covered by the clinical trials.  This plan does not cover these costs.

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance does not begin until you have met your calendar year deductible.
Example: In our HDHP Plan, you pay 20% of our allowance for durable medical equipment, after deductible.

CopaymentA copayment is a fixed amount of money you pay when you receive covered services.
Cost-sharing Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible, coinsurance, and copayments) for the covered care you receive.
Covered services Care we provide benefits for, as described in this brochure.
Custodial careCare or services that can be provided by a non-medically skilled person.  Such services help the patient with daily living activities, and include but are not limited to:  walking, dressing, bathing, exercising, preparing meals, moving the patient, acting as a companion, administering medication which can usually be self-administered, and rest cures.  Custodial care that lasts 90 days or more is sometimes known as long term care.

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 those services.  The deductible for the High Option is $750 per person regardless of enrollment tier and will not exceed more than $1,500 combined per Self Plus One or $1,500 combined for Self Plus Family. 

Experimental or investigational service

A drug, device, or biological product is experimental or investigational if the drug, device, or biological product cannot be lawfully marketed without approval of the U.S. Food and Drug Administration (FDA); and approval for marketing has not been given at the time it is furnished. Note: Approval means all forms of acceptance by the FDA.

A medical treatment or procedure, or a drug, device, or biological product, is experimental or investigational if:

1. Reliable evidence shows that it is the subject of ongoing phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or

2. Reliable evidence shows that the consensus of opinion among experts regarding the drug, device, or biological product or medical treatment or procedure, is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis.

Reliable evidence shall mean only:

  • Published reports and articles in the authoritative medical and scientific literature;
  • The written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, or biological product or medical treatment or procedure; or
  • The written informed consent used by the treating facility or by another facility studying substantially the same drug, device, or biological product or medical treatment or procedure.
Group health coverage

A plan or contract that provides coverage for health care services to eligible employees and their dependents.

Habilitative Therapy

Includes coverage for health care services and devices that help a person keep, learn, or improve skills and functioning for daily living.

Healthcare professional

A physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with state law.

Medical necessity

Services, treatment, or supplies provided by a hospital, skilled nursing facility, physician, or other provider required to identify or treat your illness or injury and that as determined by your primary care physician and the Plan are:

  • Consistent with the symptoms, diagnosis and treatment of your condition, disease, injury, or ailment;
  • In accordance with recognized standards of care for your condition
  • Appropriate standards of good medical practice
  • Not solely for your convenience, or the convenience of your primary care physician, Plan provider, hospital or other provider;
  • The most appropriate supply or level of service, which can be safely provided to you. As an inpatient this means that your medical symptoms or condition requires that the diagnosis, treatment or service cannot be safely provided to you as an outpatient.

Plan allowance

Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways. We determine our allowance as follows: We use a fee schedule which means our Plan providers accept a negotiated fee from us and you will only be responsible for your copayments or coinsurance.

You should also see Important Notice About Surprise Billing – Know Your Rights in Section 4 that describes your protections against surprise billing under the No Surprises Act.

Post-service claimsAny claims that are not pre-service claims.  In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits.
Pre-service claimsThose claims (1) that require pre-certification, prior approval, or a referral and (2) where failure to obtain pre-certification, prior approval, or a referral results in a reduction of benefits.

Rehabilitative Therapy

Includes coverage for therapies to restore and in some cases, maintain capabilities lost due to disease, illness, injury, or in the case of speech therapy, loss additionally due to congenital anomaly or prior medical treatment.

ReimbursementA carrier's pursuit of a recovery if a covered individual has suffered an illness or injury and has  received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, and the terms of the carrier's health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.
SubrogationA carrier's pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier's health benefits plan.

Urgent care claims

A physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with state law.

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:

  • Waiting could seriously jeopardize your life or health;
  • Waiting could seriously jeopardize your ability to regain maximum function; or
  • In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims usually involve pre-service claims and not post-service claims.  We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at 757-552-7550 or 800-206-1060.  You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Us/We Us and We refer to Optima Health.
You You refers to the enrollee and each covered family member.

