• No pre-existing condition limitation

• Minimum essential coverage (MEC)

Coverage under this plan qualifies as minimum essential coverage.  Please visit the Internal Revenue Service (IRS) website at www.irs.gov/affordable-care-act/individuals-and-families/questions-and-answers-on-the-individual-shared-responsibility-provision for more information on the individual requirement for MEC.

• Minimum value standard

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

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

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

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

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

We don’t determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office.  For information on your premium deductions, you must also contact your employing or retirement office.

• Types of coverage available for you and your family

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

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event.

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

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

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

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

• Family member coverage

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

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

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

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

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

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

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

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

• Children’s Equity Act

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

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

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

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

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

• When benefits and premiums start

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2021 benefits of your prior plan or option.  If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option.  However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2020 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

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

• When you retire

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

• When FEHB coverage ends

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

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

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

You may be eligible for spouse equity coverage or assistance with enrolling in a conversion policy (non-FEHB individual policy).

• Upon divorce

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

• Temporary Continuation of Coverage (TCC)

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

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

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

Converting to individual coverage

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

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health waiting period will not be imposed, and your coverage will not be limited  due to pre-existing conditions. When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 800-522-0088 or visit our website at www.healthnet.com/fehb.

• Health Insurance Marketplace

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

Identification cards

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 800-522-0088 or write to us at Health Net of California, PO Box 9103, Van Nuys, CA 91409-9103. You may also request replacement cards through our Website www.healthnet.com/fehb.

Where you get covered care

We list Plan providers in the provider directory, which we update periodically. The list is also on our Website.

What you must do to get covered care

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

You must select a Participating Physicians Group (PPG) within a 30 mile radius of your home or work-site. Each family member may choose their own PPG and primary care physician.

You may transfer to another PPG by calling us at 800-522-0088. You may change PPG’s once a month or upon our approval.  The request will be denied if you are more than three months pregnant, confined to a hospital, in a surgery follow-up period (not yet released by the surgeon) or receiving treatment for an illness that is not yet complete.

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

Specialty care

Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without additional referrals. The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you a referral. However, you may see a participating chiropractor (as described on page 37) and a woman may see her participating gynecologist at anytime without a referral.

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

• If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals.
• Your primary care physician will create your treatment plan. The physician may have to get an authorization or approval from us beforehand. If you are seeing a specialist when you enroll in our plan, talk to your primary care physician. If he or she decides to refer you to a specialist, ask if you can see your current specialist.
• If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.
• If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.
• If you have a chronic and disabling condition and lose access to your specialist because we: 

- terminate our contract with your specialist for other than cause;

- drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program plan; or

- reduce our service area and you enroll in another FEHB plan;

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

• If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.
• If you are a new Health Net of California member and are currently receiving treatment for a qualifying medical condition from a provider who is not in our network, you may be eligible to complete treatment of your condition with the provider. Or, if you are an existing member and are currently receiving treatment for a qualifying medical condition from a provider who is leaving our network, you may be eligible to complete treatment of your condition with the provider. In order to receive more information about continuity of care and qualifying medical conditions and situations, please contact us at 800-522-0088 and we will assist you.

You also have the right to a second opinion when:

• your primary care physician or a referral physician gives a diagnosis or recommends a treatment plan that you are not satisfied with;
• you are not satisfied with the result of treatment you have received; 
• you are diagnosed with, or a treatment plan is recommended for a condition that threatens loss of life, limb or bodily function, or a substantial impairment, including but not limited to a serious chronic condition; or
• your primary care physician or a referral physician is unable to diagnose your condition, or test results are conflicting.

To request an authorization for a second opinion, contact your Primary Care Physician or Health Net of California Member Services at 800-522-0088. Physicians at your Physician Group or Health Net of California will review your request in accordance with Health Net of California’s second opinion policy. You may obtain a copy of this policy from Health Net of California’s Member Service Department. All second opinions must be provided by a participating network physician who specializes in the illness, disease or condition associated with the request. If there is no appropriately qualified physician in the network, your primary care physician will arrange for an out-of-network second opinion.

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

• If you are hospitalized when your enrollment begins

We pay for covered services from the effective date of your enrollment.  However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 800-522-0088. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

• you are discharged, not merely moved to an alternative care center;
• the day your benefits from your former plan run out; or
• the 92^nd day after you become a member of this Plan, whichever happens first.

