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.

Coverage under this plan qualifies as minimum essential coverage (MEC). 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.

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.

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, give you other plans' brochures 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, you must also contact your employing or retirement office.

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

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 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 employing or retirement office if you want to change from Self Only to Self Plus One or Self and Family. If you have a Self and Family enrollment, you may contact us to add a family member.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26. We will send written notice to you 60 days before we proactively disenroll your child on midnight of their 26th birthday unless your child is eligible for continued coverage because they are incapable of self-support due to a physical or mental disability that began before 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 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 members covered under your Self and Family enrollment are your spouse (including your spouse by a valid common-law marriage from 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.

OPM implements 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, 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 does not 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.

Our PDP EGWP is only available to FEHB annuitants who are Medicare Part D-eligible and their covered Medicare Part D-eligible family members. Our PDP EGWP is limited to FEHB annuitants enrolled in this plan and their eligible family members. If you are an active FEHB employee, or covered family member, and become eligible to enroll in Medicare Part D, you are not eligible to enroll in our PDP EGWP. Please contact CMS for assistance 1-800-MEDICARE (1-800-633-4227). Please note that Sharp Health Plan does not offer a PDP EGWP.

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 processed according to the 2027 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 2026 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, 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).

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 31^st 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 60^th 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.)

If you are an enrollee, and your divorce or annulment is final, your ex-spouse cannot remain covered as a family member under your Self Plus One or Self and Family enrollment. You must contact us to let us know the date of the divorce or annulment and have us remove your ex-spouse. We may ask for a copy of the divorce decree as proof. In order to change enrollment type, you must contact your employing or retirement office. A change will not automatically be made.

If you were married to an enrollee and your divorce or annulment is final, you may not remain covered as a family member 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. We may request that you verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

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). 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, or if you are a covered dependent child and you turn 26.

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. 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 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.

You may convert to a non-FEHB individual policy if:

• Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);
• You decided not to receive coverage under TCC or the spouse equity law; or
• You are not eligible for coverage under TCC or the spouse equity law.

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 800-359-2002 or visit our website at www.sharphealthplan.com.

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.

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 1-800-359-2002 or send us a secure message through your Sharp Health Plan online account at www.sharphealthplan.com/login. You may also request replacement cards through our online member portal at www.sharphealthplan.com/login. You can visit 
www.sharphealthplan.com/account to learn more about your online account and download the Sharp Health Plan app.

You get care from “Plan providers” and “Plan facilities.” You will only pay copayments and/or coinsurance as described in Section 4. Your Cost for Covered Services.

FEHB Carriers must have clauses in their in-network (participating) provider agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure, 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 (copayment and coinsurance) contact your Carrier to enforce the terms of its provider contract. 

Plan providers are physicians and other healthcare professionals in our service area that we contract with to provide covered services to our members. Services by Plan providers are covered when acting within the scope of their license or certification under applicable state law. We credential Plan providers according to NCQA and Sharp Health Plan standards.

Benefits are provided under this Plan for the services of covered providers, in accordance with Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not determined by your state’s designation as a medically underserved area.

We list Plan providers in the provider directory, which we update monthly. The list is also on our website at www.sharphealthplan.com/findaprovider.

Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex, pregnancy or genetic information.

This plan provides case managers for complex conditions and can be reached at 1-800-359-2002 or visit our website at www.sharphealthplan.com for assistance.

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update monthly. The provider directory can be found on our website at 
www.sharphealthplan.com/findaprovider.

It depends on the type of care you need. First, you and each family member must choose a primary care provider. This decision is important since your primary care provider provides or arranges for most of your health care. Each member of your family may select a different primary care provider.  

Primary care providers specialize in different areas, and each specialty has its own benefits. A basic summary might help you narrow your search:

• General Practitioner/Family Medicine (with or without Obstetrics) focuses on healthcare for individuals and families of all ages. This includes routine and preventive care, treatment of acute and chronic illness, and coordination of your overall care. Some Family Medicine physicians also include Obstetrics (the care of women during pregnancy and childbirth).
• Internal Medicine focuses on adult patients and the aging process. Internists generally see patients over 18 years old. They also frequently care for patients with multiple ongoing health conditions. They provide preventive care, age-related screenings and health guidance.
• Pediatrics is a specialty which treats children from birth to their late teens. While pediatricians see healthy children for primary care, they also help children who have special or difficult health conditions. Pediatricians provide ongoing screenings, immunizations and preventive care throughout childhood.

Your primary care provider will provide most of your healthcare or give you a referral to see a specialist. You can also visit www.sharphealthplan.com/findaprovider for the most up-to-date listing of providers. If you want to change your primary care provider or if your primary care provider leaves the Plan, call us. We will help you select a new one.

Your primary care provider will refer you to a specialist for needed care. When you receive a referral from your primary care provider, you must return to the primary care provider after the consultation, unless your primary care provider authorized a certain number of visits without additional referrals. The primary care provider must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care provider gives you a referral. 

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

• If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care provider will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals.

Your primary care provider will create your treatment plan. The provider may have to get an authorization or approval from us beforehand. If you are seeing a specialist when you enroll in our Plan, talk to your primary care provider. If they decide to refer you to a specialist, ask if you can see your current specialist.

If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

• If you are seeing a specialist and your specialist leaves the Plan, call your primary care provider, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.
• You may continue seeing your specialist for up to 90 days if you are undergoing treatment for a chronic or disabling condition and you lose access to your specialist because:
  • we terminate our contract with your specialist for other than cause;
  • we drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or
  • we reduce our service area and you enroll in another FEHB Plan;

Contact us at 1-800-359-2002, or if we drop out of the Program, contact your new plan.

If you are in the 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.

Note: If you lose access to your specialist because you changed your carrier or plan option enrollment, contact your new plan.

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

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 our Customer Care Center immediately at 1-800-359-2002. 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;
• the day your benefits from your former plan run out; or
• the 92^nd day after you become a member of this Plan, whichever happens first.

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

You must get prior approval for certain services. Your primary care provider is responsible for requesting authorization from Sharp Health Plan or your medical group. Failure to do so will result in denied claims and you, the member, will be responsible for 100% of the total cost of services. 

Precertification (also called prior authorization) 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. 

Your primary care provider 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 practices. Examples of procedures and services that need prior authorization are listed below. This is not an all-inclusive list. You should contact your primary care provider to verify whether a procedure or service needs prior authorization.

Examples of Procedures/Services Requiring Prior Authorization:

• Acute rehabilitation and behavioral health facility admissions
• Air ambulance and non-emergent ambulance transportation
• All bariatric-related consultations, services and surgical services
• Clinical trials
• Durable medical equipment
• Home health services, including but not limited to IV infusion, hospice
• Outpatient diagnostic procedures, including but not limited to CT, MRA, MRI, PET and SPECT
• Transplants
• Growth Hormone Treatment (GHT)
• Certain formulary and non-formulary prescription drugs                                                                                                       

Services that are not authorized by your primary care provider, your plan medical group or Sharp Health Plan will not be covered.

Your physician, your hospital, you, or your representative, is responsible for requesting authorization from Sharp Health Plan or your plan medical group before admission or services requiring prior authorization are rendered. 

Your physician, your hospital, you, or your representative must 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 requested for hospital stay.

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.

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 then 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 1-800-359-2002. You may also call OPM's Health Insurance 3 at 202-606-0737 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 1-800-359-2002. 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).

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.

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 phone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital.

You do not need precertification of a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, your physician or the hospital must contact us for precertification of additional days for your baby.

Note: When a newborn requires definitive treatment during or after the mother’s hospital stay, 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.

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.

Failure to obtain authorization for non-plan providers: If you fail to obtain prior authorization (also called precertification) from your plan or plan medical group for any service requiring such an authorization, you, the member, will be responsible for 100% of the total cost of services received from any non-plan provider. It is the responsibility of the member to ensure that prior authorization has been obtained for all services.

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

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 your claim is in reference to a contraceptive, call Customer Care at 1-800-359-2002.

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.

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 healthcare 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.

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 phone, electronic mail, facsimile, or other expeditious methods.

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.

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

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

Example: When you see your primary care provider, you pay copayment of $10 per office visit, and when you go in the hospital, you pay $100 per admission. 

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.

There is no calendar year deductible for the Standard Option.

The calendar year deductible for the Basic Option is $4,800 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 $4,800. 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 $9,600. 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 $9,600.

