In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges

FHP Health Center: $5 copayment per visit

Preferred in-network: $10 copayment per visit

Other in-network: $20 copayment per visit

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges

FHP Health Center: $5 copayment per visit

Preferred in-network: $15 copayment per visit

Other in-network: $25 copayment per visit

Out-of-network: 30% 
coinsurance of our allowance plus any difference between our allowance and billed charges

In-network: $40 copayment per visit

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges

In-network: $40 copayment per visit

Out-of-network:  30% coinsurance of our allowance plus any difference between our allowance and billed charges

Emergency Services In Area

• Urgent care services at FHP Health Center

$15 copayment per visit 

$15 copayment per visit

• Hospital emergency room

In-network: $75 copayment per visit 

Out-of-network: $75 copay per visit 

In-network: $100 copayment per visit

Out-of-network: $100 copayment per visit 

Emergency Services Out of Area

• At doctor’s office, Urgent Care Clinic,  or Hospital emergency room 

In-network: $100 copayment per visit

Out-of-network: $100 copayment per visit plus any difference between our allowance and billed charges

In-network: 20% coinsurance 

Out-of-network: 20% coinsurance 

In-network:

Retail (30 day supply)

$10 copayment - generic formulary
$25 copayment - brand formulary
$70 copayment - non-formulary
$100 copayment - preferred specialty
$200 copayment - non-preferred specialty 

Mail Order (90 day supply)
$0 copayment - generic formulary
$50 copayment - brand formulary
$100 copayment - non-formulary 
Not Covered - specialty

Out-of-network: Not covered

In-network:

Retail (30 day supply)

$15 copayment - generic formulary
$40 copayment - brand formulary
$100 copayment - non-formulary
$100 copayment - preferred specialty
$250 copayment - non-preferred specialty

Mail Order (90 day supply)
$0 copayment - generic formulary
$80 copayment - brand formulary
$160 copayment - non-formulary
Not Covered - specialty

Out-of-network: Not covered

In-network: $100 copayment per visit

Out-of-network:  30% coinsurance of our allowance plus any difference between our allowance and billed charges

In-network: $150 copayment per visit

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges

In-network: $100 copayment per day, up to $500 maximum per inpatient admission

Out-of-network: 30% copay of our allowance plus any difference between our allowance and billed charges

In-network: $150 copayment per day, up to $750 maximum per inpatient admission

Out-of-network: 30% copay of our allowance plus any difference between our allowance and billed charges

In-network: All charges above $25 per visit. Maximum of 10 visits per calendar year

Out-of-network: Not covered

In-network: All charges above $25 per visit. Maximum of 10 visits per calendar year

Out-of-network: Not covered

In-network: All charges above $100 per benefit year

Out-of-network: Not covered

In-network: All charges above $100 per benefit year

Out-of-network: Not covered

In-network: All charges above $300 per ear, every two years

Out-of-network: Not covered

In-network: All charges above $300 per ear, every two years

Out-of-network: Not covered

In-network: Nothing for preventive services, 20% coinsurance of covered charges for restorative and simple extractions, 75% coinsurance of covered charges for prosthodontics

Out-of-network: 30% coinsurance of covered charges for preventive services,  50% coinsurance of covered charges for restorative and simple extractions, 95% coinsurance of covered charges for prosthodontics. In addition, you are responsible for charges between covered charges and billed charges

In-network: Nothing for preventive services. All other dental services are not covered

Out-of-network: 30% coinsurance of covered charges for preventive services plus any difference between covered charges and billed charges. All other dental services are not covered

Your combined in-network and out-of-network annual maximum for out-of-pocket expenses (coinsurance and copayments) for covered medical services is limited to $2,000 for Self Only enrollment, $4,000 for Self Plus One enrollment, or $6,000 for Self and Family enrollment. However, if you are using an out-of-network provider, you will continue to be responsible for any difference between our allowance and billed charges. Separately, your in-network prescription drug out-of-pocket maximum is $2,000 for Self Only enrollment, $4,000 for Self Plus One enrollment, or $6,000 for Self and Family enrollment. An individual under Self Plus One or Self and Family enrollment will never have to satisfy more than what is required for the out-of-pocket maximum limit under a Self Only enrollment

However, certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses even if you reach your out-of-pocket maximum (e.g., expenses in excess of the Plan’s allowable amount or benefit maximum). See page 24 for more information

Your combined in-network and out-of-network annual maximum for out-of-pocket expenses (coinsurance and copayments) for covered medical services is limited to $3,000 for Self Only enrollment, $6,000 for Self Plus One enrollment or Self and Family enrollment. However, if you are using an out-of-network provider, you will continue to be responsible for any difference between our allowance and billed charges. Separately, your in-network prescription drug out-of-pocket maximum is $3,000 for Self Only enrollment, $6,000 for Self Plus One enrollment or Self and Family enrollment. An individual under Self Plus One or Self and Family enrollment will never have to satisfy more than what is required for the out-of-pocket maximum limit under a Self Only enrollment

However, certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses even if you reach your out-of-pocket maximum (e.g., expenses in excess of the Plan’s allowable amount or benefit maximum). See page 24 for more information

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

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

In-network: Nothing

Out-of-network:  30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network:  30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule found at https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html.

In-network: Nothing

Out-of-network:  30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network:  30% coinsurance of our allowance plus any difference between our allowance and billed charges.

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

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
• Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html
• You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org

In-network: Nothing

Out-of-network:  30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network:  30% coinsurance of our allowance plus any difference between our allowance and billed charges.

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

All charges

All charges

Professional services of physicians

• In physician's office
• Office medical consultations
• Second surgical opinion

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

Preferred In-network: Primary Care - $10 copayment per visit, Specialist Care - $40 copayment per visit

In-network: Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

Preferred In-network: Primary Care - $15 copayment per visit, Specialist Care - $40 copayment per visit

In-network: Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Professional services of physicians

• During a hospital stay
• In a skilled nursing facility

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

At home

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing 

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered

• Off-island care for services received without prior authorization from TakeCare Medical Referral Services (MRS) department, except in the case of emergency.
• Specialty care services aren't covered when received without written referral from your primary care physician, except in the case of OB/GYN services.

Consultations via phone, audio/video services using a computer, tablet, or smartphone with in-network primary care or specialty providers, including behavioral health, on or off island. 

For specialty consultations, referral by primary care provider is required and coverage is limited to certain specialties.

Contact your provider regarding the availability of telehealth services and TakeCare for covered specialties.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

Preferred In-network: Primary Care - $10 copayment per visit, Specialist Care - $40 copayment per visit

In-network: Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: All charges

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

Preferred In-network: Primary Care - $15 copayment per visit, Specialist Care - $40 copayment per visit

In-network: Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: All charges

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap tests
• Pathology
• Electrocardiogram and EEG

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• X-rays
• Non-routine mammograms
• Ultrasound

FHP Health Center: $5 copayment in addition to regular office visit copayment.

In-network: $20 copayment in addition to regular office visit copayment. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: $5 copayment in addition to regular office visit copayment.

In-network: $25 copayment in addition to regular office visit copayment. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Prior authorization required for the following services:

• CT Scan
• MRI
• Sleep Studies

FHP Health Center: $30 copayment in addition to regular office visit copayment.

In-network: $40 copayment in addition to regular office visit copayment. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: $30 copayment in addition to regular office visit copayment.

