Outpatient professional services of physicians and other healthcare professionals:

• Consultations
• Genetic counseling
• Second surgical opinions
• Clinic visits
• Office visits
• Home visits
• Initial examination of a newborn needing definitive treatment when covered under a Self Plus One or Self and Family enrollment
• Pharmacotherapy (medication management) (See Section 5(f) for prescription drug coverage)
• Phone consultations and online medical evaluation and management services (telemedicine)

Note: Please refer to pages 40-42 for our coverage of laboratory, X-ray, and other diagnostic tests billed for by a healthcare professional, and to page 83 for our coverage of these services when billed for by a facility, such as the outpatient department of a hospital.

Preferred primary care provider or other healthcare professional: $25 copayment per visit (no deductible)

Preferred specialist: $35 copayment per visit (no deductible)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred primary care provider or other healthcare professional: $30 copayment per visit

Preferred specialist: $40 copayment per visit

Note: You pay 30% of the Plan allowance for agents, drugs,
and/or supplies administered or obtained in connection with your care. (See page (Applies to printed brochure only) for more information about “agents.”)

Participating/Non-participating: You pay all charges

Telehealth professional services for:

• Minor acute conditions (see page (Applies to printed brochure only) for definition)
• Dermatology care (see page (Applies to printed brochure only) for definition)

Note: Refer to Section 5(h), Wellness and Other Special Features, for information on telehealth services and how to access a provider.

Note: Benefits are combined with telehealth services listed in Section 5(e), see page 99.

Preferred Telehealth Provider: Nothing (no deductible) for the first 2 visits per calendar year for any covered telehealth service

$10 copayment per visit (no deductible) after the 2^nd visit

Participating/Non-participating: You pay all charges

Preferred Telehealth Provider: Nothing for the first 2 visits per calendar year for any covered telehealth service

$15 copayment per visit after the 2^nd visit

Participating/Non-participating: You pay all charges

Inpatient professional services:

• During a covered hospital stay
• Services for nonsurgical procedures when ordered, provided, and billed by a physician during a covered inpatient hospital admission
• Medical care by the attending physician (the physician who is primarily responsible for your care when you are hospitalized) on days we pay hospital benefits
  Note: A consulting physician employed by the hospital is not the attending physician.
• Consultations when requested by the attending physician
• Concurrent care – hospital inpatient care by a physician other than the attending physician for a condition not related to your primary diagnosis, or because the medical complexity of your condition requires this additional medical care
• Physical therapy by a physician other than the attending physician
• Initial examination of a newborn needing definitive treatment when covered under a Self Plus One or Self and Family enrollment
• Pharmacotherapy (medication management) (See Section 5(c) for our coverage of drugs you receive while in the hospital.)
• Second surgical opinion
• Nutritional counseling when billed by a covered provider

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred: Nothing

Participating/Non-participating: You pay all charges

Not covered:

• Routine services except for those Preventive care services described on pages 42-46
• Costs associated with enabling or maintaining providers' telehealth (telemedicine) technologies, non-interactive telecommunication such as email communications, or store-and-forward telehealth services
• Private duty nursing
• Standby physicians
• Routine radiological and staff consultations required by facility rules and regulations
• Inpatient physician care when your admission or portion of an admission is not covered (See Section 5(c).)

Note: If we determine that an inpatient admission is not covered, we will not provide benefits for inpatient room and board or inpatient physician care. However, we will provide benefits for covered services or supplies other than room and board and inpatient physician care at the level that we would have paid if they had been provided in some other setting.

Diagnostic tests limited to:

• Laboratory tests (such as blood tests and urinalysis)
• Pathology services
• EKGs

Note: See Section 5(c) for services billed for by a facility, such as the outpatient department of a hospital.

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Note: If your Preferred provider uses a Non-preferred laboratory or radiologist, we will pay Non-preferred benefits for any laboratory and X-ray charges.

Preferred: Nothing

Note: You pay 30% of the Plan allowance for agents, drugs,
and/or supplies administered or obtained in connection with your care. (See page (Applies to printed brochure only) for more information about “agents.”)

Participating/Non-participating: You pay all charges (except as noted below)

Note: For services billed by Participating and Non-participating laboratories or radiologists, you pay any difference between our allowance and the billed amount.

Diagnostic tests including but not limited to:

• Cardiovascular monitoring
• EEGs
• Home-based/unattended sleep studies
• Neurological testing
• Ultrasounds
• X-rays (including set-up of portable X-ray equipment)

Note: See Section 5(c) for services billed for by a facility, such as the outpatient department of a hospital.

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Note: If your Preferred provider uses a Non-preferred laboratory or radiologist, we will pay Non-preferred benefits for any laboratory and X-ray charges.

Preferred: $40 copayment

Note: You pay 30% of the Plan allowance for agents, drugs,
and/or supplies administered or obtained in connection with your care. (See page (Applies to printed brochure only) for more information about “agents.”)

Participating/Non-participating: You pay all charges (except as noted below)

Note: For services billed by Participating and Non-participating laboratories or radiologists, you pay any difference between our allowance and the billed amount in addition to the Preferred copayment listed above.

Diagnostic tests limited to:

• Bone density tests
• CT scans/MRIs/PET scans
• Angiographies
• Nuclear medicine
• Facility-based sleep studies (prior approval required)
• Genetic testing

Note: Benefits are available for specialized diagnostic genetic testing when it is medically necessary to diagnose and/or manage a patient’s existing medical condition. Benefits are not provided for genetic panels when some or all of the tests included in the panel are not covered, are experimental or investigational, or are not medically necessary.

Note: You must obtain prior approval for BRCA testing (see page 22). Diagnostic BRCA testing, including testing for large genomic rearrangements in the BRCA1 and BRCA2 genes: Benefits are available for members with a cancer diagnosis when the requirements in the note above are met, and the member does not meet criteria for Preventive BRCA testing. Benefits are limited to one test of each type per lifetime whether covered as a diagnostic test or paid under Preventive Care benefits (see page 44).

Note: See Section 5(c) for services billed for by a facility, such as the outpatient department of a hospital.

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Note: If your Preferred provider uses a Non-preferred laboratory or radiologist, we will pay Non-preferred benefits for any laboratory and X-ray charges.

Preferred: $100 copayment

Note: You pay 30% of the Plan allowance for agents, drugs,
and/or supplies administered or obtained in connection with your care. (See page (Applies to printed brochure only) for more information about “agents.”)

Participating/Non-participating: You pay all charges (except as noted below)

Note: For services billed by Participating and Non-participating laboratories or radiologists, you pay any difference between our allowance and the billed amount in addition to the Preferred copayment listed above.

Routine physical exams and the preventive care benefits separately listed below are limited to one per calendar year and to members age 22 and over. The following preventive services are covered at the time interval recommended at each of the links below as adopted by December 31, 2019.

Covered services include:

• Administration and interpretation of a Health Risk Assessment (HRA) questionnaire (see Definitions.)
  Note: As a member of the Service Benefit Plan, you have access to the Blue Cross and Blue Shield HRA, called the “Blue Health Assessment” questionnaire. See Section 5(h) for complete information.
• Basic or comprehensive metabolic panel test
• CBC
• Cervical cancer screening tests
• Human papillomavirus (HPV) tests of cervix
• Pap tests of the cervix
• Colorectal cancer tests, including:
• Colonoscopy, with or without biopsy (see page 63 for our payment levels for diagnostic colonoscopies)
• DNA analysis of stool samples
• Double contrast barium enema
• Fecal occult blood test
• Sigmoidoscopy
• EKG
• Fasting lipoprotein profile (total cholesterol, LDL, HDL, and/or triglycerides)
• General health panel
• Individual counseling on prevention and reducing health risks

Preferred: Nothing (no deductible)

Note: If you receive both preventive and diagnostic services from your Preferred provider on the same day, you are responsible for paying your cost-share for the diagnostic services.

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Note: When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.

Note: We waive your deductible and coinsurance amount for services billed by Participating/Non-participating providers related to Influenza (flu) vaccines. If you use a Non-participating provider, you pay any difference between our allowance and the billed amount.

Preferred: Nothing

Note: If you receive both preventive and diagnostic services from your Preferred provider on the same day, you are responsible for paying your cost-share for the diagnostic services.

Participating/Non-participating: You pay all charges (except as noted below)

Note: For services billed by Participating and Non-participating laboratories or radiologists, you pay any difference between our allowance and the billed amount.

Note: When billed by a Preferred facility, such as the outpatient department of a hospital, we provide benefits as shown here for Preferred providers.

Note: Benefits are not available for visits/exams for preventive care, associated laboratory tests, colonoscopies, or routine immunizations performed at Member or Non-member facilities.

Note: See Section 5(c) for our payment levels for covered cancer screenings and ultrasound screening for abdominal aortic aneurysm billed for by Member or Non-member facilities and performed on an outpatient basis.