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.

Coinsurance is the percentage of covered expenses that a member is required to pay each time covered services are provided, subject to any maximums specified in this brochure.

Coinsurance amounts are applied toward the catastrophic protection out-of-pocket maximum expense in most circumstances.

Example: In our Standard Option you pay 20% of covered expenses for durable medical equipment, and in our Basic Option you pay 50% of covered expenses, after deductible.

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.

After your (deductible, copayments and coinsurance) reaches the out-of-pocket maximum you do not have to pay any more for covered services, with the exception of certain cost sharing for the services below which do not count toward your catastrophic protection out-of-pocket maximum.

Your out-of-pocket maximum for services rendered during the 2027 calendar year is:

Standard Option

• Self Only $3,000 in network
• Self Plus One $6,000 per person
• Self and Family $6,000

Basic Option

• Self Only $8,100 in network
• Self Plus One $16,200
• Self and Family $16,200

Your out-of-pocket maximum may differ if you changed plans at Open Season.

Copayments for supplemental benefits (Chiropractic Services, Vision, etc.) do not apply to the annual out-of-pocket maximum.

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 prior 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 old option to the catastrophic protection limit of your new option.

Facilities of the Department of 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.

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” for out-of-network emergency services; out-of-network non-emergency services provided with respect to a visit to a participating health care facility; and out-of-network air ambulance services. 

A surprise bill is an unexpected bill you receive for more than your copayment or coinsurance for:

• emergency care – when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services furnished by nonparticipating providers with respect to patient visits to participating health care facilities, or for
• air ambulance services furnished by nonparticipating providers of air ambulance services.

Balance billing happens when you receive a bill from the non-participating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan. Balance billing does not include your applicable copayment or coinsurance.

Your health plan must comply with the NSA protections that hold you harmless from surprise bills.

In addition, your health plan adopts and complies with the surprise billing laws of California. For specific information on surprise billing, the rights, and protections you have, and your responsibilities go to www.sharphealthplan.com/members/notices-and-disclosures.

Healthcare FSA (HCFSA) – Reimburses an FSA participant for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, over-the-counter drugs and medications, vision and dental expenses, and much more) their tax dependents, and their 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.

Professional services of physicians

• In physician's office

$30 per office visit 

$30 per visit to your primary care provider 

$30 per visit to a specialist 

$50 per office visit, after deductible

$50 per visit to your primary care provider, after deductible

$50 per visit to a specialist, after deductible

Professional services of physicians

• In an urgent care center
• Initial examination of a newborn child
• Office medical consultations 
• Second surgical opinion 
• Advance care planning

$30 per office visit 

$30 per visit for medical consultation or second surgical opinion

$50 per office visit, after deductible

$50 per visit for medical consultation or second surgical opinion, after deductible

• During a hospital stay
• In a skilled nursing facility

Nothing 

40% coinsurance, after deductible

• At home

$30 per medically necessary home visit 

$50 per medically necessary home visit, after deductible

Not covered:

• Immunizations for occupational and foreign travel
• Treatment that is not referred by a plan provider, or authorized by Sharp Health Plan or your medical group when required
• Treatment that is not medically necessary
• Medical (hormones and GnRH agonists) and surgical treatment related to changing a person’s sex traits. Persons already in treatment to be reviewed on a case-by-case basis.

All charges

All charges

• You may receive covered benefits via telehealth when available, determined by your Plan provider to be medically appropriate, and provided by a Plan provider. Medically necessary health care services appropriately delivered via telehealth are covered on the same basis and to the same extent as coverage for the same services received through in-person visits. This means you have the same cost-share and out-of-pocket maximum for in-person and telehealth services. The same authorization rules also apply.

$30 per visit to your primary care provider 

$30 per visit to a specialist 

$50 per visit to your primary care provider, after deductible

$50 per visit to a specialist, after deductible

Non-Covered 

• All other benefits not otherwise listed in the Policy.
• Virtual visit with a provider that is not contracted with the Plan will not be covered.

Please Note:

• Not all conditions may be treated or appropriate for treatment through a virtual visit provider. You may be referred to another more appropriate care setting.

All charges

All charges

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap tests
• Pathology
• X-ray
• Non-routine mammogram
• Ultrasound
• Electrocardiogram and EEG
• Genetic testing

Nothing

$15 for Lab Tests

$20 for X-ray, after deductible

$20 for Other Diagnostic Tests (EKGs, EEGs, Ultrasounds), after deductible

• Advanced radiology (including but not limited to MRI, MRA, MRS, CT scan, PET, MUGA, SPECT)

$100 per visit

$175 per visit, after deductible

Routine physical every year

The following preventive services are covered at the time interval recommended at each of the links below.

• U.S Preventive Services Task Force (USPSTF) A and B recommended screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV and colorectal cancer. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations.
• Individual counseling on prevention and reducing health risks.
• Preventive care benefits for women 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 preventive care benefits for women go to the Health and Human Services (HHS) website at https://www.hrsa.gov/womens-guidelines.
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder.

Nothing

Nothing

• Routine screening mammogram 

Nothing

Nothing

• Routine use of adult immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) and adopted by the Centers for Disease Control and Prevention (CDC) are covered. A recommendation is considered to be for routine use if it is listed on the Immunization Schedules of the Centers for Disease Control and Prevention. For the current immunization schedule, visit https://www.cdc.gov/vaccines/imz-schedules/index.html.

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

Nothing

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy: Medically supervised weight management program, weekly visits usually for a 3- to 6-month duration provided by the PCP or structured program with PCP supervision as defined in clinical policy.

• Family-centered programs when medically identified to support obesity prevention and management by an in-network provider: Wellness education programs, weekly classes for 10 to 12 weeks.

Obesity screening and referral, for those persons below the USPSTF obesity prevention risk factor level: Wellness education programs, weekly classes for 10 to 12 weeks. Members are also encouraged to follow up with their primary care provider for lifestyle education. 

Note: Also see Section 5(h) for fitness and wellness discounts, programs and coaching.

Note: When anti-obesity medication is prescribed, see Section 5(f).

Note: When bariatric or metabolic surgical treatment or intervention is indicated for severe obesity, see Section 5(b).

In-network: Nothing

Out of network: Not covered

In-network: Nothing

Out of network: Not covered

Not covered:

• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
• Immunizations, boosters, and medications for travel or work-related exposure.
• Immunizations and vaccines for travel and/or required for work, insurance, school, marriage, adoption, immigration, camp, volunteer work, licensure, certification or registration, sports or recreational activities are not covered. Immunizations that are not specifically listed on the most current version of the Recommended Adult Immunization Schedule/United States or the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention are not covered.
• Physical examinations required for court hearings, travel, premarital, pre-adoption, employment or other non-preventive health reasons are not covered. Court-ordered or other statutorily required psychological evaluation, testing and treatment are not covered unless medically necessary and authorized by the Plan.

All charges

All charges

• Well-child visits, examinations, and other preventive 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. For preventive immunizations see guidance below.
• Routine use of children’s immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) schedule and adopted by the Centers for Disease Control and Prevention (CDC) are covered. A recommendation is considered to be for routine use if it is listed on the Immunization Schedules of the Centers for Disease Control and Prevention. For the current immunization schedule, visit https://www.cdc.gov/vaccines/imz-schedules/index.html.

Nothing

Nothing

• You can also find a complete list of U.S. Preventive Services Task Force (USPSTF) A and B recommendations online at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations.

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

Nothing

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy: Medically supervised weight management program, weekly visits usually for a 3- to 6-month duration provided by the PCP or structured program with PCP supervision as defined in clinical policy.

• Family-centered programs when medically identified to support obesity prevention and management by an in-network provider: Wellness education programs, weekly classes for 10 to 12 weeks.

Obesity screening and referral, for those persons below the USPSTF obesity prevention risk factor level: Wellness education programs, weekly classes for 10 to 12 weeks. Members are also encouraged to follow up with their primary care provider for lifestyle education.

Note: Also see Section 5(h) for fitness and wellness discounts, programs and coaching.

Note: When anti-obesity medication is prescribed, see Section 5(f).

Note: When bariatric or metabolic surgical treatment or intervention is indicated for severe obesity, see Section 5(b).