In-network: $40 copayment in addition to regular office visit copayment. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Prior authorization required for the following services:

• Nuclear Medicine

In-network: $40 copayment in addition to regular office visit copayment. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: $40 copayment in addition to regular office visit copayment. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Complete maternity (obstetrical) care, such as:

• Prenatal care
• Screening for gestational diabetes for pregnant women 
• Delivery
• Postnatal care
• Breastfeeding support, supplies and counseling for each birth

Note: Here are some things to keep in mind:

• You do not need to have your vaginal delivery pre-authorized by TakeCare if in the service area. However, prior authorization is required for vaginal delivery services (i.e., prenatal care, delivery, and postnatal care) outside the service area.
• When a newborn requires definitive treatment during or after the mother’s confinement, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.
• 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   We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment.  Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

In-network:  Primary Care, Specialist - Nothing; Outpatient Facility - $100 copayment; Inpatient hospital - $100 copayment per day, up to $500 maximum per inpatient admission.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network:  Primary Care, Specialist - Nothing; Outpatient Facility - $150 copayment; Inpatient hospital - $150 copayment per day, up to $750 maximum per inpatient admission.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Breastfeeding support, supplies and counseling for each birth.

In-network:  Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network:  Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered

• Routine sonograms to determine fetal age, size, or gender.
• Maternity-related services outside our service area unless pre-authorized by TakeCare's Medical Referral Services (MRS) department.

Medical foods to treat physician-diagnosed Inborn Errors of Metabolism (IEM) including Phenylketonuria (PKU) as prescribed by a physician.

Maximum Annual Benefit: $5,000 per covered individual

In-network: 20% coinsurance 

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: 20% coinsurance 

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered

• Special food items which can be routinely obtained in grocery stores at the same or at a minimally higher cost than similar items (e.g., gluten-free cookies, gluten-free pasta).

All charges

All charges

Contraceptive counseling on an annual basis.

A range of voluntary family planning services, limited to:

• Voluntary sterilization (See Surgical procedures Section 5 (b)
• Surgically implanted FDA-approved contraceptives
• Injectable FDA-approved contraceptive drugs (such as Depo Provera)
• FDA-approved Intrauterine devices (IUDs)
• FDA-approved Diaphragms

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

Note: Rather than paying "nothing" when using an In-network provider, if the member chooses to use a branded product when a generic is available, she will pay the difference between the brand and generic cost.

In-network:  Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network:  Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling

Diagnosis and treatment of infertility such as:

• Artificial insemination: (Up to three cycles per pregnancy attempt) 
  • intravaginal insemination (IVI)
  • intracervical insemination (ICI)

In-network: Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Specialist Care - 50% coinsurance of our allowance. (Coinsurance is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Injectable fertility drugs

Note: We cover oral fertility drugs under Section 5(f) Prescription drug benefits. 

In-network: $15 copayment per injection in addition to the office visit copayment.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: $15 copayment per injection in addition to the office visit coinsurance.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Assisted reproductive technology (ART) procedures, such as:
  •  in vitro fertilization (IVF)
  • embryo transfer, gamete intra-fallopian transfer (GIFT)  
  • zygote intra-fallopian transfer (ZIFT)
  • Intrauterine insemination (IUI)
• Services and supplies related to excluded ART procedures
• Cost of donor sperm
• Cost of donor egg

• Testing and treatment
• Allergy injections

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network: Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Clinic: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network: Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Allergy serum

In-network: nothing in addition to the office visit copayment. 

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: nothing in addition to the office visit copayment.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Provocative food testing and sublingual allergy desensitization

• Chemotherapy and Radiation therapy
  
  Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under Organ/Tissue Transplants on page 52.

• Respiratory and inhalation therapy
• Cardiac rehabilitation following qualifying event/condition is provided for up to 20 sessions per benefit period.
• Intravenous (IV) / Infusion Therapy – Home IV and antibiotic therapy
• Growth hormone therapy (GHT)

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

Note: – We only cover GHT when we pre-authorize 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; otherwise, we will only cover GHT services and related services and supplies that we determine are medically necessary. See "Other services" under "You need prior Plan approval for certain services" on page 19. 

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $20 copayment per visit ; Specialist - $40 copayment per visit; Outpatient Facility - $100 copayment; Inpatient hospital - $100 copayment per day, up to $500 maximum per inpatient admission. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $25 copayment per visit ; Specialist - $40 copayment per visit; Outpatient Facility - $150 copayment; Inpatient hospital - $150 copayment per day, up to $750 maximum per inpatient admission. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Dialysis - hemodialysis and peritoneal dialysis

In-network:  Primary Care - $20 copayment per visit ; Specialist Care - $40 copayment per visit; Outpatient Facility - $100 copayment; Inpatient hospital - $100 copayment per day, up to $500 maximum per inpatient admission. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network:  Primary Care - $25 copayment per visit ; Specialist Care - $40 copayment per visit; Outpatient Facility - $150 copayment; Inpatient hospital - $150 copayment per day, up to $750 maximum per inpatient admission. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Unlimited outpatient services and up to two (2) consecutive months per condition for the services of each of the following:

• Qualified physical therapists
• occupational therapists

Note: We only cover therapy when a physician:

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

We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury.

These therapies also apply to habilitation services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may also include speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

In-network: Specialist Care - $40 copayment per office visit; nothing for home visits; nothing during covered inpatient admission. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Specialist Care - $40 copayment per office visit; nothing for home visits; nothing during covered inpatient admission. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Long-term rehabilitative therapy
• Exercise programs, lifestyle modification programs
• Equipment, supplies or customized devices related to rehabilitative therapies, except those provided under Section 5(a) Durable Medical Equipment
• Services provided by schools or government programs
• Developmental and Neuroeducational testing and treatment beyond initial diagnosis
• Hypnotherapy
• Psychological testing
• Vocational rehabilitation

Inpatient cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is covered for up to 90 days per benefit period.

Outpatient cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is covered for up to 20 sessions per benefit period.

In-network: Specialist Care - $40 copayment per office visit; nothing for home visits; nothing during covered inpatient admission. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Specialist Care - $40 copayment per office visit; nothing for home visits; nothing during covered inpatient admission. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Qualified Speech Therapist

In-network: Specialist Care - $40 copayment per office visit; nothing for home visits; nothing during covered inpatient admission. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Specialist Care - $40 copayment per office visit; nothing for home visits; nothing during covered inpatient admission. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Hearing testing and treatment for adults, when medically necessary
• For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist
• Hearing aid testing and evaluation for adults

Adult hearing aid benefits and limits: (see Orthopedic and prosthetic devices, page 43)

Note: Hearing testing for children through age 17 to determine the need for hearing correction is covered under Preventive Care for Children.

In-network: Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Hearing services that are not shown as covered
• Hearing aids, testing and examinations for children 

• Annual eye exams through age 17 to determine the need for vision correction

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Annual eye exams for adults 
  
  
  

FHP Health or Vision Centers: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit. 

In-network: Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit. 

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health or Vision Centers: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit.  

In-network: Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit. 

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Refraction Exam

Refraction exams will be covered as part of the annual eye exam if member meets any of the following criteria:

1. Fails a screening or risk assessment test;
2. Reports a visual problem; or
3. Cannot complete a screening (e.g. developmental delay)

Otherwise, applicable member share for refraction exam applies. 