• Nutritional counseling
  Note: When nutritional counseling is via the contracted telehealth provider network, we provide benefits as shown here for Preferred providers. Refer to Section 5(h), Wellness and Other Special Features, for information on how to access a telehealth provider.
  Note: Benefits are limited to individual nutritional counseling services. We do not provide benefits for group counseling services.
• Prostate cancer test – Prostate Specific Antigen (PSA)
• Screening for chlamydial infection
• Screening for diabetes mellitus
• Screening for gonorrhea infection
• Screening for human immunodeficiency virus (HIV)
• Screening mammograms, including mammography using digital technology
• Ultrasound for abdominal aortic aneurysm for adults, ages 65 to 75, limited to one screening per lifetime
• Urinalysis
• Visits/exams for preventive care
  Note: See the definition of Preventive Care, Adult, on page 158 for included health screening services.
• 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.
  Note: U.S. FDA licensure may restrict the use of the immunizations and vaccines listed above to certain age ranges, frequencies, and/or other patient-specific indications, including gender.
• USPSTF A and B recommended screenings such as cancer, osteoporosis, depression, and high blood pressure. For a complete list of covered A and B recommendation screenings and age and frequency limitations go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org
• Well woman care such as 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 go to the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/

Note: We pay preventive care benefits on the first claim we process for each of the above tests you receive in the calendar year. Regular coverage criteria and benefit levels apply to subsequent claims for those types of tests if performed in the same year. If you receive both preventive and diagnostic services from your Provider on the same day, you are responsible for paying you cost-share for the diagnostic services.

Hereditary Breast and Ovarian Cancer Screening

Benefits are available for screening members, age 18 and over limited to one of each type of test per lifetime, to evaluate the risk for developing certain types of hereditary breast or ovarian cancer related to mutations in BRCA1 and BRCA2 genes:

• Genetic counseling and evaluation for members whose personal and/or family history is associated with an increased risk for harmful mutations in BRCA1 and BRCA2 genes.
• BRCA testing for members whose personal and/or family history is associated with an increased risk for harmful mutations in BRCA1 or BRCA2 genes.
  
  Note: You must receive genetic counseling and evaluation services and obtain prior approval before you receive preventive BRCA testing. Preventive care benefits will not be provided for BRCA testing unless you receive genetic counseling and evaluation prior to the test, and scientifically valid screening measures are used for the evaluation, and the results support BRCA testing. See page 22 for information about prior approval and additional BRCA coverage or call the phone number on the back of your ID card for additional policy information.

Note: Preventive care benefits are not available for surgical removal of breasts, ovaries, or prostate. See page 63 for the surgical benefits available for these services.

Note: See page 112 for our payment levels for medications to promote better health as recommended under the Affordable Care Act.

Note: See page 113 for our payment levels for certain bowel preparation medications, and antiretroviral medications for the prevention of HIV.

Note: Unless otherwise noted, the benefits listed above and on pages 42-43 do not apply to children up to age 22. (See benefits under Preventive Care, Child, this Section.)

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

Continued from previous page:

Note: Many Preferred retail pharmacies participate in our vaccine network. See page 111 for our coverage of these vaccines when provided by pharmacies in the vaccine network.

Continued from previous page:

Note: We waive your deductible and coinsurance amount for services billed by Participating/Non-participating providers related to Influenza (flu) vaccines. If you use a Non-participating provider, you pay any difference between our allowance and the billed amount.

Note: Many Preferred retail pharmacies participate in our vaccine network. See page 111 for our coverage of these vaccines when provided by pharmacies in the vaccine network.

Not covered:

• Genetic testing related to family history of cancer or other disease, except as described on page 44
  Note: See page 41 for our coverage of medically necessary diagnostic genetic testing.

• Genetic panels when some or all of the tests included in the panel are not covered, are experimental or investigational, or are not medically necessary
• Group counseling on prevention and reducing health risks
• Self-administered health risk assessments (other than the Blue Health Assessment)
• Screening services requested solely by the member, such as commercially advertised heart scans, body scans, and tests performed in mobile traveling vans
• 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. Medical benefits may be available for these services.
• Phone consultations and online medical evaluation and management services (telemedicine) for preventive services, except as noted on page 43 for nutritional counseling.

Benefits are provided for preventive care services for children up to age 22. This includes:

• Well-child visits, examinations, and other preventive services as adopted by December 31, 2019, and described in the Bright Future Guidelines as provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Future Guidelines go to https://brightfutures.aap.org
• Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html
  Note: U.S. FDA licensure may restrict the use of the immunizations and vaccines listed above to specific age ranges, frequencies, and/or other patient-specific indications, including gender.

Preferred: Nothing (no deductible)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Note: When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.

Preferred: Nothing

Participating/Non-participating: You pay all charges (except as noted below)

Note: For services billed by Participating and Non-participating laboratories or radiologists, you pay any difference between our allowance and the billed amount.

Note: Preventive care benefits for each of the services listed below are limited to one per calendar year.

• Screening for hepatitis B for children age 13 and over
• Screening for chlamydial infection
• Screening for gonorrhea infection
• Cervical cancer screening tests
• Pap tests of the cervix
• Human papillomavirus (HPV) tests of the cervix
• Screening for human immunodeficiency virus (HIV) infection
• Screening for syphilis infection
• Screening for latent tuberculosis infection for children ages 18 through 21
• Nutritional counseling

Note: If your child receives both preventive and diagnostic services from a Preferred provider on the same day, you are responsible for paying the cost-share for the diagnostic services.

Note: Benefits are limited to individual nutritional counseling services. We do not provide benefits for group counseling services.

Note: When nutritional counseling is via the contracted telehealth provider network, we provide benefits as shown here for Preferred providers. Refer to Section 5(h), Wellness and Other Special Features, for information on how to access a telehealth provider.

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

Note: See page 112 for our payment levels for medications to promote better health as recommended under the Affordable Care Act.

Continued from previous page:

Note: We waive the deductible and coinsurance amount for services billed by Participating/ Non-participating providers related to Influenza (flu) vaccines. If you use a Non-participating provider, you pay any difference between our allowance and the billed amount.

Continued from previous page:

Note: We provide benefits for services billed by Participating/ Non-participating providers related to Influenza (flu) vaccines. If you use a Non-participating provider, you pay any difference between our allowance and the billed amount.

Note: When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.

Maternity (obstetrical) care including related conditions resulting in childbirth or miscarriage, such as:

• Prenatal care (including ultrasound, laboratory, and diagnostic tests)
  
  Note: See Section 5(h) for details about our Pregnancy Care Incentive Program.
• Delivery
• Postpartum care

Preferred: Nothing (no deductible)

Note: For facility care related to maternity, including care at birthing facilities, we waive the per admission copayment and pay for covered services in full when you use Preferred providers.

Preferred: Nothing

Note: For Preferred facility care related to maternity, including care at Preferred birthing facilities, your responsibility for covered inpatient services is limited to $175 per admission. For outpatient facility services related to maternity, see the notes on pages 82-85.

• Assistant surgeons/surgical assistance if required because of the complexity of the delivery
• Anesthesia (including acupuncture) when requested by the attending physician and performed by a certified registered nurse anesthetist (CRNA) or a physician other than the operating physician (surgeon) or the assistant
• Tocolytic therapy and related services when provided on an inpatient basis during a covered hospital admission
• Breastfeeding education and individual coaching on breastfeeding by healthcare providers such as physicians, physician assistants, midwives, nurse practitioners/clinical specialists, and lactation consultants
  
  Note: See page 48 for our coverage of breast pump kits.

• Mental health treatment for postpartum depression and depression during pregnancy
  
  Note: We provide benefits to cover up to 4 visits per year in full to treat depression associated with pregnancy (i.e., depression during pregnancy, postpartum depression, or both) when you use a Preferred provider. See Section 5(e) for our coverage of mental health visits to Non-preferred providers and benefits for additional mental health services.

Note: See page 43 for our coverage of nutritional counseling.

Note: Benefits for home nursing visits (skilled) related to covered maternity care are subject to the visit limitations described on page 59.

Note: Maternity care benefits are not provided for prescription drugs required during pregnancy, except as recommended under the Affordable Care Act. See page 112 for more information. See Section 5(f) for other prescription drug coverage.

Note: Here are some things to keep in mind:

• You do not need to precertify your delivery; see page 26 for other circumstances, such as extended stays for you or your newborn.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will cover an extended stay if medically necessary.

• We cover routine nursery care of the newborn when performed during the covered portion of the mother’s maternity stay and billed by the facility. We cover other care of a newborn who requires professional services or non-routine treatment, only if we cover the newborn under a Self Plus One or Self and Family enrollment. Surgical benefits apply to circumcision when billed by a professional provider for a male newborn.
• Hospital services are listed in Section 5(c) and Surgical benefits are in Section 5(b).

Note: See page 156 for our payment for inpatient stays resulting from an emergency delivery at a hospital or other facility not contracted with your Local Plan.

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. Regular medical or surgical benefits apply rather than maternity benefits.

Note: See page 63 for our payment levels for circumcision.

Continued from previous page:

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Note: You may request prior approval and receive specific benefit information in advance for the delivery itself and any other maternity-related surgical procedures to be provided by a Non-participating physician when the charge for that care will be $5,000 or more. Call your Local Plan at the customer service phone number on the back of your ID card to obtain information about your coverage and the Plan allowance for the services.

Continued from previous page:

Participating/Non-participating: You pay all charges (except as noted below)

Note: For services billed by Participating and Non-participating laboratories or radiologists, you are responsible only for any difference between our allowance and the billed amount.