In-network: Nothing

Out of network: Not covered

In-network: Nothing

Out of network: Not covered

Complete maternity (obstetrical) care, such as:

• Prenatal and postpartum care
• Screening for gestational diabetes
• Screening and counseling for prenatal and postpartum depression
• Breastfeeding and lactation support, supplies and counseling for each birth

Notes:

You do not need to precertify your vaginal delivery; see page 20 for other circumstances, such as extended stays for you or your baby.

• As part of your coverage, you have access to in-network Certified Nurse Midwives (CNM), home nurse visits and board-certified lactation specialists during the prenatal and post-partum period. Your coverage includes doula services for a member who is pregnant or has been pregnant in the last 12 months. Precertification of the doula provider is not required, but the doula provider must be in-network. Find an in-network doula provider at this location: www.sharphealthplan.com/findaprovider. Visits can be in person or virtual with an in-network doula. Covered doula services include:
  • One initial visit.
  • Up to eight additional visits (any combination of prenatal and postpartum visits).
  • Support during labor and delivery (including labor and delivery resulting in a stillbirth, abortion or miscarriage).
  • Up to two extended three-hour postpartum visits after the end of a pregnancy.
  • Note: All doula visits are limited to one per day, per member. One prenatal visit or one postpartum visit can be provided on the same day as labor and delivery, stillbirth, abortion, or miscarriage support.
  • The following doula services are excluded from coverage: belly binding, birthing ceremonies (e.g., sealing, closing the bones, etc.), group classes on babywearing, massage (maternal or infant), photography, placenta encapsulation, shopping, vaginal steams, and yoga.

• 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.
• 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 hospital stay, 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. In addition, circumcision is covered at the same rate as for regular medical or surgical benefits.

Nothing for routine prenatal care or the first postpartum care visit; $0 per office visit for all routine postpartum care visits thereafter

Nothing for inpatient professional delivery services

Nothing for routine prenatal care or the first postpartum care visit; $0 per office visit for all routine postpartum care visits thereafter

40% coinsurance for inpatient professional delivery services, after deductible

Delivery:

• Inpatient hospital services

$500 per admission

40% coinsurance, after deductible

Not covered:

• Testing, services or supplies for conception by a surrogate who is not enrolled in Sharp Health Plan.
• Devices and procedures to determine the sex of a fetus.
• Elective home deliveries.

All charges

All charges

Contraceptive counseling on an annual basis

Nothing

Nothing

A range of voluntary family planning services, without cost sharing, that includes at least one form of contraception in each of the categories in the HRSA supported guidelines. This list includes:  

• Voluntary female sterilization 
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo Provera)
• Intrauterine devices (IUDs)
• Diaphragms

Note: See additional Family Planning and Prescription drug coverage in Section 5(f).

Note: Your plan offers some type of voluntary female sterilization surgery coverage at no cost to members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Any type of voluntary female sterilization surgery that is not already available without cost sharing can be accessed through the contraceptive exception process described below.

Your provider will submit a contraceptive exception request with medical justification. The Plan has 24 hours to respond to your exception request after receiving all necessary documents.

Once we have been contacted with exception request information sufficient for us to make a determination, you will receive a response within 24 hours or the next business day. Contraceptive exception requests are not subject to Section 8. The Disputed Claims Process. If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.

Nothing

Nothing

Voluntary male sterilization

Nothing

Nothing

Not covered:

• Reversal of voluntary surgical sterilization
• Non-FDA-approved contraceptive supplies

All charges

All charges

Infertility is defined as:

• A licensed physician’s findings, based on a patient’s medical, sexual, and reproductive history, age, physical findings, diagnostic testing, or any combination of those factors. This definition shall not prevent testing and diagnosis of infertility before the 12-month or 6-month period to establish infertility.
• A person’s inability to reproduce either as an individual or with their partner without medical intervention.
• The failure to establish a pregnancy or to carry a pregnancy to live birth after regular, unprotected sexual intercourse. For purposes of this section, “regular, unprotected sexual intercourse” means no more than 12 months of unprotected sexual intercourse for a person under 35 years of age or no more than 6 months of unprotected sexual intercourse for a person 35 years of age or older. Pregnancy resulting in miscarriage does not restart the 12-month or 6-month time period to qualify as having infertility.

Diagnosis and treatment of infertility specific to: 

• Artificial insemination:
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)

• Annual maximum of three oocyte retrievals (egg retrievals) and unlimited embryo transfers in accordance with the guidelines of the American Society for Reproductive Medicine (ASRM), using single embryo transfer when recommended and medically appropriate.
• Cryopreservation, when Medically Necessary only as directly pertains to the Authorized Assisted Reproductive Technologies (ART) procedures.

Fertility preservation services for iatrogenic infertility:

• Procurement of sperm or eggs including medical, surgical, and pharmacy claims associated with retrieval;
• Cryopreservation of sperm and mature oocytes; and
• Cryopreservation storage costs until age 26, or for 3 years if after the age of 26.

50% coinsurance

$50 per office visit to a specialist, after deductible

40% coinsurance per outpatient facility visit, after deductible

40% coinsurance per inpatient facility visit, after deductible

• Fertility drugs
• Assisted Reproductive Technologies (ART) services and procedures:
  • In vitro fertilization (IVF)
  • Embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
• Provider-administered medications directly associated with the covered ART procedures up to an annual maximum of three cycles
• Self-administered outpatient prescription medication for treatment for infertility up to an annual maximum of three cycles
• Intracytoplasmic sperm injection (ICSI)

50% coinsurance

$50 per office visit to a specialist, after deductible

40% coinsurance per outpatient facility visit, after deductible

40% coinsurance per inpatient facility visit, after deductible

Not covered:

• Infertility services after voluntary sterilization
• The purchase of sperm, ova or embryos
• Reversal of voluntary sterilization
• Surrogacy services or supplies
• Procedures that are not covered include, but are not limited to, Assisted Hatching, blastocyst transfer, multi-cell embryo transfer (TET), and any other procedures not specifically identified as covered
• Any service, procedure or process that prepares the member for non-covered procedures
• Services, procedures or processes provided to or performed on someone other than the member
• Medical (hormones and GnRH agonists) and surgical treatment related to changing sex traits. Persons already in treatment to be reviewed on a case-by-case basis.

All charges

All charges

• Testing and treatment

$30 per office visit

$50 per office visit, after deductible

• Allergy injections

 $10 per office visit

$50 per office visit, after deductible

• Allergy serum

 $10 copayment

$50 per office visit, after deductible

Not covered:

• Provocative food testing including tolerance induction program
• Sublingual allergy desensitization

All charges

All charges

• Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 48.

• Respiratory and inhalation therapy
• Cardiac rehabilitation following qualifying event/condition is provided for up to 12 sessions
• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy
• Growth hormone therapy (GHT)
• Proton Beam Radiation Therapy
• Intensity-Modulated Radiation Therapy (IMRT)
• Osteopathic Manipulative Treatment

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

Note: We only cover GHT when we preauthorize the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize 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 18.

$30 per office visit to your primary care provider

$30 per office visit to a specialist

$250 per outpatient facility visit

$50 per office visit to your primary care provider, after deductible

$50 per office visit to a specialist, after deductible

40% coinsurance per outpatient facility visit, after deductible

40% coinsurance per inpatient facility visit, after deductible

• Applied behavior analysis (ABA)

$30 per in home visit

$30 per office visit

$25 per group visit

40% coinsurance per in home visit, after deductible

$50 per office visit, after deductible

$25 per group visit, after deductible

• Medical foods for children under medical necessity
• Medical foods for adults under medical necessity

20% coinsurance

50% coinsurance, after deductible

• Dialysis – hemodialysis and peritoneal dialysis
• Nutrition therapy

Nothing

Nothing

Not covered:

• Alternative therapy 
• Medical (hormones and GnRH agonists) and surgical treatment related to changing a person’s sex traits (gender transition). Persons already in treatment to be reviewed on a case-by-case basis.
• Massage therapy not part of physical therapy plan

All charges 

All charges

90 visits for the services of each of the following:

• Qualified physical therapists
• Occupational therapists
• Cognitive Rehabilitation Therapy
• Habilitative Therapy 

Note:  We only cover therapy when a physician:

• orders the care (Direct referral for evaluation and 12 treatments. Prior authorization required for further treatments.);
• 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 per office visit

$30 per outpatient visit

Nothing per visit during covered inpatient admission

$50 per office visit, after deductible

$50 per outpatient visit, after deductible

Nothing per visit during covered inpatient admission

Not covered:

• Long-term rehabilitative therapy
• Exercise programs

All charges

All charges

Speech therapy services are covered when determined to be medically necessary. Prior authorization is required.