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

• Inpatient hospital admission

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

• Other services

Your primary care physician has authority to refer you for most services.  For certain services, however, your physician must obtain prior approval from us.  Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.  You must obtain prior authorization for some services such as but not limited to:

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

Services that are not authorized by your primary care physician or Health Net of California will not be covered.

First, your physician, your hospital, you, or your representative, must call us at 800-977-7282 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

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

• Non-urgent care claims

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

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

• Urgent care claims

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

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

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

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM.  Please let us know that you would like simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 800-522-0088.  You may also call OPM's FEHB 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us at 800-522-0088.  If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim). 

• Concurrent care claims

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

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

The Federal Flexible Spending Account Program – FSAFEDS

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

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

• Emergency inpatient admission   

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

• Maternity care    

Emergency services and the minimum Hospital stay requirements for maternity do not require Prior Authorization.  All other Hospital Services, whether Inpatient or Outpatient, must be arranged through the Primary Care Physician.  Any member who receives Emergency Services must contact his or her Primary Care Physician within 48 hours of treatment, or as soon thereafter as is medically possible.

Further, if your baby stays after you are discharged, then your physician or the hospital must contact us for precertification of additional days for your baby.

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

• If your treatment needs to be extended

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

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

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

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

• To reconsider a non-urgent care claim

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

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

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

2. Ask you or your provider for more information.

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

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

3. Write to you and maintain our denial.

• To reconsider an urgent care claim

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

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request. We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods.

• To file an appeal with OPM

Copayments

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

Example: When you see your primary care physician, you pay a copayment of $20 per office visit for the High Option, $30 per office visit for the Standard Option and $40 per office visit for the Basic Option.  When you go in the hospital you pay $150 per day (5 day max copay) per admission on the High Option, $750 per admission on the Standard Option, and $500 per day (3 day max copay) per admission on the Basic Option.

Example: In our Plan, you pay 50% of our allowance for infertility services and 20% to a maximum of $200 per day for injectable medications.

Your catastrophic protection out-of-pocket maximum

High and Standard Options: After your copayments and/or coinsurance for the High or Standard Option plans total $1,500 for Self Only, $3,000 for Self Plus One or $4,500 for Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. However, your prescription drug benefit on the High and Standard plans has a separate out-of-pocket maximum of $2,900 for Self Only, $5,800 for Self Plus One and $8,700 for Self and Family that must be met before prescription copayments or coinsurance are waived.  

Basic Option: After your copayments and/or coinsurance for the Basic Option plan total $3,500 for Self Only, $7,000 for Self Plus One or $7,000 for Self and Family enrollment in any calendar year, you do not have to pay any more for covered services.  However, your prescription drug benefit on the Basic Option plan has a separate out-of-pocket maximum of $2,000 for Self Only, $4,000 for Self Plus One and $4,000 for Self and Family that must be met before prescription copayments or coinsurance are waived.

The maximum annual limitation on cost sharing listed under Self Only of $1,500 for the High and Standard Options and $3,500 for the Basic Option apply to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

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

• Eyeglasses or contact lenses

• Copayments or coinsurance for infertility treatment

• Expenses for services and supplies that exceed the stated maximum dollar or day limit

• Expenses from utilizing out-of-network providers

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

Carryover

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

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

Preauthorization

The Mental Health and Substance Use Disorder benefits are administered by MHN Services, an affiliate behavioral health administrative services company (the Behavioral Health Administrator) which contracts with Health Net to administer these benefits. When you need to see a Participating Mental Health Professional, contact the Behavioral Health Administrator by calling the Health Net Customer Contact Center at the phone number on your Health Net I.D. card.

Certain services and supplies for Mental Health and Substance Use Disorder require prior authorization by the Behavioral Health Administrator to be covered. The services and supplies that require prior authorization are:

• Outpatient procedures that are not part of an office visit (for example: psychological and neuropsychological testing, outpatient electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS), outpatient detoxification, partial hospitalization, day treatment, half-day partial hospitalization and 23-hour outpatient observation; and
• Inpatient, residential, partial hospitalization, inpatient ECT, Inpatient psychological and neuropsychological testing and intensive outpatient services; and
• Behavioral health treatment for Pervasive Developmental Disorder or Autism (see below under “Outpatient Services”).

No prior authorization is required for outpatient office visits, but a voluntary registration with the Behavioral Health Administrator is encouraged.

To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes.

We will provide medical review criteria or reasons for treatment plan denials to enrollees, members or providers upon request or as otherwise required.

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

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

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

Please contact our Telecommunications Device for the Deaf at 800-995-0852.