• Breast pump kit, limited to one of the two kits listed below, per calendar year, for members who are pregnant and/or nursing
  • Ameda Manual pump kit
    or
  • Ameda Double Electric pump kit

Note: The breast pump kit will include a supply of 150 Ameda milk storage bags. You may order Ameda milk storage bags, limited to 150 bags every 90 days, even if you own your own breast pump.

Note: Benefits for the breast pump kit and milk storage bags are only available when you order them through CVS Caremark by calling 800-262-7890.

Not covered:

• Procedures, services, drugs, and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest
• Genetic testing/screening of the baby’s father (see page 41 for our coverage of medically necessary diagnostic genetic testing)
• Childbirth preparation, Lamaze, and other birthing/parenting classes
• Breast pumps and milk storage bags except as stated above on this page
• Breastfeeding supplies other than those contained in the breast pump kit described on the previous page including clothing (e.g., nursing bras), baby bottles, or items for personal comfort or convenience (e.g., nursing pads)
• Tocolytic therapy and related services provided on an outpatient basis
• Maternity care for members not enrolled in the Service Benefit Plan

A range of voluntary family planning services for women, limited to:

• Contraceptive counseling
• Diaphragms and contraceptive rings
• Injectable contraceptives
• Intrauterine devices (IUDs)
• Implantable contraceptives
• Tubal ligation or tubal occlusion/tubal blocking procedures only

Family planning services for men, limited to:

• Vasectomy

Note: We also provide benefits for professional services associated with tubal ligation/occlusion/blocking procedures, vasectomy, and with the fitting, insertion, implantation, or removal of the contraceptives listed above at the payment levels shown here.

Note: When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.

Preferred: Nothing (no deductible)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred: Nothing

Participating/Non-participating: You pay all charges

• Oral and transdermal contraceptives
  Note: We waive your cost-share for generic oral and transdermal contraceptives when you purchase them at a Preferred retail pharmacy or for Standard Option members and for Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program. See page 110 for more information.

Note: When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred: 30% of the Plan allowance

Participating/Non-participating: You pay all charges

Not covered:

• Reversal of voluntary surgical sterilization
• Contraceptive devices not described above
• Over-the-counter (OTC) contraceptives, except as described in Section 5(f)

Diagnosis and treatment of infertility including covered:

• Diagnostic and treatment services
• Laboratory tests
• Diagnostic tests
• Surgical procedures
• Prescription drugs

Note: See Section 5(a) for covered labs, diagnostic tests, and X-rays.

Note: See Section 5(b) for covered surgical services.

Note: See Section 5(f) for covered prescription drugs.

Note: See below for a list of services not covered as treatments for infertility or as alternatives to conventional conception.

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred primary care provider or other healthcare professional: $30 copayment per visit

Preferred specialist: $40 copayment per visit

Note: You pay 30% of the Plan allowance for agents, drugs,
and/or supplies administered or obtained in connection with your care. (See page (Applies to printed brochure only) for more information about “agents.”)

Participating/Non-participating: You pay all charges (except as noted below)

Note: For services billed by Participating and Non-participating laboratories or radiologists, you pay any difference between our allowance and the billed amount.

The services listed below are not covered as treatments for infertility or as alternatives to conventional conception:

• Assisted reproductive technology (ART) and assisted insemination procedures, including but not limited to:
  • Artificial insemination (AI)
  • In vitro fertilization (IVF)
  • Embryo transfer and gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT)
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intracytoplasmic sperm injection (ICSI)
  • Intrauterine insemination (IUI)
• Services, procedures, and/or supplies that are related to ART and/or assisted insemination procedures
• Cryopreservation or storage of sperm (sperm banking), eggs, or embryos
• Preimplantation diagnosis, testing, and/or screening, including the testing or screening of eggs, sperm, or embryos
• Drugs used in conjunction with ART and assisted insemination procedures
• Services, supplies, or drugs provided to individuals not enrolled in this Plan

• Allergy testing
• Allergy treatment
• Sublingual allergy desensitization drugs as licensed by the U.S. FDA

Note: See page 39 for applicable office visit copayment.

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred primary care provider or other healthcare professional: $30 copayment

Preferred specialist: $40 copayment

Note: You pay 30% of the Plan allowance for agents, drugs,
and/or supplies administered or obtained in connection with your care. (See page (Applies to printed brochure only) for more information about “agents.”)

Participating/Non-participating: You pay all charges (except as noted below)

Note: For services billed by Participating and Non-participating laboratories or radiologists, you pay any difference between our allowance and the billed amount.

• Allergy injections

Note: See page 39 for applicable office visit copayment.

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred: Nothing

Participating/Non-participating: You pay all charges

• Preparation of each multi-dose vial of antigen

Note: See page 39 for applicable office visit copayment.

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred primary care provider or other healthcare professional: $30 copayment per multi-dose vial of antigen

Preferred specialist: $40 copayment per multi-dose vial of antigen

Participating/Non-participating: You pay all charges (except as noted below)

Note: For services billed by Participating and Non-participating laboratories or radiologists, you pay any difference between our allowance and the billed amount.

Not covered: Provocative food testing

Outpatient treatment therapies:

• Chemotherapy and radiation therapy
  
  Note: We cover high-dose chemotherapy and/or radiation therapy in connection with bone marrow transplants, and drugs or medications to stimulate or mobilize stem cells for transplant procedures, only for those conditions listed as covered under Organ/Tissue Transplants in Section 5(b). See also, Other services under You need prior Plan approval for certain services in Section 3 (pages 21-24).

• Intensity-modulated radiation therapy (IMRT)
  
  Note: You must get prior approval for outpatient IMRT related to cancers, except head, neck, breast, prostate, or anal cancer. Please refer to page 22 for more information.

• Renal dialysis – Hemodialysis and peritoneal dialysis
• Intravenous (IV)/infusion therapy – Home IV or infusion therapy
  
  Note: Home nursing visits associated with Home IV/infusion therapy are covered as shown under Home Health Services on page 59.

• Outpatient cardiac rehabilitation
• Pulmonary rehabilitation therapy
• Applied behavior analysis (ABA) for the treatment of an autism spectrum disorder (see prior approval requirements on page 22)

Note: See Section 5(c) for our payment levels for treatment therapies billed for by the outpatient department of a hospital.

Note: See page 60 for our coverage of osteopathic and chiropractic manipulative treatment.

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred primary care provider or other healthcare professional: $30 copayment per visit

Preferred specialist: $40 copayment per visit

Note: You pay 30% of the Plan allowance for agents, drugs,
and/or supplies administered or obtained in connection with your care. (See page (Applies to printed brochure only) for more information about “agents.”)

Participating/Non-participating: You pay all charges

• Auto-immune infusion medications: Remicade, Renflexis and Inflectra

Note: See above for your costs for intravenous (IV)/infusion therapy - Home IV or infusion therapy.

Preferred: 10% of the Plan allowance (deductible applies)

Member: 15% of the Plan allowance (deductible applies)

Non-member: 15% of the Plan allowance (deductible applies), plus any difference between our allowance and billed amount

Preferred: 15% of the Plan allowance

Member or Non-member: You pay all charges

Inpatient treatment therapies:

• Chemotherapy and radiation therapy
  
  Note: We cover high-dose chemotherapy and/or radiation therapy in connection with bone marrow transplants, and drugs or medications to stimulate or mobilize stem cells for transplant procedures, only for those conditions listed as covered under Organ/Tissue Transplants in Section 5(b). See also Other services under You need prior Plan approval for certain services in Section 3 (pages 21-24).

• Renal dialysis – Hemodialysis and peritoneal dialysis
• Pharmacotherapy (medication management) (See Section 5(c) for our coverage of drugs administered in connection with these treatment therapies.)
• Applied behavior analysis (ABA) for the treatment of an autism spectrum disorder (see prior approval requirements on page 22)

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred: Nothing

Participating/Non-participating: You pay all charges

• Physical therapy, occupational therapy, and speech therapy
• Cognitive rehabilitation therapy

Note: When billed by a skilled nursing facility, nursing home, extended care facility, or residential treatment center, we pay benefits as shown here for professional care, according to the contracting status of the facility.

Preferred primary care provider or other healthcare professional: $25 copayment per visit (no deductible)

Preferred specialist: $35 copayment per visit (no deductible)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Note: Benefits are limited to 75 visits per person, per calendar year for physical, occupational, or speech therapy, or a combination of all three.

Note: Visits that you pay for while meeting your calendar year deductible count toward the limit cited above.

Note: When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown on page 53, according to the contracting status of the facility.

Preferred primary care provider or other healthcare professional: $30 copayment per visit

Preferred specialist: $40 copayment per visit

Note: You pay 30% of the Plan allowance for agents, drugs,
and/or supplies administered or obtained in connection with your care. (See page (Applies to printed brochure only) for more information about “agents.”)

Note: Benefits are limited to 50 visits per person, per calendar year for physical, occupational, or speech therapy, or a combination of all three.

Participating/Non-participating: You pay all charges

Note: See Section 5(c) for our payment levels for rehabilitative therapies billed for by the outpatient department of a hospital.

Not covered:

• Recreational or educational therapy, and any related diagnostic testing except as provided by a hospital as part of a covered inpatient stay
• Maintenance or palliative rehabilitative therapy
• Exercise programs
• Equine therapy and hippotherapy (exercise on horseback)
• Massage therapy

• Hearing tests related to illness or injury
• Testing and examinations for prescribing hearing aids

Note: For our coverage of hearing aids and related services, see page 57.