$30 per office visit

$30 per outpatient visit

Nothing per visit during covered inpatient admission

$50 per office visit, after deductible

$50 per outpatient visit, after deductible

Nothing per visit during covered inpatient admission

Not covered:

Non-medically necessary services are not covered:

• When services with the same treatment goals are available elsewhere, such as the school district or other community resources, or when another qualified professional, such as an occupational therapist, provides them.
• Dysfunctions that are self-correcting, behavioral disorders or attention disorders.
• When services do not require the skills of a qualified provider of speech therapy services.
• When the member has reached therapeutic goals of the treatment plan or no further functional progress is expected.
• When services are not habilitative, such as, respite care, day care, recreational care, residential treatment, social services, custodial care, or primarily educational services.
• Idiopathic delays in speech development for children younger than 18 months of age.

All charges 

All charges

• 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.

$30 per office visit to a specialist

$50 per office visit to a specialist, after deductible

• Implanted hearing-related devices, such as bone anchored hearing aids and cochlear implants

Note: For benefits for the devices, see Section 5(a). Orthopedic and prosthetic devices.

$30 per office visit

$500 per admission

$50 per office visit, after deductible

40% coinsurance, after deductible

Not covered:

• Hearing services that are not shown as covered
• External hearing aids

All charges

All charges

The following vision services are covered in emergent situations when medically necessary.

• Vision testing and examination
• Annual eye refractions

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

$30 per office visit

$50 per office visit, after deductible

Not covered:

• Eyeglasses or contact lenses
• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery
• Vision treatment or supplies. Medically necessary medical and surgical treatments of eye conditions are covered.

All charges

All charges

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

$30 per office visit

$50 per office visit, after 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 (except for surgical treatment).

All charges

All charges

• 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 and cochlear implants
• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy

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 per office visit

$50 per office visit, after deductible

Not covered:

• Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Prosthetic replacements provided less than 3 years after the last one we covered
• External hearing aids
• Implantable and semi-implantable middle ear hearing aids

All charges

All charges

We cover rental or purchase of prescribed durable medical equipment, at our option, including repair and adjustment.

 Covered items include: 

• Oxygen
• Dialysis equipment
• Hospital beds
• Wheelchairs
• Crutches
• Walkers
• Audible prescription reading devices
• Speech generating devices
• Ostomy and Catheter Supplies

Note: Your plan physician prescribes this equipment. Your prescribing physician will direct you to an affiliated vendor for authorized durable medical equipment.

20% coinsurance

(coinsurance applied per monthly rental or approved purchase price)

50% coinsurance, after deductible

(coinsurance applied per monthly rental or approved purchase price)

• Blood glucose monitors (BGM)/Continuous Glucose monitors (CGM)
• Insulin pumps/pods/tubeless insulin delivery systems
• All supplies for Insulin Pumps/pods/tubeless insulin delivery system

Note: Your plan physician prescribes this equipment. Your prescribing physician will direct you to an affiliated vendor for authorized durable medical equipment.

20% coinsurance

(coinsurance applied per monthly rental or approved purchase price)

Wigs for hair loss due to the treatment of cancer

$0, up to $300, member pays all cost over $300

$0, up to $300, member pays all cost over $300

Not covered:

• Equipment that basically serves comfort or convenience functions (e.g., physical fitness equipment, trays, backpacks, wheelchair racing equipment).
• DME that is primarily for the convenience of the member or caretaker.
• Exercise and hygiene equipment.
• Experimental or research equipment.
• Devices not medical in nature such as sauna baths and elevators or modifications to the home or automobile.
• Generators or accessories to make home dialysis equipment portable for travel.
• Deluxe equipment such as items for comfort, convenience, upgrades or add-ons.
• More than one piece of equipment that serves the same function, when the additional DME is not medically necessary.
• Replacement of lost or stolen DME.

All charges

All charges

• 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.

Nothing

$50 per office visit, after deductible

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.
• Private duty nursing

All charges

All charges

• Manipulation of the spine and extremities
• Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application
• Chiropractic and acupuncture services are covered for up to a combined maximum of 20 visits per calendar year.

$10 per office visit 

$10 per office visit

Not covered:

• Any services or treatments not approved by American Specialty Health Plans except for a New Patient Examination or Emergency Chiropractic Services 

• Any services or treatments not listed as covered in this benefit plan or not medically necessary  

• Any services or treatments not provided by a Plan Chiropractor, except Emergency Chiropractic Services 

• Adjunctive therapy not associated with spinal, muscle or joint manipulation 

• Air conditioners, air purifiers, therapeutic mattresses, supplies or any other similar devices or appliances 

• Education program, non-medical self-care or self-help, or any self-help physical exercise training or any related diagnostic training 

• Hospitalization, anesthesia, manipulation under anesthesia or other related services 

• Hypnotherapy, behavior training, sleep therapy or weight programs 

• Magnetic resonance imaging, CAT scans, bone scans, nuclear radiology and any type of diagnostic radiology other than covered plain film studies 

• Physical therapy not related to a spinal or joint adjustment 

• Prescription drugs or medicines including a non-legend or proprietary medicine or medication not requiring a prescription order 

• Services not related to neuromuscular-skeletal disorders 

• Thermography 

• Transportation costs including local ambulance charges 

• Vitamins, minerals, nutritional supplements or other similar products 

All charges

All charges

• Acupuncture – by a doctor of medicine or osteopathy, or licensed or certified acupuncture practitioner. 
• Acupuncture and chiropractic services are covered for up to a combined maximum of 20 visits per calendar year.

$10 per office visit 

$10 per office visit

Not covered: 

• Naturopathic services 

• Hypnotherapy 

• Biofeedback 

• Any services or treatments not approved by American Specialty Health Plans except for a New Patient Examination or Emergency Acupuncture Services 

• Any services or treatments not listed as covered in this benefit plan or not medically necessary  

• Any services or treatments not provided by a Plan Acupuncturist, except Emergency Acupuncture Services 

• Air conditioners, air purifiers, therapeutic mattresses, supplies or any other similar devices or appliances 

• Education program, non-medical self-care or self-help, or any self-help physical exercise training or any related diagnostic training 

• Hospitalization, anesthesia, manipulation under anesthesia or other related services 

• Hypnotherapy, behavior training, sleep therapy or weight programs 

• Magnetic resonance imaging, CAT scans, bone scans, nuclear radiology and any type of diagnostic radiology other than covered plain film studies 

• Prescription drugs or medicines including a non-legend or proprietary medicine or medication not requiring a prescription order 

• Compounded medications 

• Services not related to nausea or pain 

• Thermography 

• Transportation costs including local ambulance charges 

• Vitamins, minerals, nutritional supplements or other similar products 

All charges

All charges

Coverage is provided for:

• Tobacco cessation programs, including individual/group/telephone counseling, over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence.
• Diabetes self-management

Nothing for counseling for up to two quit attempts per year.

Nothing for OTC and prescription drugs approved by the FDA to treat tobacco dependence.

Nothing for diabetic education.

Nothing for counseling for up to two quit attempts per year.

Nothing for OTC and prescription drugs approved by the FDA to treat tobacco dependence.

Nothing for diabetic education.

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Routine 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 severe obesity (bariatric surgery) including open or laparoscopic Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding or vertical banded gastroplasty and sleeve gastrectomy
• Insertion of internal prosthetic devices. See 5(a) Orthopedic and prosthetic devices for device coverage information.
• Treatment of burns

Note: For female surgical family planning procedures see Family Planning Section 5(a)

Note: For male surgical family planning procedures see Family Planning Section 5(a)

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay inpatient benefits for a pacemaker inserted while admitted to the hospital and outpatient surgery benefits for a pacemaker inserted in an outpatient hospital facility.

$30 per visit to your primary care provider 

$30 per visit to a specialist 

$500 copayment per inpatient admission 

$250 copayment for outpatient surgery 

$50 per visit for in office surgery or procedure, after deductible

$50 per visit to a specialist, after deductible

40% coinsurance per inpatient admission, after deductible

40% coinsurance for outpatient surgery, after deductible

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot (see Section 5(a) Foot care)

All charges

All charges

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • the condition produced a major effect on the member’s appearance and
  • the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birthmarks; 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 Section 5(a) 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.