Specific to HDHP Plan: Health Reimbursement Arrangement (HRA)

An HRA combines a Fund with a deductible-based medical plan with coinsurance limits. The HRA Fund pays first. Once you exhaust your HRA Fund, Traditional medical coverage begins after you satisfy your deductible. Your HRA Fund counts toward your deductible.

Health Savings Account (HSA)

A tax-advantaged medical savings account available to taxpayers enrolled in a high-deductible health plan (HDHP). The funds contributed to an account are not subject to federal income tax at the time of deposit.

Premium contribution to HSA/HRA

The amount of money we contribute to your HSA or HRA on a monthly basis. In 2022, for each month you are eligible for an HSA premium pass through, we will contribute to your HSA or HRA $75.00 per month for Self Only, $150.00 for Self Plus One and $150.00 per month for Self and family. If you enroll after January 1, 2022, the amount contributed will be on a prorated basis.




Index

Index Entry
(Page numbers solely appear in the printed brochure)



Notes

Summary of Benefits for the High Option Optima Health Plan - 2022

  • This is a summary.  Do not rely on this chart alone. All benefits are subject to the definitions, limitations, and exclusions in this brochure.  Before making a final decision, please read this FEHB brochure. You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.optimahealth.com/federal.
  • If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
  • We only cover services provided or arranged by Plan physicians, except in emergencies.



BenefitsYou payPage

Deductible

$750 per person regardless of enrollment tier and will not exceed more than $1,500 combined per Self Plus One or $1,500 combined for Self Plus Family.

23

Medical services provided by physicians: Diagnostic and treatment services provided in the office

Office visit copayment:  $15 primary care; $50 specialist

27

Services provided by a hospital: Inpatient

30% coinsurance of Plan allowance, after deductible

46

Services provided by a hospital: Outpatient

30% coinsurance of Plan allowance, after deductible

47

Emergency benefits: In-area

30% coinsurance of Plan allowance, after deductible

$50 copayment per Urgent Care Center visit

50

Emergency benefits: Out-of-area

30% coinsurance of Plan allowance, after deductible

50

Mental health and substance use disorder treatment:

Regular cost-sharing

52

Prescription drugs: Retail pharmacy

Retail copayment/coinsurance per 31 day supply:

$5 per Tier 1 Drug

$45 per Tier 2 Drug

50% per Tier 3 Drug

50% per Specialty Drug - Specialty Drugs must be obtained through Proprium Pharmacy

55

Prescription drugs: Mail Order

Mail Order copayment/coinsurance for 90 day supply of Maintenance Drugs:

$10 per Tier 1 Drug

$90 per Tier 2 Drug

50% per Tier 3 Drug

55

Dental Care:

No benefit

58

Vision care:

Covered at 100% per eyeglass exam once every 12 months

35

Wellness and other special features:

Nothing

59

Protection against catastrophic costs (out-of-pocket maximum):

$7,350 per person regardless of enrollment tier and will not exceed more than $14,700 combined per Self Plus One or $14,700 combined per Self Plus Family.

Some costs do not count toward this protection including:  Balance-billed charges, Healthcare charges this plan does not cover, Precertification penalties or Premiums.