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred primary care provider or other healthcare professional: $30 copayment per visit

Preferred specialist: $40 copayment per visit

Note: You pay 30% of the Plan allowance for agents, drugs,
and/or supplies administered or obtained in connection with your care. (See page (Applies to printed brochure only) for more information about “agents.”)

Participating/Non-participating: You pay all charges

Not covered:

• Routine hearing tests (except as indicated on page 45)
• Hearing aids (except as described on page 57) 

Benefits are limited to one pair of eyeglasses, replacement lenses, or contact lenses per incident prescribed:

• To correct an impairment directly caused by a single instance of accidental ocular injury or intraocular surgery;
• If the condition can be corrected by surgery, but surgery is not an appropriate option due to age or medical condition;
• For the nonsurgical treatment for amblyopia and strabismus, for children from birth through age 21

Note: Benefits are provided for refractions only when the refraction is performed to determine the prescription for the one pair of eyeglasses, replacement lenses, or contact lenses provided per incident as described above and on page 54.

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred: 30% of the Plan allowance

Participating/Non-participating: You pay all charges

• Eye examinations related to a specific medical condition
• Nonsurgical treatment for amblyopia and strabismus, for children from birth through age 21

Note: See above and on page 54 for our coverage of eyeglasses, replacement lenses, or contact lenses when prescribed as nonsurgical treatment for amblyopia and strabismus.

Note: See Section 5(b), Surgical procedures, for coverage for surgical treatment of amblyopia and strabismus.

Note: See pages 40-42 in this Section for our payment levels for Lab, X-ray, and other diagnostic tests performed or ordered by your provider. Benefits are not available for refractions except as described above.

Preferred primary care provider or other healthcare professional: $25 copayment (no deductible)

Preferred specialist: $35 copayment (no deductible)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred primary care provider or other healthcare professional: $30 copayment per visit

Preferred specialist: $40 copayment per visit

Note: You pay 30% of the Plan allowance for agents, drugs,
and/or supplies administered or obtained in connection with your care. (See page (Applies to printed brochure only) for more information about “agents.”)

Participating/Non-participating: You pay all charges

Not covered:

• Eyeglasses, contact lenses, routine eye examinations, or vision testing for the prescribing or fitting of eyeglasses or contact lenses, except as described above and on page 54
• Deluxe eyeglass frames or lens features for eyeglasses or contact lenses such as special coating, polarization, UV treatment, etc.
• Multifocal, accommodating, toric, or other premium intraocular lenses (IOLs) including Crystalens, ReStor, and ReZoom
• Eye exercises, visual training, or orthoptics, except for nonsurgical treatment of amblyopia and strabismus as described above
• LASIK, INTACS, radial keratotomy, and other refractive surgical services
• Refractions, including those performed during an eye examination related to a specific medical condition, except as described above

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

Note: See Orthopedic and Prosthetic Devices for information on podiatric shoe inserts.

Note: See Section 5(b) for our coverage for surgical procedures.

Preferred primary care provider or other healthcare professional: $25 copayment for the office visit (no deductible); 15% of the Plan allowance for all other services (deductible applies)

Preferred specialist: $35 copayment for the office visit (no deductible); 15% of the Plan allowance for all other services (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred primary care provider or other healthcare professional: $30 copayment per visit

Preferred specialist: $40 copayment per visit

Note: You pay 30% of the Plan allowance for agents, drugs,
and/or supplies administered or obtained in connection with your care. (See page (Applies to printed brochure only) for more information about “agents.”)

Participating/Non-participating: You pay all charges

Orthopedic braces and prosthetic appliances such as:

• Artificial limbs and eyes
• Functional foot orthotics when prescribed by a physician
• Rigid devices attached to the foot or a brace, or placed in a shoe
• Replacement, repair, and adjustment of covered devices
• Following a mastectomy, breast prostheses and surgical bras, including necessary replacements
• Surgically implanted penile prostheses limited to treatment of erectile dysfunction or as part of an approved plan for gender reassignment surgery
• Surgical implants

Note: A prosthetic appliance is a device that is surgically inserted or physically attached to the body to restore a bodily function or replace a physical portion of the body.

We provide hospital benefits for internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implants following mastectomy; see Section 5(c) for payment information. Insertion of the device is paid as surgery; see Section 5(b).

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred: 30% of the Plan allowance

Participating/Non-participating: You pay all charges

• Hearing aids for children up to age 22, limited to $2,500 per calendar year
• Hearing aids for adults age 22 and over, limited to $2,500 every 5 calendar years

Note: Benefits for hearing aid dispensing fees, fittings, batteries, and repair services are included in the benefit limits described above.

• Bone-anchored hearing aids when medically necessary, limited to $5,000 per calendar year

• Wigs for hair loss due to the treatment of cancer

Note: Benefits for wigs are paid at 100% of the billed amount, limited to $350 for one wig per lifetime.

Not covered:

• Shoes (including diabetic shoes)
• Over-the-counter orthotics
• Arch supports
• Heel pads and heel cups
• Wigs (including cranial prostheses), except for scalp hair prosthesis for hair loss due to the treatment of cancer, as stated above
• Over the counter hearing aids, enhancement devices, accessories or supplies (including remote controls and warranty packages)

Durable medical equipment (DME) is equipment and supplies that are:

1. Prescribed by your attending physician (i.e., the physician who is treating your illness or injury);
2. Medically necessary;
3. Primarily and customarily used only for a medical purpose;
4. Generally useful only to a person with an illness or injury;
5. Designed for prolonged use; and
6. Used to serve a specific therapeutic purpose in the treatment of an illness or injury.

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

• Home dialysis equipment
• Oxygen equipment
• Hospital beds
• Wheelchairs 
• Crutches
• Walkers
• Continuous passive motion (CPM) devices
• Dynamic orthotic cranioplasty (DOC) devices
• Insulin pumps
• Other items that we determine to be DME, such as compression stockings

Note: We cover DME at Preferred benefit levels only when you use a Preferred DME provider. Preferred physicians, facilities, and pharmacies are not necessarily Preferred DME providers.

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Note: See Section 5(c) for our coverage of DME provided and billed by a facility.

Preferred: 30% of the Plan allowance

Participating/Non-participating: You pay all charges

Note: See Section 5(c) for our coverage of DME provided and billed by a facility.

• Speech-generating devices, limited to $1,250 per calendar year

Not covered:

• Exercise and bathroom equipment
• Vehicle modifications, replacements, or upgrades
• Home modifications, upgrades, or additions
• Lifts, such as seat, chair, or van lifts
• Car seats
• Diabetic supplies, except as described in Section 5(f) or when Medicare Part B is primary
• Air conditioners, humidifiers, dehumidifiers, and purifiers
• Breast pumps, except as described on page 48
• Communications equipment, devices, and aids (including computer equipment) such as “story boards” or other communication aids to assist communication-impaired individuals (except for speech-generating devices as listed above)
• Equipment for cosmetic purposes
• Topical Hyperbaric Oxygen Therapy (THBO)

• Medical foods and nutritional supplements when administered by catheter or nasogastric tubes
  
  Note: See Section 10, Definitions, for more information about medical foods.

• Ostomy and catheter supplies
• Oxygen
  
  Note: When billed by a skilled nursing facility, nursing home, or extended care facility, we pay benefits as shown here for oxygen, according to the contracting status of the facility.
• Blood and blood plasma, except when donated or replaced, and blood plasma expanders

Note: We cover medical supplies at Preferred benefit levels only when you use a Preferred medical supply provider. Preferred physicians, facilities, and pharmacies are not necessarily Preferred medical supply providers.

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred: 30% of the Plan allowance

Participating/Non-participating: You pay all charges

Not covered:

• Infant formulas used as a substitute for breastfeeding
• Diabetic supplies, except as described in Section 5(f) or when Medicare Part B is primary
• Medical foods administered orally, except as described in Section 5(f)

Home nursing care (skilled) for two hours per day when:

• A registered nurse (R.N.) or licensed practical nurse
  (L.P.N.) provides the services; and
• A physician orders the care

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Note: Benefits for home nursing care are limited to 50 visits per person, per calendar year.

Note: Visits that you pay for while meeting your calendar year deductible count toward the annual visit limit.

Preferred: $30 copayment per visit

Note: You pay 30% of the Plan allowance for agents, drugs,
and/or supplies administered or obtained in connection with your care. (See page (Applies to printed brochure only) for more information about “agents.”)

Note: Benefits for home nursing care are limited to 25 visits per person, per calendar year.

Participating/Non-participating: You pay all charges

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient’s family
• Services primarily for bathing, feeding, exercising, moving the patient, homemaking, giving medication, or acting as a companion or sitter
• Services provided by a nurse, nursing assistant, health aide, or other similarly licensed or unlicensed person that are billed by a skilled nursing facility, extended care facility, or nursing home, except as included in the benefits described on pages 88-89.
• Private duty nursing

Manipulative treatment performed by a professional provider, when the provider is practicing within the scope of his/her license, limited to:

• Osteopathic manipulative treatment to any body region
• Chiropractic spinal and/or extraspinal manipulative treatment

Note: Benefits for manipulative treatment are limited to the services and combined treatment visits stated here.