$50 per visit for in office surgery or procedure, after deductible

$500 copayment per inpatient admission 

$250 copayment for outpatient surgery 

$50 per in office surgery or procedure, after deductible

40% coinsurance per inpatient admission, after deductible

40% coinsurance for outpatient surgery, after deductible

$0 for outpatient anesthesia

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 (See Section 5(d) Accidental injury)
• Surgery for Sex-Trait Modification to treat gender dysphoria

Oral surgical procedure, 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 maxillofacial cysts and incision of abscesses when done as independent procedures; and 

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

$500 copayment per inpatient admission

$250 copayment for outpatient surgery 

40% coinsurance per inpatient admission, after deductible

40% coinsurance for outpatient surgery, after deductible

Not covered:

• Oral implants and transplants 

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

All charges

All charges

These solid organ and tissue transplants are covered and are limited to:

• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
• 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

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)

$500 per admission 

40% coinsurance per admission, after deductible

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below. Transplants are subject to medical necessity review by the Plan.  

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced neuroblastoma
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • 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, Paroxysmal Nocturnal Hemoglobinuria, 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
  • X-linked lymphoproliferative syndrome
• 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
  • Ependymoblastoma
  • Epithelial ovarian cancer
  • Ewing's sarcoma
  • Multiple myeloma
  • Pineoblastoma
  • Neuroblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

$500 per admission 

40% coinsurance per admission, after deductible

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
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, 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

$500 per admission 

40% coinsurance per admission, after deductible

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
  • Beta Thalassemia Major
  • Chronic inflammatory demyelination polyneuropathy (CIDP)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • 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 lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Colon cancer
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Myelodysplasia/Myelodysplastic Syndromes
  • Myeloproliferative disorders (MDDs)
  • 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
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Aggressive non-Hodgkin lymphomas
  • Breast cancer
  • Childhood rhabdomyosarcoma
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Epithelial ovarian cancer
  • Mantle Cell (Non-Hodgkin lymphoma)
  • Multiple sclerosis
  • Small cell lung cancer
  • Systemic lupus erythematosus
  • Systemic sclerosis

$500 per admission 

40% coinsurance per admission, after deductible

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.

$500 per admission

40% coinsurance per admission, after deductible

Not covered:

• Donor screening tests and donor search expenses, except as shown above
• Implants of artificial organs
• Transplants not listed as covered

All charges

All charges

Professional services provided in –

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

Nothing

Nothing

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.

$500 per admission

40% coinsurance, after deductible

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Take-home items

Nothing

40% coinsurance, after deductible

• Anesthetics, including nurse anesthetist services

• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

20% coinsurance

(copayment applied per monthly rental or purchase)

50% coinsurance, after deductible

(coinsurance applied per monthly rental or purchase)

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
• Personal or comfort items or a private room in a hospital, unless medically necessary, are not covered

• 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

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.

$250 copayment for outpatient surgery or procedure

40% coinsurance for outpatient surgery or procedure, after deductible

Not covered: 

• Blood and blood derivatives not replaced by the member 

All charges 

All charges

Extended care benefit and Skilled Nursing Facility (SNF) services:

Skilled Nursing Facility services are covered for up to a maximum of 100 days per Calendar Year in a semi-private room (unless a private room is medically necessary). Covered benefits for skilled nursing care are those services prescribed by a Plan provider and provided in a qualified licensed Skilled Nursing Facility. Covered benefits include:

• Physician and skilled nursing on a 24–hour basis.
• Room and board.
• X-ray and laboratory procedures.
• Respiratory therapy.
• Short-term physical, occupational and speech therapy.
• Medical social services.
• Prescribed drugs and medications.
• Blood, blood products and their administration.
• Medical supplies, appliances and equipment normally furnished by the Skilled Nursing Facility.

$150 per admission

40% coinsurance, after deductible

Not covered: 

• Custodial care

Hospice services are covered for members diagnosed with a terminal illness, with a life expectancy of twelve months or less, and who elect hospice care for the illness instead of restorative services. 

Covered benefits include: 

• Nursing care 

• Medical social services 

• Home health aide services, skilled nursing services and homemaker services under the supervision of a qualified registered nurse 

• Physician services 

• Drugs 

• Pharmaceuticals, medical equipment and supplies 

• Counseling and social services with medical social services provided by a qualified social worker 

• Dietary counseling by a qualified provider 

• Bereavement services 

• Physical, occupational and speech therapy 

• Interdisciplinary team care with development and maintenance of an appropriate plan of care 

• Volunteer services 

• Short-term inpatient care arrangements 

Nothing

$200 per admission, after deductible

Not covered:

• Independent nursing, homemaker services

Local professional ambulance service when medically appropriate

$100 per trip 

40% coinsurance, after deductible

• Emergency care at a doctor’s office 

• Emergency care at an urgent care center 

• Emergency care as an outpatient at a hospital, including doctors’ services 

Note: We waive the emergency room copayment if you are admitted to the hospital. 

$30 per office visit 

$30 per urgent care visit 

$100 per emergency care visit 

$50 per office visit, after deductible

$50 per urgent care visit, after deductible

40% coinsurance for emergency care visit, after deductible

Not covered: Elective care or non-emergency care

Emergency facility and professional services that are not required on an immediate basis for treatment of an emergency medical condition are not covered. 

• Emergency care at a doctor’s office 

• Emergency care at an urgent care center 

• Emergency care as an outpatient at a hospital, including doctors’ services 

Note: We waive the emergency room copayment if you are admitted to the hospital. 

$30 per office visit 

$30 per urgent care visit 

$100 per emergency care visit 

$50 per office visit, after deductible

$50 per urgent care visit, after deductible

40% coinsurance for emergency care visit, after deductible

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

All charges

Professional ambulance service when medically appropriate (ground or air).

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

$100 per trip

40% coinsurance, after deductible

Not covered:

Ambulance services are not covered when a member does not reasonably believe that his or her medical condition is an emergency medical condition that requires ambulance transport services, unless for a nonemergency ambulance service listed as covered in this member handbook.

Wheelchair transportation services (e.g., a private vehicle or taxi fare) are also not covered.

All charges

All charges

Accidental injury

$100 copayment for emergency care visit

40% coinsurance for emergency care visit, after deductible

When part of a treatment plan we approve, 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 

• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment 

• 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 

$30 per office visit 

$30 per urgent care visit 

$100 per emergency care visit 

$50 per office visit, after deductible

40% coinsurance per urgent care visit, after deductible

40% coinsurance for emergency care visit, after deductible

• Medication evaluation and management (pharmacotherapy)

$30 per office visit

$30 per urgent care visit

$100 per emergency care visit

$30 per office visit

$30 per urgent care visit

$100 per emergency care visit

• Mental health treatment and counseling (including individual or group therapy visits)

$30 per individual visit 

$25 per group visit 

$50 per individual visit, after deductible

$25 per group visit, after deductible

• Substance use disorder treatment and counseling (including individual or group therapy visits)

$30 per individual visit 

$7 per group visit 

$50 per individual visit, after deductible

$7 per group visit, after 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

Nothing

Nothing

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 

$500 per admission

40% coinsurance, after deductible

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

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

$30 per visit 

$500 per admission for half-way house and residential treatment

Home-based applied behavioral analysis for treatment of pervasive developmental disorder or autism: $30 per visit 

$50 per visit, after deductible

40% coinsurance for half-way house and residential treatment, after deductible

Home-based applied behavioral analysis for treatment of pervasive developmental disorder or autism: $50 per visit, after deductible 

Not covered:

The following services are not Covered Benefits: 

• Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation, custody, or visitation. 

All charges

All charges

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

• Drugs and medicines that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered.
• Insulin vials and pens
• Diabetic supplies limited to:
  • Disposable needles and syringes for the administration of covered medications
• Drugs for sexual dysfunction.
• Medications prescribed to treat obesity 

Contraceptive drugs and devices as listed in the Health Resources and Service Administration site https://www.hrsa.gov/womens-guidelines.

Contraceptive coverage is available at no cost to FEHB members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process described below.