23




Summary of Benefits for the HDHP of the Optima Health Plan - 2022

  • Do not rely on this chart alone. This is a summary.  All benefits are subject to the definitions, limitations, and exclusions in this brochure. Before making a final decision, please read this FEHB brochure. You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.optimahealth.com/federal.
  • If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
  • We only cover services provided or arranged by Plan physicians, except in emergencies. On this page we summarize specific expenses we cover; for more detail, look inside. If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
  • In 2020, for each month you are eligible for the Health Savings Account (HSA) Optima Health will deposit $75.00 per month for Self Only enrollment, $150.00 for Self Plus One enrollment or $150.00 per month for Self and Family enrollment to your HSA. For the HSA you may use your HSA or pay out of pocket to satisfy your calendar year deductible of $2,000 for Self Only, $4,000 for Self Plus One and $4,000 for Self and Family. Once you satisfy your calendar year deductible, Traditional medical coverage begins.
  • For the Health Reimbursement Arrangement (HRA), your health charges are applied to your annual HRA Fund of $900 for Self Only, $,1800 for Self Plus One, and $1,800 for Self and Family. Once your HRA is exhausted, you must satisfy your calendar year deductible. Once your calendar year deductible is satisfied, Traditional medical coverage begins.
  • Below, an asterisk (*) means the item is not subject to the $2,000 calendar year deductible. 



Benefit DescriptionYou payPage

In-network preventive care

*Nothing

71

Deductible

$2,000 per person, $4,000 per Self Plus One enrollment or $4,000 per Self and Family enrollment.

73

Medical services provided by physicians: Diagnostic and treatment services provided in the office

After satisfying the annual deductible, 20% coinsurance of our Plan allowance

75

Services provided by a hospital: Inpatient

After satisfying the annual deductible, 20% coinsurance of our Plan allowance

91

Services provided by a hospital: Outpatient

After satisfying the annual deductible, 20% coinsurance of our Plan allowance

92

Emergency benefits: In-area

After satisfying the annual deductible, 20% coinsurance of our Plan allowance

95

Emergency benefits: Out-of-area

After satisfying the annual deductible, 20% coinsurance of our Plan allowance

95

Mental health and substance use disorder treatment:

Regular cost-sharing

96

Prescription drugs: Retail pharmacy

$15 copayment per Tier 1 Drug

$50 copayment per Tier 2 Drug

20% coinsurance not to exceed $85 copayment per Tier 3 Drug

99

Prescription drugs: Mail Order

$30 copayment per Tier 1 Drug

$100 copayment per Tier 2 Drug

20% coinsurance not to exceed $170 copayment retail per Tier 3 Drug

99

Specialty Drugs are only available through Proprium Pharmacy (limited to a 31 day supply):

20% coinsurance per Tier 4 Specialty Drug

100

Dental Care:

No benefit

102

Vision care:

Covered at 100% per eyeglass exam once every 12 months

79

Wellness and other special features:

Nothing

103

Protection against catastrophic costs (out of pocket maximum):

When you use network providers, your annual maximum for out-of-pocket expenses (deductibles, coinsurance and copayments) for covered services is limited to $6,000 for Self Only, $12,000 for Self Plus One or $12,000 for Self and Family enrollment. 

Some costs do not count toward this protection including: Balance-billed charges, Healthcare charges this plan does not cover, Precertification penalties or Premiums.

64




2022 Rate Information for Optima Health

To compare your FEHB health plan options please go to www.opm.gov/fehbcompare.

To review premium rates for all FEHB health plan options please go to www.opm.gov/FEHBpremiums or www.opm.gov/Tribalpremium.

Premiums for Tribal employees are shown under the Monthly Premium Rate column. The amount shown under employee contribution is the maximum you will pay. Your Tribal employer may choose to contribute a higher portion of your premium. Please contact your Tribal Benefits Officer for exact rates.




Virginia
Type of EnrollmentEnrollment CodePremium Rate
BiWeekly
Gov't Share
Premium Rate
BiWeekly
Your Share
Premium Rate
Monthly
Gov't Share
Premium Rate
Monthly
Your Share
High Option Self OnlyPG1$244.86$87.24$530.53$189.02
High Option Self Plus OnePG3$524.63$277.78$1,136.70$601.86
High Option Self and FamilyPG2$574.13$228.34$1,243.95$494.74
HDHP Option Self OnlyPG4$196.89$65.63$426.59$142.20
HDHP Option Self Plus OnePG6$425.81$141.93$922.58$307.52
HDHP Option Self and FamilyPG5$434.31$144.77$941.00$313.67