FHP Vision Center: $20 copayment per visit

In-network: $40 copayment per visit

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Vision Center: $25 copayment per visit

In-network: $40 copayment per visit

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Prescription eyeglasses or contact lenses

In-network: All charges in excess of $100 per benefit year

Out-of-network: All charges

In-network: All charges in excess of $100 per benefit year

Out-of-network: All charges

• Medical and surgical benefits for the diagnosis and treatment of diseases of the eye

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit. 

In-network: Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit. 

In-network: Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Eye exercises and orthoptics (vision therapy)
• Radial keratotomy and other refractive surgery such as LASIK (Laser-Assisted Stromal In-situ Keratomileusis) surgery
• Routine vision services outside the service area

• Foot care and podiatry services

Note: When you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes, routine foot care may be covered. Prior authorization is required.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit. 

In-network: Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit. 

In-network: Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Routine footcare including: cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above.
• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery).

• Artificial eyes
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy (up to two (2) surgical bras per benefit year)
• Internal prosthetic devices, such as spinal implants, bone segments, artificial disks, artificial joints, artificial plates, stents, leads, intraocular lenses, and surgically implanted breast implant following mastectomy. 
• Single and dual pacemakers, biventricular pacemakers, pacemaker monitors, accessories such as pacemaker batteries and leads, including the cost of the devices, their placement, repair or replacement and related Medical Travel Benefit, hospital, and surgical charges will accrue towards the Pacemaker Annual Limit of $50,000 per member.
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome. 
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants

Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b) - Surgical and anesthesia services.  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.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit.  In addition to the copayment, you are responsible for 10% coinsurance of our allowance for the device.

In-network: Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit. In addition to the copayment, you are responsible for 10% coinsurance of our allowance for the device. (Copayment and coinsurance is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Clinic: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit.  In addition to the copayment, you are responsible for 10% coinsurance of our allowance for the device.

In-network: Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit. In addition to the copayment, you are responsible for 10% coinsurance of our allowance for the device. (Copayment and coinsurance is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Orthopedic devices, such as braces

FHP Clinic: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit.  In addition to the copayment, you are responsible for 10% coinsurance of our allowance for the device.

In-network: Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit. In addition to the copayment, you are responsible for 10% coinsurance of our allowance for the device. (Copayment and coinsurance is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• External hearing aid for adults (limited to $300 maximum benefit per ear every two (2) years)

In-network: All charges in excess of $300 per ear, every two years

Out-of-network: All charges

In-network: All charges in excess of $300 per ear, every two years

Out-of-network: All charges

Not covered:

• Orthopedic and corrective shoes
• Arch supports, foot orthotics, heel pads and heel cups
• Artificial limbs 
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Lumbosacral supports
• Splints
• Over-the-counter (OTC) items
• Internal prosthetics such as heart valves, automatic implantable cardioverter defibrillator (AICD) and other implantable devices not specified above.
• Prosthetic replacements provided less than 3 years after the last one we covered

We will cover the rental or purchase of DME, at our option, including repair and adjustment. Covered items include:

• Manual hospital beds
• Standard manual wheelchairs
• Crutches/walk aids
• CPAP (Continuous Positive Airway Pressure)
• BPAP (Bi-Level Positive Airways Pressure)

Note

Pre-authorization is required. Contact us at 671-300-5995 or via email at tc.mrs@takecareasia.com as soon as your physician prescribes this equipment. We will arrange with a healthcare provider to rent or sell you DME at discounted rates and will tell you more about this service when you call.

In-network: 15% coinsurance towards rental or purchase of covered equipment from an in-network provider. You will be advised of the coinsurance amount when the pre-authorization is issued.

Out-of-network: All charges

In-network: 15% coinsurance towards rental or purchase of covered equipment from an in-network provider. You will be advised of the coinsurance amount when the pre-authorization is issued.

Out-of-network: All charges

We will cover the following devices with a written prescription:

• Blood Glucose Monitors
• Continuous Glucose Monitor (CGM) System, including transmitter and sensors, if patient is actively participating in TakeCare’s Diabetes Management Program and meets criteria for coverage based on HbA1c level

In-network: Nothing

Out-of-network: All charges

In-network: Nothing

Out-of-network: All charges

• Motorized wheelchairs
• Motorized beds
• CPAP and BPAP supplies including masks
• Insulin pumps

Home healthcare ordered by a physician, pre-authorized by us, and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide while under an active treatment plan with a home health agency including services such as:

• Oxygen therapy, intravenous therapy and medications.
• Services ordered by a physician for members who are confined to the home.
• Nursing
• Medical supplies included in the home health plan of care.
• Physical therapy, speech therapy, occupational therapy, and respiratory therapy.

In-network: Nothing

Out-of-network:  30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network:  30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• 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.

Chiropractic services - You may self refer to a participating chiropractor for up to 10 visits per benefit year.

Services are limited to:

• Manipulation of the spine and extremities
• Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application 
• Osteopathic Manipulative Treatment (OMT) when provided by a licensed, trained and credentialed practitioner.

In-network: All charges above $25 per visit and all charges after your 10th visit in a benefit year.

Out-of-network: All charges 

Not covered:

• Consults and evaluations
• Ancillary services for chiropractic purposes (e.g., x-rays)

1. All charges

Acupuncture Services - You may self refer to a participating acupuncture practitioner for up to 10 visits per benefit year.

The Plan defines acupuncture as the practice of insertion of needles into specific exterior body locations to relieve pain, to induce surgical anesthesia, or for therapeutic purposes.

These providers are required to submit itemized bills and their Federal Tax I.D. Number (if a United States provider) as outlined in Section 7, Filing a claim for covered services.

In-network: All charges above $25 per visit and all charges after 10th visit per benefit year.

Out-of-network: All charges

In-network: All charges above $25 per visit and all charges after 10th visit per benefit year.

Out-of-network: All charges

Massage Therapy - You may self refer to a participating, licensed massage therapist for up to 10 visits per benefit year.

These providers are required to submit itemized bills and their Federal Tax I.D. Number (if a United States provider) as outlined in Section 7, Filing a claim for covered services.

In-network: $10 copayment per visit (up to 10 visits per benefit year).

Out-of-network: All charges

In-network: $10 copayment per visit (up to 10 visits per benefit year).

Out-of-network: All charges

Not covered:

• Chelation therapy except for acute arsenic, gold, mercury or lead poisoning; or use of Desferoxamine in iron poisoning
• Naturopathic services and medicines
• Homeopathic services and medicines
• Rolfing

All charges

All charges

Programs are administered through the TakeCare Wellness Team including:

• Cardiac Risk Management Class
• Nicotine Cessation Program 
• Diabetes Management
• Wellness Workshop
• Group Fitness Program
• Nutrition Coaching
• Children's Health Improvement Program
• Well Mommy, Well Baby Program

Note:  For more information on these and other classes, see pages 77-80 or call the TakeCare Wellness team at 671-300-7161 or via email at wellness@takecareasia.com.

Nothing. All health education classes are FREE to TakeCare members unless otherwise specified. Referral is required from your primary care physician. No referral is required for TakeCare's Group Fitness classes.

Nothing. All health education classes are FREE to TakeCare members unless otherwise specified. Referral is required from your primary care physician. No referral is required for TakeCare's Group Fitness classes.