• Over-the-counter and prescription drugs approved by the FDA to prevent unintended pregnancy.
• Provider to submit a contraceptive exception request with medical justification.
• Once we have been contacted with exception request information sufficient for us to make a determination, you will receive a response within 24 hours or the next business day. Contraceptive exception requests are not subject to Section 8. The Disputed Claims Process. If you have difficulty accessing contraceptive coverage or other reproductive healthcare you can contact contraception@opm.gov.
• Reimbursement for covered over-the-counter contraceptives can be submitted in accordance with Section 7.

Note: For additional Family Planning benefits see Section 5(a) 

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation Educational Classes and Programs in Section 5(a).

Retail (30-day supply)

• $20 for preferred generic drugs
• $40 for preferred brand-name drugs
• $80 for non-preferred drugs

Mail Order (90-day supply) 

• $40 for preferred generic maintenance drugs
• $80 preferred brand-name maintenance drugs
• $160 for non-preferred maintenance drugs

Specialty (30-day supply)

• 40% coinsurance (up to $350) for specialty drugs

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

Retail (30-day supply)

• $20 for preferred generic drugs
• $40 for preferred brand-name drugs
• $80 for non-preferred drugs

Mail Order (90-day supply) 

• $40 for preferred generic maintenance drugs
• $80 preferred brand-name maintenance drugs
• $160 for non-preferred maintenance drugs

Specialty (30-day supply)

• 40% coinsurance (up to $350) for specialty drugs

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

Not covered

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
• Nonprescription medications
• Drugs that are prescribed solely for the purposes of losing weight, except when medically necessary for the treatment of severe (Class III) obesity. Members must be enrolled in a Sharp Health Plan approved comprehensive weight loss program prior to and concurrent with receiving the weight loss drug.

All charges

All charges

The following are covered:

• Aspirin for members capable of pregnancy age 12-59 years at risk for preeclampsia (81mg)
• Medication to reduce the risk of breast cancer
• Medication to reduce the duration of COVID infections
• Contraceptive agents to prevent pregnancy (including tablets, vaginal rings, condoms, spermicides) – does not include implanted contraceptives (IUD, contraceptive implant)
• Folic acid for members capable of pregnancy age 55 years and under (400mcg, 800mcg)
• Select bowel prep laxative combinations for colonoscopy
• Fluoride tablets, solution (not toothpaste, rinses) for children ages 5 and under
• Tobacco cessation medications, including prescribed over-the-counter medications, approved by the FDA to treat tobacco dependence
• Statins for members age 40 through 75 for the primary prevention of cardiovascular disease 

Note: Preventive medications with a USPSTF A and B recommendation. These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. For current recommendations go to http://www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations.

Opioid rescue agents are covered under this Plan with no cost sharing when obtained with a prescription from a network pharmacy. This includes over-the-counter or prescription products such as nasal spray. The injectable forms are provided through the medical benefit.

For more information consult the FDA guidance at https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose.

Or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go to https://www.findtreatment.samhsa.gov/.

Nothing when prescribed by a healthcare professional and filled by a network pharmacy

Nothing when prescribed by a healthcare professional and filled by a network pharmacy

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Drugs that are prescribed solely for the purposes of losing weight, except when medically necessary for the treatment of severe (Class III) obesity. Members must be enrolled in a Sharp Health Plan approved comprehensive weight loss program prior to and concurrent with receiving the weight loss drug.
• Drugs obtained at a non-Plan pharmacy, except for out-of-area emergencies
• Nonprescription medications

All charges

All charges

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 per office visit

$30 per urgent care visit

$100 per emergency care visit

$50 per office visit, after deductible

$50 per urgent care visit, after deductible

40% coinsurance per emergency care visit, after deductible

We have no other dental benefits.

All charges

All charges

24/7 Access to your Health Care Information

Sharp Health Plan Member Portal

One of the best ways to manage your plan is to create your Sharp Health Plan online account. Your online account will connect you to your coverage and give you quick, secure access to:

• Check benefits, balances and costs
• See claims and coverage documents
• Change a primary care physician
• View or print your member ID card
• Choose paperless options
• Set communication preferences
• Share access to your account
• And much more

Plus, it’s available on any device with internet access, including desktop and mobile. Visit www.sharphealthplan.com/login and follow the instructions to create an account.

Sharp Health Plan app

Designed for members, the official Sharp Health Plan app makes it easy to access your online account anytime, anywhere. Visit www.sharphealthplan.com/account. Activate your online account today to easily manage your plan.

Sharp Nurse Connection®

Registered nurses are available through Sharp Nurse Connection® after hours and on weekends. They can talk with you about an illness or injury, help you decide where to seek care and provide advice on any of your health concerns. Call 1-800-359-2002, 5 p.m. – 8 a.m., Monday to Friday and 24 hours on weekends and select the option to speak with a nurse.

Services for deaf and hearing impaired

Sharp Heath Plan provides free interpreter services at scheduled appointments. For language interpreter services, please call Customer Care at 1-800-359-2002. The hearing and speech impaired may dial “711” or use California’s Relay Service’s toll-free numbers to contact us:

• 1-800-735-2922 Voice
• 1-800-735-2929 TTY
• 1-800-855-3000 Voz en español y TTY (teléfono de texto)

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).

Centers of excellence

Sharp Health Plan maintains centers of excellence for:

• Stroke
• Kidney transplant
• Total joints

Travel benefit/services overseas

When faced with a medical emergency while traveling 100 miles or more away from home or in another country for less than 90 days, we can connect you to doctors, hospitals, pharmacies and other service providers.

We partner with Assist America^® to bring you key services including medical consultation, evaluation and referral, foreign hospital admission assistance, emergency medical evacuation, medical monitoring, prescription assistance, compassionate visits and more.

To learn more visit www.sharphealthplan.com/travel.

Fitness and wellness discounts 

Sharp Health Plan members can stay healthy with discounts on studios, gyms, online classes, and wellness products.

• Active and Fit Direct™.
  • Enjoy access to 18,000+ workout videos designed for every style and fitness level at no cost.
  • Access 12,900+ participating fitness centers nationwide with a Sharp Health Plan member promo rate.
• ChooseHealthy®. Save 15%-50% on wellness products.

To learn more visit www.sharphealthplan.com/discounts.

Wellness program and coaching

Best Health is a comprehensive wellness program available to all Sharp Health Plan members at no extra cost. Offering robust online wellness tools, one-on-one health coaching and more, Best Health provides resources you can use to reach your health goals. Visit www.sharphealthplan.com/wellness/best-health to learn more.

Behavioral health support

We believe your mental health is just as important as your physical health. Behavioral health care services are a covered benefit for members of all ages. No referral is needed to access outpatient therapy from a provider in your Plan network. To learn more visit www.sharphealthplan.com/bh.

If you or a family member are not eligible under the FEHB Program benefits, Sharp Health Plan offers individual and family health insurance plans. For more information, visit our website at: www.sharphealthplan.com/our-plans/individual-and-family-plans.

Whether you are eligible for Medicare coverage now, or will be soon, Sharp Health Plan is here to help you understand more about Medicare. For more information, visit our website at www.sharpmedicareadvantage.com. If you are turning 65 and need current year plan information, call one of our Medicare Representatives directly at 1-888-632-8724 (TTY: 711).

In most cases, providers and facilities file HIPAA compliant electronic claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. In cases where a paper claim must be used, the facility will file on the UB-04 form. 

When you must file a claim – such as for services you receive outside the Plan’s service area – complete the member reimbursement form found online at www.sharphealthplan.com/members/manage-your-plan/get-reimbursed and 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 medical claims to:

Sharp Health Plan
Attention: Claims
P.O. Box 969036
San Diego, CA 92193

For claims questions and assistance, call us at 1-800-359-2002, or at our website at www.sharphealthplan.com/members/forms.

If you receive prescription drugs from a non-network pharmacy in an emergency or urgent situation, please submit your receipts along with a Prescription Drug Claim Form found on our website at www.sharphealthplan.com/members/forms

Submit your prescription drug claims to: 

CVS Caremark
P.O. Box 52136
Phoenix, AZ 85072-2136

If you receive services from a health care provider that requires you to submit the claim to us for reimbursement, you must obtain an itemized bill. Reimbursement request forms are available online at www.sharphealthplan.com/members/manage-your-plan/get-reimbursed.

Submit your claims to:

Sharp Health Plan
Attention: Claims Research
8520 Tech Way, Suite 200
San Diego, CA 92123-1450

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 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.

Keep a separate record of the medical expenses of each covered family member as deductibles and maximum allowances apply separately to each person. Save copies of all medical bills, including those you accumulate to satisfy a deductible. In most instances they will serve as evidence of your claim. We will not provide duplicate or year-end statements.