Note: When billed by a facility, such as the outpatient department of a hospital, we provide benefits as shown here, according to the contracting status of the facility.

Preferred: $25 copayment per visit (no deductible)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Note: Benefits for osteopathic and chiropractic manipulative treatment are limited to a combined total of 12 visits per person, per calendar year.

Note: Manipulation visits that you pay for while meeting your calendar year deductible count toward the treatment limit cited above.

Preferred: $30 copayment per visit

Note: Benefits for osteopathic and chiropractic manipulative treatment are limited to a combined total of 20 visits per person, per calendar year.

Participating/Non-participating: You pay all charges

Acupuncture

Note: Acupuncture must be performed and billed by a healthcare provider who is licensed or certified to perform acupuncture by the state where the services are provided, and who is acting within the scope of that license or certification. See page 17 for more information.

Note: When billed by a facility such as the outpatient department of a hospital, you are limited to the number of visits per calendar year listed on this page. See Section 5(c) for your cost-share.

Note: See page 77 for our coverage of acupuncture when provided as anesthesia for covered surgery.

Note: See page 46 for our coverage of acupuncture when provided as anesthesia for covered maternity care.

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Note: Benefits for acupuncture are limited to 24 visits per calendar year.

Note: Visits that you pay for while meeting your calendar year deductible count toward the limit cited above.

Preferred primary care provider or other healthcare professional: $30 copayment per visit

Preferred specialist: $40 copayment per visit

Note: Benefits for acupuncture are limited to 10 visits per calendar year.

Note: You pay 30% of the Plan allowance for drugs and supplies.

Participating/Non-participating: You pay all charges

Not covered:

• Biofeedback
• Self-care or self-help training

• Smoking and tobacco cessation treatment
  • Individual counseling for smoking and tobacco cessation
    
    Note: Benefits are not available for group counseling.
  • Smoking and tobacco cessation classes
    
    Note: See Section 5(f) for our coverage of smoking and tobacco cessation drugs.

Preferred: Nothing (no deductible)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred: Nothing

Participating/Non-participating: You pay all charges

• Diabetic education
  
  Note: See pages 40, 43 and 46 for our coverage of nutritional counseling services that are not part of a diabetic education program.

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred primary care provider or other healthcare professional: $30 copayment per visit

Preferred specialist: $40 copayment per visit

Participating/Non-participating: You pay all charges

Not covered:

• Marital, family, educational, or other counseling or training services, or applied behavior analysis (ABA), when performed as part of an educational class or program
• Premenstrual syndrome (PMS), lactation (except as described on page 47), headache, eating disorder (except as described on pages 40 and 43), and other educational clinics
• Recreational or educational therapy, and any related diagnostic testing except as provided by a hospital as part of a covered inpatient stay
• Services performed or billed by a school or halfway house or a member of its staff

A comprehensive range of services, such as:

• Operative procedures
• Assistant surgeons/surgical assistance if required because of the complexity of the surgical procedures
• Treatment of fractures and dislocations, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Colonoscopy, with or without biopsy
  
  Note: Preventive care benefits apply to the professional charges for your first covered colonoscopy of the calendar year (see page 42). We provide benefits as described here for subsequent colonoscopy procedures performed by a professional provider in the same year.
• Endoscopic procedures
• Injections
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive Surgery on page 67)
• Treatment of burns
• Male circumcision
• Insertion of internal prosthetic devices. See Section 5(a), Orthopedic and Prosthetic Devices, and Section 5(c), Other Hospital Services and Supplies, for our coverage for the device.

• Gender reassignment surgical benefits are limited to the following:
  • For female to male surgery: mastectomy, hysterectomy, vaginectomy, salpingo-oophorectomy, metoidioplasty, phalloplasty, urethroplasty, scrotoplasty, electrolysis (hair removal at the covered operative site), and placement of testicular and erectile prosthesis
  • For male to female surgery: penectomy, orchiectomy, vaginoplasty, clitoroplasty, labiaplasty, and electrolysis (hair removal at the covered operative site)

Note: Prior approval is required for gender reassignment surgery. For more information about prior approval, please refer to page 22.

Note: Benefits for gender reassignment surgery are limited to once per covered procedure, per lifetime. Benefits are not available for repeat or revision procedures when benefits were provided for the initial procedure. Benefits are not available for gender reassignment surgery for any condition other than gender dysphoria.

• Gender reassignment surgery on an inpatient or outpatient basis is subject to the pre-surgical requirements listed below. The member must meet all requirements.
  • Prior approval is obtained
  • Member must be at least 18 years of age at the time prior approval is requested and the treatment plan is submitted
  • Diagnosis of gender dysphoria by a qualified healthcare professional
    • New gender identity has been present for at least 24 continuous months
    • Member has a strong desire to be rid of primary and/or secondary sex characteristics because of a marked incongruence with the member’s identified gender
    • Member’s gender dysphoria is not a symptom of another mental disorder or chromosomal abnormality
    • Gender dysphoria causes clinical distress or impairment in social, occupational, or other important areas of functioning
  • Member must meet the following criteria:
    • Living 12 months of continuous, full-time, real-life experience in the desired gender (including place of employment, family, social and community activities)
    • 12 months of continuous hormone therapy appropriate to the member’s gender identity
    • Two referral letters from qualified mental health professionals – one must be from a psychotherapist who has treated the member for a minimum of 12 months. Letters must document: diagnosis of persistent and chronic gender dysphoria; any existing co-morbid conditions are stable; member is prepared to undergo surgery and understands all practical aspects of the planned surgery
    • If medical or mental health concerns are present, they are being optimally managed and are reasonably well-controlled
• Procedures to treat morbid obesity – a condition in which an individual has a Body Mass Index (BMI) of 40 or more, or an individual with a BMI of 35 or more with one or more co-morbidities; eligible members must be age 18 or over. Benefits are available only for the following procedures:
  • Roux-en-Y
  • Gastric bypass
  • Laparoscopic adjustable gastric banding
  • Sleeve gastrectomy
  • Biliopancreatic bypass with duodenal switch

Note: Benefits for the surgical treatment of morbid obesity are subject to the requirements listed on pages 62-63.

Note: For certain surgical procedures, your out-of-pocket costs for facility services are reduced if you use a facility designated as a Blue Distinction Center. See pages 86-87 for information.

Note: Prior approval is required for outpatient surgery for morbid obesity. For more information about prior approval, please refer to page 22.

• Benefits for the surgical treatment of morbid obesity, performed on an inpatient or outpatient basis, are subject to the pre-surgical requirements listed below. The member must meet all requirements.
  • Diagnosis of morbid obesity (as defined above) for a period of 1 year prior to surgery
  • Participation in a medically supervised weight loss program, including nutritional counseling, for at least 3 months prior to the date of surgery. (Note: Benefits are not available for commercial weight loss programs; see pages 43 and 46 for our coverage of nutritional counseling services.)
  • Pre-operative nutritional assessment and nutritional counseling about pre- and post-operative nutrition, eating, and exercise
  • Evidence that attempts at weight loss in the 1-year period prior to surgery have been ineffective
  • Psychological clearance of the member’s ability to understand and adhere to the pre- and post-operative program, based on a psychological assessment performed by a licensed professional mental health practitioner (see page 99 for our payment levels for mental health services)
  • Member has not smoked in the 6 months prior to surgery
  • Member has not been treated for substance use disorder for 1 year prior to surgery and there is no evidence of substance use disorder during the 1-year period prior to surgery
• Benefits for subsequent surgery for morbid obesity, performed on an inpatient or outpatient basis, are subject to the following additional pre-surgical requirements:
  • All criteria listed above for the initial procedure must be met again, except when the subsequent surgery is necessary to treat a complication from the prior morbid obesity surgery.
  • Previous surgery for morbid obesity was at least 2 years prior to repeat procedure
  • Weight loss from the initial procedure was less than 50% of the member’s excess body weight at the time of the initial procedure
  • Member complied with previously prescribed post-operative nutrition and exercise program
  • Claims for the surgical treatment of morbid obesity must include documentation from the member’s provider(s) that all pre-surgical requirements have been met

Note: When multiple surgical procedures that add time or complexity to patient care are performed during the same operative session, the Local Plan determines our allowance for the combination of multiple, bilateral, or incidental surgical procedures. Generally, we will allow a reduced amount for procedures other than the primary procedure.

Note: We do not pay extra for “incidental” procedures (those that do not add time or complexity to patient care).

Note: When unusual circumstances require the removal of casts or sutures by a physician other than the one who applied them, the Local Plan may determine that a separate allowance is payable.

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Note: You may request prior approval and receive specific benefit information in advance for surgeries to be performed by Non-participating physicians when the charge for the surgery will be $5,000 or more. See page 24 for more information.

Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting

Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings

Note: Your provider will document the place of service when filing your claim for the procedure(s). Please contact the provider if you have any questions about the place of service.

Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. No additional copayment applies to the services of assistant surgeons.

Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care. (See page (Applies to printed brochure only) for more information about “agents.”)