Decision Power

Decision Power addresses the health needs of the whole person - from wellness health coaching to chronic condition management to chronic case management. The member chooses how and when to use the information, resources and support available.

Members can take a Health Risk Questionnaire (HRQ) to identify potential health risks, create an action plan for improving health and measure how lifestyle changes will impact overall health. Experienced nurses are available 24/7 through the Nurse Advice Line  to help you with your health related questions and guide you through next steps with your immediate care.

Quality and cost tools such as Hospital and Medical Group Comparison Reports or Treatment Cost Estimators help ensure the care members receive is the right care for them. To get more information on The Decision Power Health and Wellness Programs, members can call the Customer Service number found on the back of the Health Net member ID card or go to www.healthnet.com/fehb and click on "Wellness Center" Decision Power.

Active & Fit Direct program

Active and Fit Direct program offers fitness center membership to 10,000+ fitness centers nationwide for just $29.99 a month (plus a one time $29.99 enrollment fee).  For more information, please visit our website at www.healthnet.com/fehb or contact us at 800-522-0088.

Health Net has affordable health care plans members can depend on. We offer a wide range of competitively-priced plans with the benefits your dependents are looking for. Members can also take advantage of our Wellness Center® a free series of tools and services to help you manage and support your well-being.

For more information on Health Net Individual and Family plans go to www.healthnet.com and click on Shoppers or call Health Net at 800-909-3447.

Medical and hospital benefits

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, contact us at 800-522-0088, or at our Website www.healthnet.com/fehb.

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

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

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

Submit your claims to:

Health Net of California, Commercial Claims, P.O. Box 9040, Farmington, MO 63640-9040

When you purchase a prescription drug, and your Plan ID card is not available, eligibility cannot be determined, or the prescription is for a medical emergency outside of California, you must pay for the drug when it is dispensed, and file a claim for reimbursement. For claims questions and assistance, or to request a prescription drug claim form call us at 800-522-0088.

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

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

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

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

Notice Requirements

If you live in a county where at least 10 percent of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language.  You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language.  The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the health care provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes.

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

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

     b) Send your request to us at: Health Net of California, P.O. Box 10348, Van Nuys, CA 91410-0348; and

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

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

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

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

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

   a) Pay the claim or

   b) Write to you and maintain our denial or

   c) Ask you or your provider for more information

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

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

3

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

You must write to OPM within:

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

Write to OPM at:  United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 3, 1900 E Street, NW, Washington, DC 20415-3630.

Send OPM the following information:

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

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

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

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

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

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

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

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

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

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

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

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

Workers’ Compensation

We do not cover services that:

• You (or a covered family member) need because of a workplace-related illness or injury that the Office of Workers’ Compensation Programs (OWCP) or a similar federal or state agency determines they must provide; or
• OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care.

Medicaid

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

Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these state programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the state program.

When other Government agencies are responsible for your care

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

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

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

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

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

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

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

Clinical Trials

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

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

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

When you have Medicare

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

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

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share.

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

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. Your care must continue to be authorized by your Plan physician.

Claims process when you have the Original Medicare Plan – You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.

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

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. You will not need to do anything. To find out if you need to do something to file your claim, call us at 800-522-0088 or see our website at www.healthnet.com/fehb.

We do not waive any costs on the High Option or Standard Option Plans if the Original Medicare Plan is your primary payor. 

Benefit Description: Deductible
You pay without Medicare- (High & Standard Options): N/A - no deductible
You pay with Medicare Part B - (High & Standard Options):  N/A - No deductible 

Benefit Description: Out-of-Pocket Maximum
You pay without Medicare- (High & Standard Options): $1,500 Self Only/$3,000 Self Plus One/$4,500 Self and Family
You pay with Medicare Part B - (High & Standard Options): $1,500 Self Only/$3,000 Self Plus One/$4,500 Self and Family

Benefit Description: Part B Premium Reimbursement Offered 
You pay without Medicare- (High & Standard Options): N/A 
You pay with Medicare Part B - (High & Standard Options):  N/A 

Benefit Description: Primary Care Physician
You pay without Medicare- (High & Standard Options): High Option $20 copay; Standard Option $30
You pay with Medicare Part B - (High & Standard Options): High Option $20 copay; Standard Option $30

Benefit Description: Specialist
You pay without Medicare- (High & Standard Options): High Option $30 copay; Standard Option $50
You pay with Medicare Part B - (High & Standard Options): High Option $30 copay; Standard Option $50