Send us all 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. If you could not file on time because of Government administrative operations or legal incapacity, you must submit your claim as soon as reasonably possible. Once we pay benefits, there is a 3-year limitation on the re-issuance of uncashed checks.

For assistance filing a claim for covered services you receive by providers and hospitals outside the United States and Puerto Rico, please contact our Customer Care Center at 1-800-359-2002.

Please reply promptly when we ask for additional information. We may delay processing or deny benefits for your claim if you do not respond. Our deadline for responding to your claim is stayed while we await all of the additional information needed to process your claim.

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.

If you live in a county where at least 10% 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 phone 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.

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: Sharp Health Plan, Attention: Appeal/Grievance Department, 8520 Tech Way, Suite 200, San Diego, CA 92123-1450; 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 email 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.

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.

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 Employees Insurance Operations, Health Insurance 3, 1900 E Street, NW, Washington, DC 20415-3630.

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 healthcare 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.

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 or notify you of the status of OMP's review within 60 days. There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to file a lawsuit. If you decide to sue, 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.

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.sharphealthplan.com.

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 processes the benefit, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance.

Every job-related injury or illness should be reported as soon as possible to your supervisor. Injury also means any illness or disease that is caused or aggravated by the employment as well as damage to medical braces, artificial limbs and other prosthetic devices. If you are a federal or postal employee, ask your supervisor to authorize medical treatment by use of form CA-16 before you obtain treatment. If your medical treatment is accepted by the Dept. of Labor Office of Workers’ Compensation (OWCP), the provider will be compensated by OWCP. If your treatment is determined not job-related, we will process your benefit according to the terms of this Plan, including use of in-network providers. Take form CA-16 and form OWCP-1500/HCFA-1500 to your provider, or send it to your provider as soon as possible after treatment, to avoid complications about whether your treatment is covered by this Plan or by OWCP.

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.

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 or employing 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.

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 or employing 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.

We do not cover services and supplies when a local, state, or federal government agency directly or indirectly pays for them.

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.

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 www.benefeds.gov 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.

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.

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

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.

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. To find out if you need to do something to file your claim, call us at 1-800-359-2002 or see our website at www.sharphealthplan.com.

We do not waive any costs if the Original Medicare Plan is your primary payor. 

Please review the following examples which illustrates your cost share if you are enrolled in Medicare Part B. 

Benefit Description: Deductible
Standard Option without Medicare you pay: No deductible
Standard Option with Medicare Part B you pay: No deductible
Basic Option without Medicare you pay: $4,800 self only / $9,600 family
Basic Option with Medicare Part B you pay: $4,800 self only / $9,600 family

Benefit Description: Catastrophic Protection Out-of-Pocket Maximum
Standard Option without Medicare you pay: $3,000 self only / $6,000 family
Standard Option with Medicare Part B you pay: $3,000 self only / $6,000 family
Basic Option without Medicare you pay: $8,100 self only / $16,200 family
Basic Option with Medicare Part B you pay: $8,100 self only / $16,200 family

Benefit Description: Primary Care Provider
Standard Option without Medicare you pay: $30 copayment per visit
Standard Option with Medicare Part B you pay: $30 copayment per visit
Basic Option without Medicare you pay: $50 copayment per visit, after deductible
Basic Option with Medicare Part B you pay: $50 copayment per visit, after deductible

Benefit Description: Specialist
Standard Option without Medicare you pay: $30 copayment per visit
Standard Option with Medicare Part B you pay: $30 copayment per visit
Basic Option without Medicare you pay: $50 copayment per visit, after deductible
Basic Option with Medicare Part B you pay: $50 copayment per visit, after deductible

Benefit Description: Inpatient Hospital
Standard Option without Medicare you pay: $500 copayment per admission
Standard Option with Medicare Part B you pay: $500 copayment per admission
Basic Option without Medicare you pay: 40% coinsurance, after deductible
Basic Option with Medicare Part B you pay: 40% coinsurance, after deductible

Benefit Description: Outpatient Hospital
Standard Option without Medicare you pay: $250 copayment per visit
Standard Option with Medicare Part B you pay: $250 copayment per visit
Basic Option without Medicare you pay: 40% coinsurance, after deductible
Basic Option with Medicare Part B you pay: 40% coinsurance, after deductible

You can find out more information on how our plan coordinates benefits with Medicare by calling our Customer Care at 1-800-359-2002.

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.

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 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 or employing 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.

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.

• 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

• 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

• 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

• 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)

An authorization by you (the enrollee or covered family member) that is approved by us (the Carrier), for us to issue payment of benefits directly to the provider.

• We reserve the right to pay you directly for all covered services. Benefits payable under the contract are not assignable by you to any person without express written approval from us, and in the absence of such approval, any assignment shall be void.
• Your specific written consent for a designated authorized representative to act on your behalf to request reconsideration of a claim decision (or, for an urgent care claim, for a representative to act on your behalf without designation) does not constitute an Assignment.
• OPM’s contract with us, based on federal statute and regulation, gives you a right to seek judicial review of OPM's final action on the denial of a health benefits claim but it does not provide you with authority to assign your right to file such a lawsuit to any other person or entity. Any agreement you enter into with another person or entity (such as a provider, or other individual or entity) authorizing that person or entity to bring a lawsuit against OPM, whether or not acting on your behalf, does not constitute an Assignment, is not a valid authorization under this contract, and is void.

See Section 4, Your Costs for Covered Services, page 22.

All treatments or procedures that include the handling of human eggs, sperm, and/or embryos to help an individual become pregnant. ART includes, but is not limited to, gamete intrafallopian transfer (GIFT), uterine embryo lavage, embryo transfer, in vitro fertilization (IVF), pronuclear state transfer (PROST), tubal embryo transfer (TET), zygote intrafallopian transfer (ZIFT), low tubal ovum transfer, intracytoplasmic sperm injection, cryopreservation (e.g., egg, embryo, sperm), and other third party-assisted ART methods (e.g., sperm donation, egg donation, Traditional Surrogates and Gestational Carriers, embryo donation).

See Section 4, Your Costs for Covered Services, page 22.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is considered 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 (FDA); or is a drug trial that is exempt from the requirement of an investigational new drug application.

• 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.

See Section 4, Your Costs for Covered Services, page 22.

a) The period of time between admission to and discharge from an inpatient or outpatient hospital, AODA residential center, skilled nursing facility, or licensed ambulatory surgical center on the advice of your physician, and discharge there from; or b) the time spent in a hospital receiving emergency care for illness or injury. Hospital swing bed Confinement is considered the same as Confinement in a skilled nursing facility. If the Member is transferred to another facility for continued treatment of the same or related condition, it is one Confinement.

Specific to a skilled nursing facility (SNF), an inpatient stay begins on the day of admission into a skilled nursing facility. The 120-day SNF benefit renews when you haven't received any inpatient hospital care or skilled care in a skilled nursing facility for the same or a similar diagnosis for 60 days in a row. If you go into a hospital or a skilled nursing facility after one SNF benefit period has ended, a new benefit period begins.

There is no limit to the number of SNF Inpatient benefit periods. However, an additional 120 days is not available until skilled care has not been required for at least 60 consecutive days.

Services and procedures that improve physical appearance but do not correct or improve a physiological function and that are not medically necessary unless the service or procedure meets the definition of Reconstructive Surgery.

See Section 4, Your Costs for Covered Services, page 22.

Care we provide benefits for, as described in this brochure. Also called covered benefits.

Care that does not require the regular services of trained medical or health professionals, including but not limited to, help in walking, getting in and out of bed, bathing, dressing, preparation and feeding of special diets, and supervision of medications that are ordinarily self-administered.

Doulas are non-medical professionals who provide health education, advocacy, and physical, emotional, and non-medical support for pregnant and postpartum women before, during, and after childbirth, including support during miscarriage, stillbirth, and abortion.