Participating/Non-participating: You pay all charges

Not covered:

• Reversal of voluntary sterilization
• Services of a standby physician
• Routine surgical treatment of conditions of the foot (see Section 5(a), Foot Care)
• Cosmetic surgery
• LASIK, INTACS, radial keratotomy, and other refractive surgery
• Surgeries related to sexual inadequacy (except surgical placement of penile prostheses to treat erectile dysfunction and gender reassignment surgeries specifically listed as covered)
• Reversal of gender reassignment surgery

• Surgery to correct a functional defect
• Surgery to correct a congenital anomaly (See Section 10, page (Applies to printed brochure only), for definition.)
• Treatment to restore the mouth to a pre-cancer state
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • Surgery to produce a symmetrical appearance of the patient’s breasts
  • Treatment of any physical complications, such as lymphedemas
    
    Note: Internal breast prostheses are paid as orthopedic and prosthetic devices; see Section 5(a). See Section 5(c) when billed by a facility.
    
    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.
• Surgery for placement of penile prostheses to treat erectile dysfunction

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Note: You may request prior approval and receive specific benefit information in advance for surgeries to be performed by Non-participating physicians when the charge for the surgery will be $5,000 or more. See page 24 for more information.

Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting

Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings

Note: Your provider will document the place of service when filing your claim for the procedure(s). Please contact the provider if you have any questions about the place of service.

Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. No additional copayment applies to the services of assistant surgeons.

Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care. (See page (Applies to printed brochure only) for more information about “agents.”)

Participating/Non-participating: You pay all charges

Not covered:

• Cosmetic surgery – any operative procedure or any portion of a procedure performed primarily to improve physical appearance through change in bodily form – unless required for a congenital anomaly or to restore or correct a part of the body that has been altered as a result of accidental injury, disease, or surgery (does not include anomalies related to the teeth or structures supporting the teeth)
• Surgeries related to sexual dysfunction or sexual inadequacy (except surgical placement of penile prostheses to treat erectile dysfunction and gender reassignment surgeries specifically listed as covered)
• Reversal of gender reassignment surgery

Oral surgical procedures, limited to:

• Excision of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of mouth when pathological examination is necessary
• Surgery needed to correct accidental injuries (see Definitions) to jaws, cheeks, lips, tongue, roof and floor of mouth
  
  Note: You must get prior approval for outpatient surgery needed to correct accidental injuries as described above. Please refer to page 22 for more information.

• Excision of exostoses of jaws and hard palate
• Incision and drainage of abscesses and cellulitis
• Incision and surgical treatment of accessory sinuses, salivary glands, or ducts
• Reduction of dislocations and excision of temporomandibular joints
• Removal of impacted teeth

Note: Dentists and oral surgeons who are in our Preferred Dental Network for routine dental care are not necessarily Preferred providers for other services covered by this Plan under other benefit provisions (such as the surgical benefit for oral and maxillofacial surgery). Call us at the customer service phone number on the back of your ID card to verify that your provider is Preferred for the type of care (e.g., routine dental care or oral surgery) you are scheduled to receive.

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Note: You may request prior approval and receive specific benefit information in advance for surgeries to be performed by Non-participating physicians when the charge for the surgery will be $5,000 or more. See page 24 for more information.

Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting

Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings

Note: Your provider will document the place of service when filing your claim for the procedure(s). Please contact the provider if you have any questions about the place of service.

Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. No additional copayment applies to the services of assistant surgeons.

Note: You pay 30% of the Plan allowance for agents, drugs, and/or supplies administered or obtained in connection with your care. (See page (Applies to printed brochure only) for more information about “agents.”)

Participating/Non-participating: You pay all charges

Not covered:

• Oral implants and transplants except for those required to treat accidental injuries as specifically described on page 68 and in Section 5(g)
• Surgical procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone), except for those required to treat accidental injuries as specifically described on page 68 and in
  Section 5(g)
• Surgical procedures involving dental implants or preparation of the mouth for the fitting or the continued use of dentures, except for those required to treat accidental injuries as specifically described on page 68 and in Section 5(g)
• Orthodontic care before, during, or after surgery, except for orthodontia associated with surgery to correct accidental injuries as specifically described on page 68 and in
  Section 5(g)

All charges

• Transplants of corneal tissue
• Heart transplant
• Heart-lung transplant
• Kidney transplant
• Liver transplant
• Pancreas transplant
• Simultaneous pancreas-kidney transplant
• Simultaneous liver-kidney transplant
• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
• Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach, and pancreas
• Single, double, or lobar lung transplant

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Note: You may request prior approval and receive specific benefit information in advance for kidney and cornea transplants to be performed by Non-participating physicians when the charge for the surgery will be $5,000 or more. See page 24 for more information.

Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting

Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings

Note: Your provider will document the place of service when filing your claim for the procedure(s). Please contact the provider if you have any questions about the place of service.

• For members with end-stage cystic fibrosis, benefits for lung transplantation are limited to double lung transplants
• Implantation of an artificial heart as a bridge to transplant or destination therapy

Note: See pages 69-70 for the prior approval and facility requirements that apply to organ/tissue transplants.

See previous page

Continued from previous page:

Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. No additional copayment applies to the services of assistant surgeons.

Participating/Non-participating: You pay all charges

Allogeneic blood or marrow stem cell transplants for the diagnoses as indicated below:

• Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
• Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) with poor response to therapy, short time to progression, transformed disease, or high-risk disease
• Chronic myelogenous leukemia
• Hemoglobinopathy (i.e., sickle cell anemia, thalassemia major)
• High-risk neuroblastoma
• Hodgkin’s lymphoma
• Infantile malignant osteopetrosis
• Inherited metabolic disorders (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy, Hurler’s syndrome and Maroteaux-Lamy syndrome variants)
• Marrow failure (i.e., severe or very severe aplastic anemia, Fanconi’s anemia, paroxysmal nocturnal hemoglobinuria (PNH), pure red cell aplasia, congenital thrombocytopenia)
• MDS/MPN (e.g., chronic myelomonocytic leukemia (CMML))
• Myelodysplasia/myelodysplastic syndromes (MDS)
• Myeloproliferative neoplasms (MPN) (e.g., polycythemia vera, essential thrombocythemia, primary myelofibrosis)
• Non-Hodgkin’s lymphoma (e.g., Waldenstrom’s macroglobulinemia, B-cell lymphoma, Burkitt lymphoma)
• Plasma cell disorders (e.g., multiple myeloma, amyloidosis, polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome)

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting

Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings

Note: Your provider will document the place of service when filing your claim for the procedure(s). Please contact the provider if you have any questions about the place of service.

Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. No additional copayment applies to the services of assistant surgeons.

Participating/Non-participating: You pay all charges.

• Primary immunodeficiencies (e.g., severe combined immunodeficiency, Wiskott-Aldrich syndrome, hemophagocytic lymphohistiocytosis, X-linked lymphoproliferative syndrome, Kostmann’s syndrome, leukocyte adhesion deficiencies)

Note: See pages 69-70 for the prior approval and facility requirements that apply to blood or marrow stem cell transplants.

Note: Refer to pages 73-75 for information about blood or marrow stem cell transplants covered only in clinical trials.

See previous page

See previous page

Autologous blood or marrow stem cell transplants for the diagnoses as indicated below:

• Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
• Central nervous system (CNS) embryonal tumors (e.g., atypical teratoid/rhabdoid tumor, primitive neuroectodermal tumors (PNETs), medulloblastoma, pineoblastoma, ependymoblastoma)
• Ewing’s sarcoma
• Germ cell tumors (e.g., testicular germ cell tumors)
• High-risk neuroblastoma
• Hodgkin’s lymphoma
• Non-Hodgkin’s lymphoma (e.g., Waldenstrom’s macroglobulinemia, B-cell lymphoma, Burkitt lymphoma)
• Plasma cell disorders (e.g., multiple myeloma, amyloidosis, polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome)
• Scleroderma

Note: See pages 69-70 for the prior approval and facility requirements that apply to blood or marrow stem cell transplants.

Note: Refer to pages 73-75 for information about blood or marrow stem cell transplants covered only in clinical trials.

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting

Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings

Note: Your provider will document the place of service when filing your claim for the procedure(s). Please contact the provider if you have any questions about the place of service.

Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. No additional copayment applies to the services of assistant surgeons.

Participating/Non-participating: You pay all charges

Blood or marrow stem cell transplants for the diagnoses as indicated below, only when performed as part of a clinical trial that meets the facility criteria described on page 69 and the requirements listed on page 74:

• Allogeneic blood or marrow stem cell transplants for:
  • Breast cancer
  • Colon cancer
  • Epidermolysis bullosa
  • Glial tumors (e.g., anaplastic astrocytoma, choroid plexus tumors, ependymoma, glioblastoma multiforme)
  • Ovarian cancer
  • Prostate cancer
  • Renal cell carcinoma
  • Retinoblastoma
  • Rhabdomyosarcoma
  • Sarcoma
  • Wilm’s tumor
• Autologous blood or marrow stem cell transplants for:
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Glial tumors (e.g., anaplastic astrocytoma, choroid plexus tumors, ependymoma, glioblastoma multiforme)
  • Retinoblastoma
  • Rhabdomyosarcoma
  • Wilm’s tumor and other childhood kidney cancers

Note: If a non-randomized clinical trial for a blood or marrow stem cell transplant listed above meeting the requirements shown on page 74 is not available, we will arrange for the transplant to be provided at an approved transplant facility, if available.