Nicotine Cessation Program

• primary care physician referral required
• individual/group/telephone counseling
• over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence
  • Nicotrol Nasal Spray
  • Nicotrol Inhaler
  • Chantix
  • Zyban
  • Bupropion hydrochloride
  • Nicorette Gum
  • Nicorette DS Gum
  • Habitrol Transdermal film
  • Nicoderm CQ Transdermal system
  • Commit Lozenge
  • Nicorette Lozenge
  • Nicotine Film
  • Nicotine Polacrilex, Gum, Chewing; Buccal
  • Thrive (Nicotine Polacrilex) Gum, Chewing; Buccal
  • Nicotine Polacrilex, Trocher/Lozenge
  • Nicotine Patch
  • Varenicline

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 counseling for up to two quit attempts per year.

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

• Operative procedures
• Treatment of fractures, including casting
• Normal pre and post-operative care by the surgeon
• Correction of amblyopia and strabismus 
• Endoscopy procedures 
• Biopsy procedures
• Circumcision  
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Surgical treatment of morbid obesity  (bariatric surgery). Surgery is limited to Roux-en-Y bypass, laparoscopic gastric band placement, and vertical banded gastroplasty.
  
  Concerning bariatric surgery, the following conditions must be met:
  • Eligible members must be age 18 or over
  • Eligible members must weigh 100 pounds or 100% over their normal weight according to current underwriting standards
  • Eligible members must meet the National Institute of Health Guidelines
  • We may require you to participate in a non-surgical multidisciplinary program approved by us for six months prior to your bariatric surgery
  • We will determine the provider for the non-surgical program and surgery based on quality and outcomes.
• Insertion of internal prosthetic devices.  See Section 5(a) – Orthopedic and prosthetic devices for device coverage information.
• Cardiac surgery for the implantation of stents, leads and pacemaker
• Cardiac surgery for the implantation of  valves (Plan pays for the cost of procedure only)
• Voluntary sterilization (e.g., tubal ligation, vasectomy)
• Treatment of burns

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

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $100 copayment per visit; Inpatient hospital - $100 copayment per day, up to $500 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $150 copayment per visit; Inpatient hospital - $150 copayment per day, up to $750 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot: see Foot care
• Services and supplies provided for circumcisions performed beyond thirty-one (31) days from the date of birth that are not determined to be medically necessary.
• Surgeries related to gender reassignment

Covered services include:

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • the condition produced a major effect on the member’s appearance and
  • the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers and toes.
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • surgery to produce a symmetrical appearance of breasts;
  • treatment of any physical complications, such as lymphedemas;
  • breast prostheses and surgical bras and replacements (see Prosthetic devices) 

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

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $100 copayment per visit; Inpatient hospital - $100 copayment per day, up to $500 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $150 copayment per visit; Inpatient hospital - $150 copayment per day, up to $750 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

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

All charges

All charges

• Reduction of fractures of the jaws or facial bones
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion
• Removal of stones from salivary ducts
• Excision of leukoplakia or malignancies
• Excision of cysts and incision of abscesses when done as independent procedures
• Other surgical procedures that do not involve the teeth or their supporting structures
• TMJ surgery and other related non-dental treatment

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $100 copayment per visit; Inpatient hospital - $100 copayment per day, up to $500 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $150 copayment per visit; Inpatient hospital - $150 copayment per day, up to $750 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
• Dental services related to treatment of TMJ

The following solid organ transplants are covered and subject to medical necessity and experimental/investigational review by the Plan. Pre-authorization is required. Solid organ transplants are limited to:

• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for those 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

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $100 copayment per visit; Inpatient hospital - $100 copayment per day, up to $500 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $150 copayment per visit; Inpatient hospital - $150 copayment per day, up to $750 maximum per admission. Copayment is waived at in-network facility in the Philippines.
.
Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

The following tandem blood or marrow stem cell transplants for covered transplants are covered and subject to medical necessity review by the Plan. Pre-authorization is required.

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

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $100 copayment per visit; Inpatient hospital - $100 copayment per day, up to $500 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $150 copayment per visit; Inpatient hospital - $150 copayment per day, up to $750 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Blood or marrow stem cell transplants  

The Plan extends coverage for the diagnoses as indicated below. Not subject to medical necessity. Plan’s denial is limited to indicators for transplant such as refractory or relapsed disease, cytogenetics, subtype, staging or the  diagnosis.

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced neuroblastoma
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Hodgkin's lymphoma - relapsed
  • 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
  • Non-Hodgkin's lymphoma - relapsed
  • 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)
  • Aggressive non-Hodgkin lymphomas
  • Amyloidosis
  • Breast Cancer
  • Ependymoblastoma
  • Epithelial ovarian cancer
  • Ewing’s sarcoma
  • Hodgkin's lymphoma - relapsed
  • Medulloblastoma
  • Multiple myeloma
  • Neuroblastoma
  • Non-Hodgkin's lymphoma - relapsed
  • Pineoblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $100 copayment per visit; Inpatient hospital - $100 copayment per day, up to $500 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $150 copayment per visit; Inpatient hospital - $150 copayment per day, up to $750 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) are covered for members with a diagnosis listed below, subject to medical necessity review by the Plan. There is no defined age limits for the use of RIC for an allogeneic stem cell transplant.

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, PNH, Pure Red Cell Aplasia)
  • Myelodysplasia/Myelodysplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
• Autologous transplants for
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Neuroblastoma

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $100 copayment per visit; Inpatient hospital - $100 copayment per day, up to $500 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $150 copayment per visit; Inpatient hospital - $150 copayment per day, up to $750 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

The following 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 subject to prior authorization 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 (Mantle Cell lymphoma, adult T-cell leukemia/lymphoma, peripheral T-cell lymphomas and aggressive Dendritic Cell neoplasms) 
  • 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
  • Multiple sclerosis
  • Small cell lung cancer
  • Systemic lupus erythematosus
  • Systemic sclerosis

Limited Benefits

• Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may be provided in an NCI- or NIH-approved clinical trial at a Plan-designated center of excellence subject to prior authorization by the Plan’s medical director in accordance with the Plan’s protocols.
• Bone marrow stem cell donor search and testing for compatible unrelated donors up to $15,000 per procedure at a National Preferred Transplant Facility when you are the intended recipient.

Transportation, food and lodging - the following benefits are provided on a reimbursement basis, if you live over 60 miles from the transplant center and the services are pre-authorized by us:

• Transportation limited to you and one escort to a National Preferred Transplant Network or other Company Approved Transplant Facility.
• A $125 per day allowance for housing and food.  This allowance excludes liquor and tobacco.

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.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $100 copayment per visit; Inpatient hospital - $100 copayment per day, up to $500 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $150 copayment per visit; Inpatient hospital - $150 copayment per day, up to $750 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

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

Professional anesthesia services provided in:

• Inpatient hospital
• Outpatient hospital
• Skilled nursing facility
• Ambulatory surgical center
• Physician's office

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Coverage includes room and board, such as

• Ward, semiprivate, or intensive care accommodations
• General nursing care
• Meals and special diets

In-network: $100 copayment per day up to $500 maximum per inpatient admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: $150 copayment per day up to $750 maximum per inpatient admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests, x-rays and pathology tests
• Administration of blood and blood products
• Dressings, splints, casts and sterile tray services
• Medical supplies and equipment including oxygen
• Anesthetics, including nurse anesthetist services
• Rehabilitative therapies - See Section 5(a) for benefit limitations

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Any inpatient hospitalization for dental procedure
• Blood and blood products, whether synthetic or natural
• Custodial care
• Internal prosthetics except for those covered under Section 5(a) - Prosthetic and Orthopedic Devices.
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home
• Non-covered facilities, such as nursing homes, schools
• Personal comfort items, such as telephone, television, barber services, guest meals and beds
• Private nursing care
• Take-home items

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Administration of blood, blood plasma, and other biologicals
• Pre-surgical testing
• Dressings, casts and sterile tray services
• Medical supplies including oxygen
• Anesthetics and anesthesia service

Note:  We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment.  We do not cover the dental procedures.