Benefit Description: Inpatient Hospital
You pay without Medicare- (High & Standard Options): High Option $150/per day (5 day max copay); Standard Option $750 
You pay with Medicare Part B - (High & Standard Options):  High Option $150/per day (5 day max copay);Standard Option $750

Benefit Description: Outpatient Surgery - Hospital
You pay without Medicare- (High & Standard Options): High Option $200; Standard Option $350
You pay with Medicare Part B - (High & Standard Options):  High Option $200; Standard Option $350

Benefit Description: Incentives offered 
You pay without Medicare- (High & Standard Options): N/A 
You pay with Medicare Part B - (High & Standard Options): N/A 

We waive some costs on the Basic Option Plan if the Original Medicare Plan is your primary Payor and you are a U.S. resident - We will waive some out-of-pocket costs as follows:

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

Benefit Description: Deductible
You pay without Medicare- (High & Standard Options): N/A - no deductible
You pay with Medicare Part B - (High & Standard Options):  N/A - No deductible

Benefit Description: Out-of-Pocket Maximum
You pay without Medicare- (High & Standard Options): $3,500 Self Only/$7,000 Self Plus One/$7,000 Self Plus Family
You pay with Medicare Part B - (High & Standard Options): $3,500 Self Only/$7,000 Self Plus One/$7,000 Self Plus Family

Benefit Description: Part B Premium Reimbursement Offered 
You pay without Medicare- (High & Standard Options): N/A 
You pay with Medicare Part B - (High & Standard Options):  N/A

Benefit Description: Primary Care Physician
You pay without Medicare- (High & Standard Options): $40 copay
You pay with Medicare Part B - (High & Standard Options): $0 copay

Benefit Description: Specialist
You pay without Medicare- (High & Standard Options): $40 copay
You pay with Medicare Part B - (High & Standard Options): $0 copay

Benefit Description: Inpatient Hospital
You pay without Medicare- (High & Standard Options): $500/ per day (3 day max copay)
You pay with Medicare Part B - (High & Standard Options):  $0 copay

Benefit Description: Outpatient Surgery - Hospital
You pay without Medicare- (High & Standard Options): $500 copay when performed at a hospital/ $200 copay when performed at an ambulatory surgery center
You pay with Medicare Part B - (High & Standard Options):  $0 copay

Benefit Description: Incentives offered 
You pay without Medicare- (High & Standard Options): N/A 
You pay with Medicare Part B - (High & Standard Options): N/A 

• Tell us about your Medicare coverage

• Medicare Advantage (Part C)

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

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

This Plan and our Medicare Advantage plan:

You may enroll in our Medicare Advantage plan and also remain enrolled in our FEHB plan. In this case, we do not waive cost-sharing for your FEHB coverage.

This Plan and another Plan’s Medicare Advantage plan:

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

Suspended FEHB coverage to enroll in a Medicare Advantage plan:

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

• Medicare prescription drug coverage (Part D)

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

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

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

Coinsurance

See Section 4, page 20

Copayment

See Section 4, page 20

Cost-sharing

See Section 4, page 20

Deductible

See Section 4, page 20

Experimental or investigational services are services that are not widely accepted or recognized within the organized medical community as standards of care. Our Medical Policy Committee determines what procedures and services are experimental/investigational using published peer review medical and surgical literature. The procedure or service will be evaluated based on its health effects, safety, quality and cost effectiveness. In some cases, we use an independent medical review for expert evaluation and determination of coverage.

Medical necessity is the criteria used by us and the participating physician group to provide covered services in the prevention, diagnosis, and treatment of your illness or condition. Medically necessary services are determined to be:

• Not experimental or investigational
• Appropriate and necessary for the symptoms, diagnosis, or treatment of a condition, illness or injury
• Provided for the diagnosis or care and treatment of the condition, illness or injury
• Not primarily for the convenience of the member, member’s physician, or anyone else
• The most appropriate supply or level that can safely be provided. For example, outpatient rather than inpatient surgery may be authorized when the setting is safe and adequate.

Determination of whether services or supplies are medically necessary will be made according to procedures we and the participating physician group have established.