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting

Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings

Note: Your provider will document the place of service when filing your claim for the procedure(s). Please contact the provider if you have any questions about the place of service.

Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. No additional copayment applies to the services of assistant surgeons.

Participating/Non-participating: You pay all charges

Blood or marrow stem cell transplants for the diagnoses as indicated below, only when performed at a FACT-accredited facility (see page 19) as part of a clinical trial that meets the requirements listed below:

• Allogeneic blood or marrow stem cell transplants for:
  • Autoimmune disease (limited to: multiple sclerosis, scleroderma, systemic lupus erythematosus and chronic inflammatory demyelinating polyneuropathy)
• Autologous blood or marrow stem cell transplants for:
  • Autoimmune disease (limited to: multiple sclerosis, systemic lupus erythematosus and chronic inflammatory demyelinating polyneuropathy)

Requirements for blood or marrow stem cell transplants covered only under clinical trials:

• You must contact us at the customer service phone number listed on the back of your ID card to obtain prior approval (see page 23); and
• The patient must be properly and lawfully registered in the clinical trial, meeting all the eligibility requirements of the trial; and
  • For the transplant procedures listed above, the clinical trial must be reviewed and approved by the Institutional Review Board (IRB) of the FACT-accredited facility where the procedure is to be performed; and
  • For the transplant procedures listed on page 73, the clinical trial must be reviewed and approved by the IRB of the FACT-accredited facility, Blue Distinction Center for Transplants, or Cancer Research Facility where the procedure is to be performed.

Note: Clinical trials are research studies in which physicians and other researchers work to find ways to improve care. Each study tries to answer scientific questions and to find better ways to prevent, diagnose, or treat patients. A clinical trial has possible benefits as well as risks. Each trial has a protocol which explains the purpose of the trial, how the trial will be performed, who may participate in the trial, and the beginning and end points of the trial. Information regarding clinical trials is available at www.cancer.gov/about-cancer/treatment/clinical-trials.

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting

Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings

Note: Your provider will document the place of service when filing your claim for the procedure(s). Please contact the provider if you have any questions about the place of service.

Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. No additional copayment applies to the services of assistant surgeons.

Participating/Non-participating: You pay all charges

Even though we may state benefits are available for a specific type of clinical trial, you may not be eligible for inclusion in these trials or there may not be any trials available in a FACT-accredited facility, Blue Distinction Center for Transplants, or Cancer Research Facility to treat your condition at the time you seek to be included in a clinical trial. If your physician has recommended you participate in a clinical trial, we encourage you to contact the Case Management Department at your Local Plan for assistance.

Note: See pages 144-145 for our coverage of other costs associated with clinical trials.

See previous page

Related transplant services:

• Extraction or reinfusion of blood or marrow stem cells as part of a covered allogeneic or autologous transplant

• Harvesting, immediate preservation, and storage of stem cells when the autologous blood or marrow stem cell transplant has been scheduled or is anticipated to be scheduled within an appropriate time frame for patients diagnosed at the time of harvesting with one of the conditions listed on pages 71-74
  
  Note: Benefits are available for charges related to fees for storage of harvested autologous blood or marrow stem cells related to a covered autologous stem cell transplant that has been scheduled or is anticipated to be scheduled within an appropriate time frame. No benefits are available for any charges related to fees for long term storage of stem cells.
• Collection, processing, storage, and distribution of cord blood only when provided as part of a blood or marrow stem cell transplant scheduled or anticipated to be scheduled within an appropriate time frame for patients diagnosed with one of the conditions listed on pages 71-74
• Covered medical and hospital expenses of the donor, when we cover the recipient
• Covered services or supplies provided to the recipient
• Donor screening tests for up to three non-full sibling (such as unrelated) potential donors, for any full sibling potential donors, and for the actual donor used for transplant

Note: See Section 5(a) for coverage for related services, such as chemotherapy and/or radiation therapy and drugs administered to stimulate or mobilize stem cells for covered transplant procedures.

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred: $150 copayment per performing surgeon, for surgical procedures performed in an office setting

Preferred: $200 copayment per performing surgeon, for surgical procedures performed in all other settings

Note: Your provider will document the place of service when filing your claim for the procedure(s). Please contact the provider if you have any questions about the place of service.

Note: If you receive the services of a co-surgeon, you pay a separate copayment for those services, based on where the surgical procedure is performed. No additional copayment applies to the services of assistant surgeons.

Participating/Non-participating: You pay all charges

Not covered:

• Any transplant not listed as covered and transplants for any diagnosis not listed as covered
• Donor screening tests and donor search expenses, including associated travel expenses, except as defined on page 75
• Implants of artificial organs, including those implanted as a bridge to transplant and/or as destination therapy, other than medically necessary implantation of an artificial heart as described on pages 70-71
• Allogeneic pancreas islet cell transplantation
• Travel costs related to covered transplants performed at facilities other than Blue Distinction Centers for Transplants; travel costs incurred when prior approval has not been obtained; travel costs outside those allowed by IRS regulations, such as food-related expenses

Anesthesia (including acupuncture) for covered medical or surgical services when requested by the attending physician and performed by:

• A certified registered nurse anesthetist (CRNA), or
• A physician other than the physician (or the assistant) performing the covered medical or surgical procedure

Professional services provided in:

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

Anesthesia services consist of administration by injection or inhalation of a drug or other anesthetic agent (including acupuncture) to obtain muscular relaxation, loss of sensation, or loss of consciousness.

Note: Anesthesia acupuncture services do not accumulate toward the member’s annual maximum.

Note: See Section 5(c) for our payment levels for anesthesia services billed by a facility.

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred: Nothing

Participating/Non-participating: You pay all charges

Not covered:

• Anesthesia related to non-covered surgeries or procedures

All charges

All charges

Room and board, such as:

• Semiprivate or intensive care accommodations
• General nursing care
• Meals and special diets

Note: We cover a private room only when you must be isolated to prevent contagion, when your isolation is required by law, or when a Preferred or Member hospital only has private rooms. If a Preferred or Member hospital only has private rooms, we base our payment on the contractual status of the facility. If a Non-member hospital only has private rooms, we base our payment on the Plan allowance for your type of admission. Please see pages 155-157 for more information.

See pages 87-88 and 100-101 for inpatient residential treatment center.

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic studies, radiology services, laboratory tests, and pathology services
• Administration of blood or blood plasma
• Dressings, splints, casts, and sterile tray services
• Internal prosthetic devices
• Other medical supplies and equipment, including oxygen
• Anesthetics and anesthesia services
• Take-home items
• Pre-admission testing recognized as part of the hospital admissions process
• Nutritional counseling
• Acute inpatient rehabilitation

Note: Observation services are billed as outpatient facility care. As a result, benefits for observation services are provided at the outpatient facility benefit levels described on page 82. See page (Applies to printed brochure only) for more information about these types of services.

Preferred facilities: $350 per admission copayment for unlimited days (no deductible)

Note: For facility care related to maternity, including care at birthing facilities, we waive the per admission copayment and pay for covered services in full when you use a Preferred facility.

Member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible)

Non-member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible), and any remaining balance after our payment

Note: If you are admitted to a Member or Non-member facility due to a medical emergency or accidental injury, you pay a $450 per admission copayment for unlimited days and we then provide benefits at 100% of the Plan allowance.

Preferred facilities: $175 per day copayment up to $875 per admission for unlimited days

Note: For Preferred facility care related to maternity (including inpatient facility care, care at birthing facilities, and services you receive on an outpatient basis), your responsibility for the covered services you receive is limited to $175 per admission.

Member/Non-member facilities: You pay all charges

Note: Here are some things to keep in mind:

• You do not need to precertify your delivery; see page 26 for other circumstances, such as extended stays for you or your newborn.
• If you need to stay longer in the hospital than initially planned, we will cover an extended stay if it is medically necessary. However, you must precertify the extended stay. See page 26 for information on requesting additional days.
• We pay inpatient hospital benefits for an admission in connection with the treatment of children up to age 22 with severe dental caries. We cover hospitalization for other types of dental procedures only when a non-dental physical impairment exists that makes hospitalization necessary to safeguard the health of the patient. We provide benefits for dental procedures as shown in Section 5(g).

Note: See pages 46-48 for other covered maternity services.

Note: See page 59 for coverage of blood and blood products.

Note: For certain surgical procedures, your out-of-pocket costs for facility services are reduced if you use a facility designated as a Blue Distinction Center. See pages 86-87 for information.

See previous page

See previous page

Not covered:

• Admission to non-covered facilities, such as nursing homes, extended care facilities, schools, or residential treatment centers (except as described on pages 87-88 and 100-101)
• Personal comfort items, such as guest meals and beds, phone, television, beauty and barber services
• Private duty nursing
• Facility room and board expenses when, in our judgment, an admission or portion of an admission is:
  • Custodial or long term care (see Definitions)
  • Convalescent care or a rest cure
  • Domiciliary care provided because care in the home is not available or is unsuitable
• Care that is not medically necessary, such as:
  • When services did not require the acute hospital inpatient (overnight) setting but could have been provided safely and adequately in a physician’s office, the outpatient department of a hospital, or some other setting, without adversely affecting your condition or the quality of medical care you receive.
  • Admissions for, or consisting primarily of, observation and/or evaluation that could have been provided safely and adequately in some other setting (such as a physician’s office)
  • Admissions primarily for diagnostic studies, radiology services, laboratory tests, or pathology services that could have been provided safely and adequately in some other setting (such as the outpatient department of a hospital or a physician’s office)

Note: If we determine that an inpatient admission is one of the types listed above, we will not provide benefits for inpatient room and board or inpatient physician care. However, we will provide benefits for covered services or supplies other than room and board and inpatient physician care at the level that we would have paid if they had been provided in some other setting. Benefits are limited to care provided by covered facility providers (see pages 18-19).