In-network:  $100 copayment per visit. Copayments waived when using in-network providers in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: $150 copayment per visit. Copayments waived when using in-network providers in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Blood and blood products, whether synthetic or natural

The Plan provides a comprehensive range of benefits when full-time skilled nursing care and confinement in a skilled nursing facility  is medically appropriate as determined by a Plan doctor and approved by the Plan.

Benefit Limits:

• Standard Option – up to 60 days confinement per calendar year
• High Option – up to 100 days confinement per calendar year

All necessary services are covered, including:

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

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered: 

• Custodial care
• Skilled nursing facility services in the Philippines

Supportive and palliative care for a terminally ill member is covered in the home or hospice facility when approved by TakeCare's Medical Referral Services department.

To be covered, services must be provided under the direction of a physician who certifies the patient is in the terminal stages of illness with a life expectancy of approximately six months or less.

Covered services include:

• Inpatient and outpatient care
• Family counseling

Note:  This benefit is limited to a maximum of up to 180 days per lifetime.

In-network: Nothing

Out-of-network: All charges

In-network: Nothing

Out-of-network: All charges

Not covered:

• Independent nursing, homemaker services
• Hospice-related services in the Philippines

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Transport that the Plan determined are not medically necessary
• Air ambulance services

All charges

All charges

• Urgent care services at the FHP Health Center
  • No appointment necessary
  • Including lab, x-ray, limited pharmacy services
  • Clinic is open from 8:00am – 8:00pm, Monday thru Saturdays. 10:00am – 6:00pm Sundays, except Christmas, New Year's, and one staff development day per year.

$15 copayment per visit

$15 copayment per visit

• Urgent care at a doctor's office other than FHP or at Guam Memorial Hospital (GMH).

In-network: Primary Care - $20 copayment per visit;  Specialist Care - $40 copayment per visit

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Primary Care - $25 copayment per visit;  Specialist Care - $40 copayment per visit

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

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

Note: We waive the ER copay if you are admitted to the hospital and inpatient copay will apply

In-network: $75 copayment per emergency room visit

Out-of-network: $75 copayment per emergency room visit 

In-network: $100 copayment per emergency room visit

Out-of-network: $100 copayment per emergency room visit

• 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 ER copay if you are admitted to the hospital and inpatient copay will apply

If you are covered by Medicare on a primary basis, our coverage is secondary and will be dependent on what Medicare considers an eligible expense.

In-network: $100 copayment per visit

Out-of-network: $100 copayment per visit 

In-network: 20% coinsurance 

Out-of-network: 20% coinsurance 

• Elective care or non-emergency care and follow-up care recommended by out-of-network providers that has not received prior authorization by the Plan
• 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 that has not received prior authorization by the Plan

Not covered:

• Transport that the Plan determined are not medically necessary
• Air ambulance

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.

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

• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Medication evaluation and management  (pharmacotherapy)
• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
• Treatment and counseling (including individual or group therapy visits, in person or via phone, audio and video services using a computer, tablet or smartphone)
• 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

In-network: Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit ; Outpatient facility - $100 copayment per visit

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit ; Outpatient facility - $150 copayment per visit

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Applied Behavior Analysis (ABA) for the treatment of Autism Spectrum Disorder (ASD) is covered as any other condition, subject to prior authorization and benefit limitations.

ASD is a condition that begins early in life and typically affect areas of a person’s daily functioning. ASD is a group of developmental disabilities defined by uncharacteristic social interactions and communication (both verbal and nonverbal).

The following benefit limitations apply:

• Limited to children up to age 21
• Prior Authorization and treatment plan required
• An Autism Spectrum Disorder diagnosis meeting minimum criteria such as, but not limited to, impairment in social interaction, lack of social reciprocity, delay in the development of spoken language and inflexible adherence to specific non-functional routines
• Services must be performed by Qualified Autism Service Provider, Qualified Autism Service Professional, or Qualified Autism Service Paraprofessional
• Travel and/or lodging expenses are not covered

In-network: Specialist Care - $40 copayment per visit; Outpatient Facility - $100 copayment per visit; Inpatient hospital - $100 copayment per day, up to $500 maximum per admission. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Maximum Annual Benefit: $50,000 ages 9 and below, $25,000 ages 10 to 21

In-network: Specialist Care - $40 copayment per visit; Outpatient Facility - $150 copayment per visit; Inpatient hospital - $150 copayment per day, up to $750 maximum per admission. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Maximum Annual Benefit: $50,000 ages 9 and below, $25,000 ages 10 to 21

• 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

In-network: Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit ; Outpatient facility - $100 copayment per visit

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit ; Outpatient facility - $150 copayment per visit

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

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
• Preauthorization required

In-network: $100 copayment per day up to $500 maximum per inpatient admission

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: $150 copayment per day up to $750 maximum per inpatient admission

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

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
• Preauthorization required

In-network: $100 copayment

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: $150 copayment

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Evaluation or therapy on court order or as a condition of parole or probation, or otherwise required by the criminal justice system, unless determined by a Plan physician to be medically necessary

Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.

We cover the following medications and supplies prescribed by a physician and obtained from an in-network 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.
• Diabetic supplies limited to disposable needles and syringes for the administration of covered medications.
• Weight loss medication, subject to prior authorization and benefit coverage criteria such as but not limited to Body Mass Index (“BMI”) and/or co-morbidities.
• Drugs to treat gender dysphoria

Note: Insulin and other glucose-lowering agents for diabetes are covered as Preventive Medications (see below). 

Note: If there is no generic equivalent available, you will still have to pay the non-formulary copay if your physician did not specify "Dispense as Written" on the prescription.

In-network:
Retail Pharmacy Copay - (30-day supply)

Generic formulary: $10 copay 

Brand formulary: $25 copay

Non-formulary: $70 copay

Preferred Specialty drugs: $100 copay

Non-Preferred Specialty drugs: $200 copay

Mail Order Copay - (90-day supply)

Generic formulary: $0 copay

Brand formulary: $50 copay

Non-formulary: $100 copay

Specialty: Not covered

Out-of-network:
No coverage except for out-of-area emergencies or approved referrals

In-network:
Retail Pharmacy Copay - (30-day supply)

Generic formulary: $15 copay 

Brand formulary: $40 copay

Non-formulary: $100 copay

Preferred Specialty drugs: $100 copay

Non-Preferred Specialty drugs: $250 copay

Mail Order Copay - (90-day supply)

Generic formulary: $0 copay

Brand formulary: $80 copay

Non-formulary: $160 copay

Specialty: Not Covered

Out-of-network:
No coverage except for out-of-area emergencies or approved referrals 

• Women's FDA-approved contraceptive drugs and devices.

Note: Rather than paying "nothing" when using an In-network provider, if the member chooses to use a branded product when a generic is available, she will pay the difference between the brand and generic cost.