Any evaluation, treatment, therapy, or device which involves the application, administration or use of procedures, techniques, equipment, supplies, products, remedies, vaccines, biological products, drugs, pharmaceuticals, or chemical compounds if, as determined by Sharp Health Plan, one of the following is true:

• Such evaluation, treatment, therapy, or device cannot be lawfully marketed without approval of the U.S. Food and Drug Administration (FDA), and approval for marketing has not, in fact, been given at the time such service is furnished to the member.
• Such evaluation, treatment, therapy or device is provided pursuant to a written protocol that describes among its objectives the following: determinations of safety, efficacy, toxicity, maximum tolerated dosage(s) or efficacy in comparison to the standard evaluation, treatment, therapy or device.
• Such evaluation, treatment, therapy or device is delivered or should be delivered subject to the approval and supervision of an institutional review board or other entity as required and defined by federal regulations.
• Such evaluation, treatment, therapy, or device is the subject of an ongoing Phase I or II clinical trial, or experimental or research arm of a Phase III clinical trial.
• The consensus among experts, as expressed in published authoritative medical literature, is that further studies, research, or clinical investigations are necessary to determine maximum tolerated dosage(s), toxicity, safety, efficacy, or efficacy as compared with the standard means for treatment or diagnosis of the medical condition in question.
• There is no consensus among practicing physicians that the treatment, therapy, or device is safe and effective for the condition in question.
• Such evaluation, treatment, therapy or device is not yet considered the standard of care by a nationally recognized technology assessment organization, specialty society or medical review organization in treating patients with the same or similar condition

The sources of information that may be relied upon by Sharp Health Plan in determining whether a particular treatment is Experimental or Investigational include, but are not limited to, the following:

• The member’s medical records.
• Peer-reviewed scientific studies published in, or accepted for publication by, medical journals that meet nationally recognized requirements for scientific manuscripts.
• Peer-reviewed literature that meet the criteria of the National Institutes of Health’s National Library of Medicine for indexing in Index Medicus, Excerpta Medicus (EMBASE), Medline, and MEDLARS database of Health Services Technology Assessment Research (HSTAR).
• The Cochrane Library.
• Medical journals recognized by the Secretary of Health and Human Services under Section 1861(t)(2) of the Social Security Act.
• The American Hospital Formulary Service’s Drug Information.
• The American Dental Association Accepted Dental Therapeutics.
• Any of the following reference compendia, if recognized by the federal Centers for Medicare & Medicaid Services as part of an anticancer chemotherapeutic regimen: (A) The Elsevier Gold Standard’s Clinical Pharmacology, (B) The National Comprehensive Cancer Network Drug and Biologics Compendium, or (C) The Thomson Micromedex DrugDex.
• Findings, studies or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes.
• Peer-reviewed abstracts accepted for presentation at major medical association meetings.

The agreement between Us and FEHB to provide health insurance coverage to Members.

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

Infertility is defined as (1) the inability to conceive a pregnancy or to carry a pregnancy to a live birth after a year or more of regular sexual intercourse without contraception, or (2) the presence of a demonstrated condition recognized by a physician as a cause of infertility

A treatment or service necessary to protect life; to prevent illness or disability; to diagnose, treat or control illness, disease or injury; or to alleviate severe pain. The treatment or service should be:

• Based on generally accepted clinical evidence;
• Consistent with recognized standards of practice;
• Demonstrated to be safe and effective for the member’s medical condition; and
• Provided at the appropriate level of care and setting based on the member’s medical condition.

Plan allowance is the amount we use to determine our payment and your co-insurance for covered services. Plans determine their allowances in different ways.

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.

We use providers in a specific geographic area. Being a member of Sharp Health Plan means you agree to use the provider(s), hospital(s), Skilled Nursing Facility or Facilities, home health agency or agencies, pharmacy or pharmacies, medical transportation company or companies, laboratory or laboratories, diagnostic facility or facilities, durable medical equipment supplier(s), and other licensed health care entities or professionals who are part of your Plan Network, or who provide covered benefits  through an agreement with Sharp Health Plan.

When you enroll as a member you will choose a physician from our network of providers to be responsible for managing your health care. This is your primary care provider (PCP) and is the provider you contact first whenever you need health care services. Your PCP evaluates your total health needs and provides personal medical care in one or more medical fields. 

Any 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.

Those claims (1) that require precertification, prior approval, or a referral and (2) where failure to obtain precertification, prior approval, or a referral results in a reduction of benefits.

A Network Plan Provider who is primarily responsible for supervising, coordinating and providing initial care to you; for maintaining the continuity of your care; and providing or initiating referrals for covered benefits for you. Primary Care Providers include general and family practitioners, internists, pediatricians and qualified OB-GYNs who have the ability to deliver and accept the responsibility for delivering primary care services

Certain covered Drugs have limits on the maximum quantity allowed per prescription over a specific time period. The medications subject to Quantity Limits are shown on Our Drug List with the abbreviation “QL.” Some Quantity Limits are based on the manufacturer’s packaging, FDA labeling or clinical guidelines.

A 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.

Surgery to rebuild or correct a physical defect that has a direct adverse effect on the physical health of a body part, and for which the restoration or correction is medically necessary.

Process specifying the sequence in which different prescription drugs for a given medical condition and medically appropriate for a particular patient are prescribed. Sharp Health plan may require you to try one or more drugs to treat your medical condition before the Plan will cover a particular drug for the condition pursuant to a Step Therapy request. If your prescribing provider submits a request for Step Therapy exception, Sharp Health Plan shall make exceptions to Step Therapy when the criteria is met.

A 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.

An unexpected bill you receive for:

• emergency care – when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services furnished by nonparticipating providers with respect to patient visits to participating health care facilities, or for
• air ambulance services furnished by nonparticipating providers of air ambulance services.

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 Care at 1-800-359-2002. 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 and We refer to Sharp Health Plan.

Nothing (this plan does not have a deductible)

22

$3,000 Self Only

$6,000 Self Plus One or Self and Family

22

$30 office visit copayment (Primary Care Provider)

$30 office visit copayment (Specialist)

29

Nothing

29

Inpatient - $500/admission

Outpatient - $250

54

$100 copayment per emergency room visit (waived if you are admitted to the hospital)

58

Doctor's Office - $30

Urgent Care Center - $30

Outpatient Hospital - $100

Accidental Injury - $100 copayment

Ambulance - $100 (emergencies only)

58

Professional Services - $30

Diagnostics - $30 (MH/SUD office visit setting)

Inpatient Hospital/Other Covered Facility - $500/admission (Preauthorization required)

Outpatient Hospital or Other Covered Facility - $30 (Preauthorization required)

60

30-day supply:

Tier 1: Preferred Generic Drugs - $20

Tier 2: Preferred Brand-Name Drugs - $40

Tier 3: Non-Preferred Drugs- $80

63

90-day supply:

Tier 1: Preferred Generic Maintenance Drugs - $40

Tier 2: Preferred Brand-Name Maintenance Drugs - $80

Tier 3: Non-Preferred Maintenance Drugs - $160

63

30-day supply:

Tier 4: Specialty Drugs - 40% (up to $350) 

63

$4,800 Self Only

$9,600 Self Plus One or Self and Family

22

$8,100 Self Only

$16,200 Self Plus One or Self and Family

22

$50, after deductible, office visit copayment (Primary Care Provider)

$50, after deductible, office visit copayment (Specialist)

29

$50, after deductible, office visit copayment (Primary Care Provider)
$50, after deductible, office visit copayment (Specialist)

29

Inpatient - 40% coinsurance, after deductible

Outpatient - 40% coinsurance, after deductible

54

40% coinsurance, after deductible (waived if you are admitted to the hospital)

58

Doctor's Office - $50, after deductible

Urgent Care Center - $50, after deductible

Outpatient Hospital - 40% coinsurance, after deductible

Accidental Injury - 40% coinsurance, after deductible

Ambulance - 40% coinsurance, after deductible (emergencies only)

58

Professional Services - $50, after deductible

Diagnostics - $50, after deductible (MH/SUD office visit setting)

Inpatient Hospital/Other Covered Facility - 40% coinsurance, after deductible (Preauthorization required)

Outpatient Hospital or Other Covered Facility - 40% coinsurance, after deductible (Preauthorization required)

60

30-day supply:

Tier 1: Preferred Generic Drugs - $20

Tier 2: Preferred Brand-Name Drugs - $40

Tier 3: Non-Preferred Drugs - $80

63

90-day supply:

Tier 1: Preferred Generic Maintenance Drugs - $40

Tier 2: Preferred Brand-Name Maintenance Drugs - $80

Tier 3: Non-Preferred Maintenance Drugs - $160

63

30-day supply:

Tier 4: Specialty Drugs - 40% (up to $350)

63