Urgent care claims

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

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:

• Waiting could seriously jeopardize you life or health;
• Waiting could seriously jeopardize your ability to regain maximum function; or
• In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims usually involve Pre-service  and not Post-service claims.  We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at 800-522-0088.  You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Medical services provided by physicians: Diagnostic and treatment services provided in the office

$20 primary care; $30 specialist

25

Services provided by a hospital: Inpatient

$150 per day up to 5 days per admission copay

49

Services provided by a hospital: Outpatient Surgery at a Hospital or Ambulatory Surgical Center

$200 copay

50

Emergency benefits: In-area

$100 per visit (waived if admitted to Hospital)

53

Emergency benefits: Out-of-area

$100 per visit (waived if admitted to Hospital)

53

Mental health and substance use disorder treatment:

Regular cost-sharing

54

Prescription drugs:

$10 copay for a 30-day supply of formulary generic drugs - $20 for a 90-day supply through mail order.

$35 copay for a 30-day supply of formulary brand name drugs - $70 for a 90-day supply through mail order.

$60 copay for a 30-day supply of non-formulary drugs - $120 for a 90-day supply through mail order.

20% to a maximum of $200 per prescription for specialty drugs - not available through mail order.

58

Dental care - Accidental Injury

$20 PCP office visit; $30 specialist visit; $100 Emergency Room

62

Vision care:

$20 PCP office visit, $30 specialist visit

34

Special features:

Services for the deaf and hearing impaired, Centers of Excellence, Decision Power, Active & Fit Direct program

63

Protection against catastrophic costs (your catastrophic out-of-pocket maximum):

Nothing after $1,500/Self Only, $3,000/Self Plus One or $4,500/Self and Family enrollment per year.  

For prescriptions Nothing after $2,900/Self Only, $5,800/Self Plus One or $8,700/Family enrollment per year.

20

Medical services provided by physicians: Diagnostic and treatment services provided in the office

$30 primary care; $50 specialist

25

Services provided by a hospital: Services provided by a hospital: Inpatient  

$750 copay

49

Services provided by a hospital: Outpatient surgery at a hospital or ambulatory surgical center

$350 copay

50

Emergency benefits: In-area

$150 per visit (waived if admitted to hospital)

53

Emergency benefits: Out-of-area

$150 per visit (waived if admitted to hospital)

53

Mental health and substance use disorder treatment:

Regular cost-sharing

54

Prescription drugs:

$15 copay for a 30-day supply of formulary generic drugs - $30 for a 90-day supply through mail order.

$35 copay for a 30-day supply of formulary brand name drugs - $70 for a 90-day supply through mail order.

$65 copay for a 30-day supply of non-formulary drugs - $130 for a 90-day supply through mail order.

20% to a maximum of $200 per prescription for specialty drugs - not available through mail order.

58

Dental care - accidental injury

$30 PCP office visit; $50 Specialist visit; $150 emergency room

62

Vision care:

$30 office visit

34

Special features:

Services for the deaf and hearing impaired, Centers of Excellence, Decision Power, Active & Fit Direct program

63

Protection against catastrophic costs (your catastrophic out-of-pocket maximum):

Nothing after $1,500/Self Only, $3,000/Self Plus One or $4,500/Self and Family enrollment per year.

For prescriptions Nothing after $2,900/Self Only, $5,800/Self Plus One or $8,700/Family enrollment per year.

20

Medical services provided by physicians: Diagnostic and treatment services provided in the office

$40 per office visit 

25

Services provided by a hospital: Inpatient

$500 copayment per day up to 3 days for inpatient admission

49

Services provided by a hospital: Outpatient surgery at a hospital or ambulatory surgical center

$500 copayment when performed at a hospital / $200 copayment when performed at an ambulatory surgery center

50

Emergency benefits: In-area

$100 per visit 

53

Emergency benefits: Out-of-area

$100 per visit

53

Mental health and substance use disorder treatment:

Regular cost-sharing

54

Prescription drugs:

$15 copay for a 30-day supply of formulary generic drugs - $30 for a 90-day supply through mail order.

$30 copay for a 30-day supply of formulary brand name drugs - $60 for a 90-day supply through mail order.

$50 copay for a 30-day supply of non-formulary drugs - $100 for a 90-day supply through mail order.

20% to a maximum of $200 per prescription for specialty drugs - not available through mail order.

58

Dental care - accidental injury

$40 per office visit; $100 copay at emergency room 

62

Vision care:

$40 per office visit

34

Special features:

Services for the deaf and hearing impaired; Centers of Excellence, Decision Power, Active & Fit Direct program

63

Protection against catastrophic costs (your catastrophic out-of-pocket maximum):

Nothing after $3,500/Self Only, $7,000/Self Plus One or $7,000/Self and Family enrollment per year.

For prescriptions Nothing after $2,000/Self Only, $4,000/Self Plus One or $4,000/Family enrollment per year.

20