• Growth hormone

• Drugs for sexual dysfunction are covered when Plan criteria is met. For information about these criteria and dose limits, please have the prescribing physician call Elixir, formerly Envision Pharmaceuticals, at 1-800-361-4542.
• Oral fertility drugs

Medications to promote better health as recommended by ACA.

The following generic drugs and supplements are covered without cost-share, even if over-the-counter, if prescribed by a healthcare professional and filled at a network pharmacy.

• Aspirin (81 mg) for adults, ages 50-59, who have a 10% or greater 10-year cardiovascular risk, are not an increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years
• Aspirin (81 mg) for women of childbearing age, after 12 weeks gestation, who are at high risk for preeclampsia 
• Folic acid daily supplements (0.4 to 0.8 mg) for women ages 14-45 
• Liquid iron supplements for children age 6 months -1 year
• Vitamin D supplements (prescription strength) (400 & 1000 units) for members 65 or older
• Fluoride tablets, solution ( not toothpaste, rinses) for children age 0-5
• Formulary drugs and devices for the management of conditions as listed below:
  • Angiotensin Converting Enzyme (ACE) inhibitors for congestive heart failure, diabetes, and/or coronary artery disease
  • Anti-resorptive therapy for osteoporosis and/or osteopenia
  • Beta-blockers for congestive heart failure and/or coronary artery disease
  • Blood pressure monitor for hypertension
  • Inhaled corticosteroids and peak flow meters for asthma
  • Insulin and other glucose-lowering agents for diabetes
  • Opioid dependence treatments for opioid addiction
  • Selective Serotonin Reuptake Inhibitors (SSRIs) for depression
  • Statins for heart disease and/or diabetes

Note: Rather than paying "nothing" when using an In-network provider, if the member chooses to use a branded product when a generic is available, they will pay the difference between the brand and generic cost.

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

Note:  To receive this benefit a prescription from a doctor must be presented to pharmacy.

In-network:  Nothing

Out-of-network:
No coverage except for out-of-area emergencies or approved referrals

In-network:  Nothing

Out-of-network:
No coverage except for out-of-area emergencies or approved referrals

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies 
• Drugs or substances not approved by the Food and Drug Administration (FDA)
• Newly approved FDA drugs and medication within one year from the date of FDA approval. Coverage after the one year period is subject to the review, determination and approval of TakeCare’s pharmacy committee.
• Hospital take-home drugs
• Medical supplies (such as dressing, and antiseptics) 
• Non-prescription medications
• Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them 
• Replacement of lost, stolen or destroyed medication

Note: Over-the-counter and prescription drugs approved by the FDA to treat tobacco dependence are covered under the Nicotine Cessation programs benefit. See page 47.

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

OFFICE VISIT
Oral examination and treatment plan; vitality test; and oral cancer exam. X-rays, including bitewings (once a year) and panoramic (once every three years).

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

RESTORATIVE DENTISTRY
Amalgam - one, two or three surfaces.
Composite - one or two surfaces, anterior only. Posterior composites are not covered; however, an allowance for a comparable silver amalgam restoration will be made. The difference in fees is the member's responsibility.

In-network: 20% coinsurance of covered charges

Out-of-network: 50% coinsurance of our allowance plus any difference between our allowance and billed charges.

All charges

In-network: 20% coinsurance of covered charges

Out-of-network: 50% coinsurance of our allowance plus any difference between our allowance and billed charges.

All charges

PROSTHODONTICS
Full and partial dentures; crowns and bridges; repair; relining and/or reconstruction of dentures.

In-network: 75% coinsurance of covered charges

Out-of-network: 95% coinsurance of our allowance plus any difference between our allowance and billed charges.

All charges

$1,500 per member per benefit year.

$1,500 per member per benefit year.

• Oral Surgery
• Prescription Drugs
• Orthodontics

All charges

All charges

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

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

Not subject to deductible

In-network – Nothing 

Out-of-network – 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule found at https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html.

Not subject to deductible

In-network – Nothing 

Out-of-network – 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

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.

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
• Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html
• You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org

Not subject to deductible

In-network – Nothing

Out-of-network –  30% coinsurance of our allowance plus any difference between our allowance and billed charges.

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.

All charges.

The plan deductible applies to almost all benefits in this Section.  In the You pay column, we say “Not subject to deductible” when it does not apply.  When you receive covered services from in-network or out-of-network providers, you are responsible for paying the eligible charges until you meet the deductible. The Self and Family deductible can be satisfied when at least two (2) covered family members have met their individual deductible in a calendar year.

After you meet the deductible, we pay our portion of eligible charges (less your coinsurance or copayment) until you meet the annual catastrophic out-of-pocket maximum. Once you've met the out-of-pocket maximum, we pay eligible charges at 100% for the balance of the year for in-network services.

Please refer to Section 4 for your out-of-pocket maximum and services/expenses that do not count towards your out-of-pocket maximum.

Plan deductible: You are responsible for 100% of eligible charges until you meet the combined in-network and out-of-network plan deductible of $3,000 for Self Only or $6,000 for Self Plus One or $6,000 for Self and Family enrollment. You may choose to pay the deductible from your HSA or HRA, or you can pay it out-of-pocket.

After you meet your plan deductible, you pay the indicated coinsurance or copayments for covered in-network services until you have met your annual catastrophic out-of-pocket maximum.  

For out-of-network services, in addition to your indicated coinsurance or copayments, you are always responsible for the difference between our allowance and billed charges, even after you have met your annual catastrophic out-of-pocket maximum.

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

Professional services of physicians

• In physician’s office
• Office medical consultations
• Second surgical opinion
• During a hospital stay
• In a skilled nursing facility

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered

• Off-island care for services received without prior authorization from TakeCare Medical Management department, except in the case of emergency.

Consultations via phone, audio/video services using a computer, tablet, or smartphone with in-network primary care or specialty providers, including behavioral health, on or off island. 

For specialty consultations, referral by primary care provider is required and coverage is limited to certain specialties.

Contact your provider regarding the availability of telehealth services and TakeCare for covered specialties.

FHP Health Center: 20% coinsurance

In-network: 20% coinsurance

Out-of-network: All charges

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine Pap tests
• Pathology
• Electrocardiogram and EEG

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• X-rays
• Non-routine mammograms
• CT Scans/MRI/Nuclear Medicine/Sleep Studies (prior authorization required)
• Ultrasound

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Complete maternity (obstetrical) care, such as:

• Prenatal care
• Screening for gestational diabetes for pregnant women 
• Delivery
• Postnatal care
• Breastfeeding support, supplies and counseling for each birth

Note: Here are some things to keep in mind:

• You do not need to have your vaginal delivery pre-authorized by TakeCare if in the service area. However, prior authorization is required for vaginal delivery services (i.e., prenatal care, delivery, and postnatal care) outside the service area.
• When a newborn requires definitive treatment during or after the mother’s confinement, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.
• 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   We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment.  Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

In-network: Primary care, Specialist - Nothing; Outpatient Facility, Inpatient Hospital - 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Routine sonograms to determine fetal age, size or sex
• Maternity-related services outside our service area unless pre-authorized by TakeCare's Medical Management Department.

Medical foods to treat physician-diagnosed Inborn Errors of Metabolism (IEM) including Phenylketonuria (PKU) as prescribed by a physician. 

Maximum Annual Benefit: $5,000 per covered individual

In-network: 20% coinsurance 

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered

• Special food items which can be routinely obtained in grocery stores at the same or at a minimally higher cost than similar items (e.g., gluten-free cookies, gluten-free pasta).

All charges

Contraceptive counseling on an annual basis

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

A range of voluntary family planning services, limited to:

• Voluntary sterilization (See Surgical procedures Section 5 (b)
• Surgically implanted FDA-approved contraceptives
• Injectable FDA-approved contraceptive drugs (such as Depo Provera)
• FDA-approved Intrauterine devices (IUDs)
• FDA-approved Diaphragms

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

Note: Rather than paying "nothing" when using an In-network provider, if the member chooses to use a branded product when a generic is available, she will pay the difference between the brand and generic cost.

In-network:  20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing counseling 

Diagnosis and treatment of infertility such as:

• Artificial insemination: (up to three cycles per pregnancy attempt)
  • intravaginal insemination (IVI)
  • intracervical insemination (ICI)

In-network: Specialty Care - 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Injectable fertility drugs

Note: Oral fertility drugs are covered under Section 5(f) Prescription Drug Benefits.

In-network: $15 copayment in addition to the office visit coinsurance after you've met your deductible.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Assisted reproductive technology (ART) procedures, such as:
  • in vitro fertilization
  • embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
  • Zygote transfer
• Intrauterine insemination (IUI)
• Services and supplies related to ART procedures
• Cost of donor sperm
• Cost of donor egg

• Testing and treatment

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Allergy injections - Allergy serum

In-network: $150 copayment

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Provocative food testing and sublingual allergy desensitization

• Chemotherapy and Radiation therapy
  Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed on page 109.

• Organ/Tissue Transplants
• Respiratory and inhalation therapy
• Cardiac rehabilitation following qualifying event/condition is provided for up to 20 sessions per benefit period
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy
• Growth hormone therapy (GHT)
  Note: Growth hormone is covered under the prescription drug benefit. We only cover GHT when we prior authorize the treatment. We will ask you to submit information that establishes 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 we determine are medically necessary. See Other services under You need prior Plan approval for certain services on page 19.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Unlimited outpatient services and up to two (2) consecutive months per condition for the services of each of the following:

• qualified physical therapists
• qualified occupational therapists

Note: We only cover therapy when a physician:

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

We will only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury.

These therapies also apply to habilitation services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may also include speech pathology therapy and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Long-term rehabilitative therapy
• Exercise programs, lifestyle modification programs
• Equipment, supplies or customized devices related to rehabilitative therapies, except those provided under Section (a) Durable Medical Equipment
• Services provided by schools or government programs
• Developmental and Neuroeducational testing and treatment beyond initial diagnosis
• Hypnotherapy
• Psychological testing
• Vocational Rehabilitation

Inpatient cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is covered for up to 90 days per benefit period.

Outpatient cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is covered for up to 20 sessions per benefit period.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Unlimited visits for the services of a qualified Speech Therapist

Note: Speech therapy also applies to habilitation services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may also include physical/occupational therapies and other services for people with disabilities in a variety of inpatient and/or outpatient settings. All therapies are subject to medical necessity.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed 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 HDHP Section 5(a)  -Preventive care for children

In-network: Specialist Care - 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Hearing testing and treatment for adults when medically indicated for other than hearing aids 

Note: Hearing exams for children through age 17 covered under HDHP Preventive Care for Children

Note: for adult hearing device coverage information, see HDHP Sec. 5(a) - Orthopedic and prosthetic devices

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Hearing services that are not shown as covered

• Hearing aids, testing and examinations for children

Medical and surgical benefits for the diagnosis and treatment of diseases of the eye

• Annual eye examinations for adults

Note: See HDHP Preventive care for children for coverage of eye exams for children

In-network: 20% coinsurance 

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: All charges in excess of $100 per benefit year

Out-of-network: All charges

Refraction Exam

Refraction exams will be covered as part of the annual eye exam if member meets any of the following criteria:

• Fails a screening or risk assessment test;
• Reports a visual problem; or
• Cannot complete a screening (e.g. developmental delay)

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Eye exercises and orthoptics (vision therapy)
• Radial keratotomy and other refractive surgery such as LASIK
• Routine vision services outside the service area

Foot care and podiatry services

Note: When you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes, routine foot care may be covered.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Routine foot care including: cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

• Artificial eyes
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy (up to (2) surgical bras per benefit year)
• Internal prosthetic devices, such as spinal implants, bone segments, artificial disks, artificial plates, stents, leads, intraocular lens implants, cochlear implants, and surgically implanted breast implant following mastectomy. 
• Single and dual pacemakers, biventricular pacemakers, pacemaker monitors, accessories such as pacemaker batteries and leads, including the cost of the devices, their placement, repair or replacement and related Medical Travel Benefit, hospital, and surgical charges will accrue towards the Pacemaker Annual Limit of $50,000 per member.
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants
• External hearing aids for adults (benefit limited to $300 per ear, every two (2) years)
• Orthopedic devices, such as braces

Note: See HDHP Section 5(b) for coverage of the surgery to insert the device. 

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

 Not covered:

• Orthopedic and corrective shoes
• Arch supports, foot orthotics, heel pads and heel cups 
• Artificial joints and limbs
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Lumbosacral supports
• Splints
• Over-the-counter (OTC) items
• Internal prosthetics such as heart valves, automatic implantable cardioverter defibrillator (AICD) and other implantable devices not specified above
• Prosthetic replacements provided less than 3 years after the last one we covered

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

• Manual hospital beds;
• Standard manual wheelchairs;
• Crutches/walk aids
• CPAP (Continuous Positive Airway Pressure)
• BPAP (Bi-Level Positive Airways Pressure)
• Blood Glucose Monitors

Note: Pre-authorization is required. Contact us at 671-300-5995 or via email at tc.mrs@takecareasia.com as soon as your physician prescribes this equipment. We will arrange with a healthcare provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

We will cover the following devices with a written prescription:

• Blood Glucose Monitors
• Continuous Glucose Monitor (CGM) System, including transmitter and sensors, if patient is actively participating in TakeCare’s Diabetes Management Program and meets criteria for coverage based on HbA1c level

In-network: Nothing. Not subject to deductible.

Out-of-network: All charges

Not covered:

• Motorized wheel chairs
• Motorized beds
• CPAP and BPAP supplies including masks
• Insulin pumps

Home healthcare ordered by a physician, pre-authorized by us, and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide while under an active treatment plan with a home health agency including services such as:  

• Oxygen therapy, intravenous therapy and medications.
• Services ordered by a physician for members who are confined to the home.
• Nursing
• Medical supplies included in the home health plan of care.
• Physical therapy, speech therapy, occupational therapy, and respiratory therapy.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

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.
• Home care services in the Philippines.

Chiropractic services - You may self refer to a in-network chiropractor for up to 10 visits per calendar year. Services are limited to:

• Manipulation of the spine and extremities
• Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application 
• Osteopathic Manipulative Treatment (“OMT”) when provided by a licensed, trained and credentialed practitioner.

In-network: All charges above $25 per visit and all charges after 10th visit

Out-of-network: All charges

• Consults and evaluations
• Ancillary services for chiropractic purposes (e.g., x-rays)

Acupuncture Services - You may self refer to a participating acupuncture practitioner for up to 10 visits per benefit year.

The Plan defines acupuncture as the practice of insertion of needles into specific exterior body locations to relieve pain, to induce surgical anesthesia, or for therapeutic purposes.

These providers are required to submit itemized bills and their Federal Tax I.D. Number (if a United States provider) as outlined in Section 7, Filing a claim for covered services.

In-network: 20% coinsurance and all charges after the 10th visit in a benefit year.

Out-of-network: All charges

Massage Therapy - You may self refer to a participating, licensed massage therapist for up to 10 visits per benefit year.

These providers are required to submit itemized bills and their Federal Tax I.D. Number (if a United States provider) as outlined in Section 7, Filing a claim for covered services.

In-network: $10 copayment per visit (up to 10 visits per benefit year).

Out-of-network: All charges

Not covered:

• Chelation therapy except for acute arsenic, gold, mercury or lead poisoning; or use of Desferoxamine in iron poisoning
• Naturopathic services and medicines
• Homeopathic services and medicines
• Rolfing

All charges

Programs are administered through the TakeCare Wellness Team include:

• Cardiac Risk Management Class
• Nicotine Cessation 
• Diabetes Management
• Wellness Workshop
• Group Fitness Program
• Nutrition Coaching
• Children's Health Improvement Program
• Well mommy, Well Baby Program

Note:  For more information on these and other classes, see pages 130-132 or call the TakeCare Wellness team at 671-300-7161 or via email at wellness@takecareasia.com.

All health education classes are FREE to TakeCare members unless otherwise specified. Referral is required from your primary care physician. No referral is required for TakeCare's Group Fitness classes.

Nicotine Cessation programs

• primary care physician referral required
• individual/group/telephone counseling
• over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence
  • Nicotrol Nasal Spray
  • Nicotrol Inhaler
  • Chantix
  • Zyban
  • Bupropion hydrochloride
  • Nicorette Gum
  • Nicorette DS Gum
  • Habitrol Transdermal film
  • Nicoderm CQ Transdermal system
  • Commit Lozenge
  • Nicorette Lozenge
  • Nicotine Film
  • Nicotine Polacrilex, Gum, Chewing; Buccal
  • Thrive (Nicotine Polacrilex) Gum, Chewing; Buccal
  • Nicotine Polacrilex, Trocher/Lozenge
  • Nicotine Patch
  • Varenicline

There is no charge for counseling for up to two quit attempts per year. Plan deductible does not apply.

There is no charge for OTC and prescription drugs approved by the FDA to treat tobacco dependence. Plan deductible does not apply.

A comprehensive range of services, such as:

• Operative procedures
• Anesthesia and related professional services
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Circumcision 
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Surgical treatment of morbid obesity (bariatric surgery). Surgery is limited to Roux-en-Y bypass, laparoscopic gastric band placement, and vertical banded gastroplasty. Please note the following conditions must be met:
  
  
  • Eligible members must be age 18 or over
  • Eligible members must weigh 100 pounds or 100% over their normal weight according to current underwriting standards
  • Eligible members must meet the National Institute of Health guidelines
  • We may require you to participate in a non-surgical multidisciplinary program approved by us for six (6) months prior to your bariatric surgery
  • We will determine the provider for the non-surgical program and surgery based on quality and outcomes.
• Insertion of internal prosthetic devices. See 5(a) Orthopedic and prosthetic devices for device coverage information
• Cardiac surgery for the implantation of stents, leads and pacemaker
• Cardiac surgery for the implantation of valves
• Voluntary sterilization (e.g., tubal ligation, vasectomy)
• Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. Plan pays for the cost of the insertion only.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot; see Foot Care on page 99.
• Services and supplies provided for circumcisions performed beyond thirty-one (31) days from the date of birth that are not determined to be medically necessary.
• Surgeries related to gender reassignment

• 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 (e.g., protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers and toes).
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • surgery to produce a symmetrical appearance of breasts 
  • treatment of any physical complications, such as lymphedema
  • breast prostheses and surgical bras and replacements (see  Prosthetic devices)

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

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

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

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones;
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
• Removal of stones from salivary ducts;
• Excision of leukoplakia or malignancies;
• Excision of cysts and incision of abscesses when done as independent procedures; and
• Other surgical procedures that do not involve the teeth or their supporting structures
• TMJ surgery and other related non-dental treatment 

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
• Dental services related to treatment of TMJ

These solid organ transplants are covered.  These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. Pre-authorization is required. 

Solid organ transplants 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

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Pre-authorization is required.

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

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Blood or marrow stem cell transplants  
The Plan extends coverage for the diagnoses as indicated below. Not subject to medical necessity. Plan's denial is limited to indicators for transplant such as refractory or relapsed disease, cytogenetics, subtype, staging or the diagnosis.

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced neuroblastoma
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Hodgkin's lymphoma - relapsed
  • 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
  • Non-Hodgkin's lymphoma - relapsed
  • 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)
  • Aggressive non-Hodgkin lymphomas
  • Amyloidosis
  • Breast Cancer
  • Ependymoblastoma
  • Epithelial ovarian cancer
  • Ewing’s sarcoma
  • Hodgkin's lymphoma - relapsed
  • Medulloblastoma
  • Multiple myeloma
  • Neuroblastoma
  • Non-Hodgkin's lymphoma - relapsed
  • Pineoblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

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 and prior authorization by the Plan. There is no defined age limits for the use of RIC for an allogeneic stem cell transplant.

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, PNH, Pure Red Cell Aplasia)
  • Myelodysplasia/Myelodysplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
• Autologous transplants for
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Neuroblastoma

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

The following 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
  • Myelodysplasia/Myelodysplastic Syndromes
  • Multiple sclerosis
  • 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

Limited Benefits

• Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may be provided in an NCI- or NIH-approved clinical trial at a Plan-designated center of excellence subject to prior authorization by the Plan’s medical director in accordance with the Plan’s protocols.
• Bone marrow stem cell donor search and testing for compatible unrelated donors up to $15,000 per procedure at a National Preferred Transplant Facility when you are the intended recipient.

Transportation, food and lodging - the following benefits are provided, if you live over 60 miles from the transplant center and the services are pre-authorized by us:

• Transportation limited to you and one escort to a National Preferred Transplant Network or other Company Approved Transplant Facility.
• A $125 per day allowance for housing and food.  This allowance excludes liquor and tobacco.

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.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

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

Professional anesthesia services provided in:

• Inpatient hospital
• Outpatient hospital
• Skilled nursing facility
• Ambulatory surgical center
• Physician's office

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

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 will be responsible for the additional charge above the semiprivate room rate.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Other hospital services and supplies, such as:

• Operating, recovery, maternity and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Administration of blood and blood products
• Dressings , splints , casts , and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Rehabilitative therapies - See Section 5(a) for benefit limitation

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Any inpatient hospitalization for dental procedure
• Blood and blood products, whether synthetic or natural
• Custodial care
• Internal prosthetics except for those covered under Section 5(a) - Prosthetic and Orthopedic Devices
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home
• Non-covered facilities, such as nursing homes, schools
• Personal comfort items, such as telephone, television, barber services, guest meals and beds
• Private nursing care
• Take-home items

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Administration of blood, blood plasma, and other biologicals
• Pre-surgical testing
• Dressings, casts and sterile tray services
• Medical supplies including oxygen
• Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.