Outpatient surgical and treatment services performed and billed by a facility, such as:

• Operating, recovery, and other treatment rooms
• Anesthetics and anesthesia services
• Acupuncture
• Pre-surgical testing performed within one business day of the covered surgical services
• Chemotherapy and radiation therapy
• Colonoscopy, with or without biopsy
  
  Note: Preventive care benefits apply to the facility charges for your first covered colonoscopy of the calendar year (see page 42). We provide diagnostic benefits for services related to subsequent colonoscopy procedures in the same year.
• Intravenous (IV)/infusion therapy
• Renal dialysis
• Visits to the outpatient department of a hospital for non-emergency treatment services
• Diabetic education
• Administration of blood, blood plasma, and other biologicals
• Blood and blood plasma, if not donated or replaced, and other biologicals
• Dressings, splints, casts, and sterile tray services
• Facility supplies for hemophilia home care
• Other medical supplies, including oxygen
• Surgical implants

 Notes:

• See pages 95-97 for our payment levels for care related to a medical emergency or accidental injury.
• See page 49 for our coverage of family planning services.
• For our coverage of hospital-based clinic visits, please refer to the professional benefits described on pages 39-40 and page 55 for vision services.
• For certain surgical procedures, your out-of-pocket costs for facility services are reduced if you use a facility designated as a Blue Distinction Center. See pages 86-87 for information.
• For outpatient facility care related to maternity, including outpatient care at birthing facilities, we waive your cost-share amount and pay for covered services in full when you use a Preferred facility.
  See pages 46-48 for other included maternity services.
• See page 85 for outpatient drugs, medical devices, and durable medical equipment billed for by a facility.
• We cover outpatient hospital services and supplies related to the treatment of children up to age 22 with severe dental caries.

We cover outpatient care related to other types of dental procedures only when a non-dental physical impairment exists that makes the hospital setting necessary to safeguard the health of the patient. See Section 5(g), Dental Benefits, for additional benefit information.

Preferred facilities: 15% of the Plan allowance (deductible applies)

Member facilities: 35% of the Plan allowance (deductible applies)

Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.

Preferred facilities: $100 copayment per day per facility (except as noted below)

Note: You may be responsible for paying a $150 copayment per day per facility if other diagnostic services are billed in addition to the services listed here.

Note: You pay 30% of the Plan allowance for surgical implants, agents, or drugs administered or obtained in connection with your care. (See page (Applies to printed brochure only) for more information about “agents.”)

Member/Non-member facilities: You pay all charges

Outpatient observation services performed and billed by a hospital or freestanding ambulatory facility

Note: All outpatient services billed by the facility during the time you are receiving observation services are included in the cost-share amounts shown here. Please refer to Section 5(a) for services billed by professional providers during an observation stay and pages 79-81 for information about benefits for inpatient admissions.

Note: For outpatient observation services related to maternity, we waive your cost-share amount and pay for covered services in full when you use a Preferred facility.

Preferred facilities: $350 copayment for the duration of services (no deductible)

Member facilities: $450 copayment for the duration of services, plus 35% of the Plan allowance (no deductible)

Non-member facilities: $450 copayment for the duration of services, plus 35% of the Plan allowance (no deductible), and any remaining balance after our payment

Preferred facilities: $175 per day copayment up to $875

Member/Non-member facilities: You pay all charges

Outpatient diagnostic testing and treatment services performed and billed by a facility, limited to:

• Angiographies
• Bone density tests
• CT scans/MRIs/PET scans
• Nuclear medicine
• Facility-based sleep studies (prior approval is required)
• Genetic testing
  
  Note: We cover specialized diagnostic genetic testing billed for by a facility, such as the outpatient department of a hospital, as shown here. See page 41 for coverage criteria and limitations.

Preferred facilities: 15% of the Plan allowance (deductible applies)

Member facilities: 35% of the Plan allowance (deductible applies)

Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.

Preferred facilities: $150 copayment per day per facility

Member facilities: $150 copayment per day per facility

Non-member facilities: $150 copayment per day per facility, plus any difference between our allowance and the billed amount

Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care. (See page (Applies to printed brochure only) for more information about “agents.”)

Outpatient diagnostic testing services performed and billed by a facility, such as:

• Cardiovascular monitoring
• EEGs
• Home-based/unattended sleep studies
• Ultrasounds
• Neurological testing
• X-rays (including set-up of portable X-ray equipment)

Note: For outpatient facility care related to maternity, including outpatient care at birthing facilities, we waive your cost-share amount and pay for covered services in full when you use a Preferred facility.

Preferred facilities: 15% of the Plan allowance (deductible applies)

Member facilities: 35% of the Plan allowance (deductible applies)

Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.

Preferred facilities: $40 copayment per day per facility

Member facilities: $40 copayment per day per facility

Non-member facilities: $40 copayment per day per facility, plus any difference between our allowance and the billed amount

Note: You may be responsible for paying a higher copayment per day per facility if other diagnostic and/or treatment services are billed in addition to the services listed here.

Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care. (See page (Applies to printed brochure only) for more information about “agents.”)

Outpatient treatment and therapy services performed and billed by a facility, limited to:

• Cognitive rehabilitation therapy
• Physical, occupational, and speech therapy
  • Standard Option benefits are limited to a combined total of 75 visits per person per calendar year
  • Basic Option benefits are limited to a combined total of 50 visits per person per calendar year
• Manipulative treatment services
  • Standard Option benefits are limited to a combined total of 12 visits per person per calendar year
  • Basic Option benefits are limited to a combined total of 20 visits per person per calendar year

Preferred facilities: $25 copayment per day per facility (no deductible)

Member facilities: 35% of the Plan allowance (deductible applies)

Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.

Preferred facilities: $30 copayment per day per facility

Member/Non-member facilities: You pay all charges

Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care. (See page (Applies to printed brochure only) for more information about “agents.”)

Outpatient treatment services performed and billed by a facility, limited to:

• Cardiac rehabilitation
• Pulmonary rehabilitation
• Applied behavior analysis (ABA) for an autism spectrum disorder (see prior approval requirements on page 22)

Preferred facilities: 15% of the Plan allowance (deductible applies)

Member facilities: 35% of the Plan allowance (deductible applies)

Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.

Preferred facilities: $30 copayment per day per facility

Note: You may be responsible for paying a higher copayment per day per facility if other diagnostic and/or treatment services are billed in addition to the services listed here.

Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care. (See page (Applies to printed brochure only) for more information about “agents.”)

Member/Non-member facilities: You pay all charges

Outpatient diagnostic and treatment services performed and billed by a facility, limited to:

• Laboratory tests and pathology services
• EKGs

Note: For outpatient facility care related to maternity, including outpatient care at birthing facilities, we waive your cost-share amount and pay for covered services in full when you use a Preferred facility.

Preferred facilities: 15% of the Plan allowance (deductible applies)

Member facilities: 35% of the Plan allowance (deductible applies)

Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.

Preferred facilities: Nothing

Member facilities: Nothing

Non-member facilities: You pay any difference between our allowance and the billed amount

Note: You may be responsible for paying a copayment per day per facility if other diagnostic and/or treatment services are billed in addition to the services listed here.

Note: You pay 30% of the Plan allowance for agents or drugs administered or obtained in connection with your care. (See page (Applies to printed brochure only) for more information about “agents.”)

Outpatient adult preventive care performed and billed by a facility, limited to:

• Visits/exams for preventive care, screening procedures, and routine immunizations described on pages 42-45
• Cancer screenings listed on page 42-43 and ultrasound screening for abdominal aortic aneurysm

Note: See page 44 for our coverage requirements for preventive BRCA testing.

Note: See pages 45-46 for our payment levels for covered preventive care services for children billed for by facilities and performed on an outpatient basis.

See page 42 for our payment levels for covered preventive care services for adults

Preferred facilities: Nothing

Member/Non-member facilities: Nothing for cancer screenings and ultrasound screening for abdominal aortic aneurysm

Note: Benefits are not available for routine adult physical examinations, associated laboratory tests, colonoscopies, or routine immunizations performed at Member or Non-member facilities.

Outpatient drugs, medical devices, and durable medical equipment billed for by a facility, such as:

• Prescribed drugs
• Orthopedic and prosthetic devices
• Durable medical equipment
• Surgical implants

Note: For outpatient facility care related to maternity, including outpatient care at birthing facilities, we waive your cost-share amount and pay for covered services in full when you use a Preferred facility.

Note: Certain self-injectable drugs are covered only when dispensed by a pharmacy under the pharmacy benefit. These drugs will be covered once per lifetime per therapeutic category of drugs when dispensed by a non-pharmacy-benefit provider. This benefit limitation does not apply if you have primary Medicare Part B coverage.

Preferred facilities: 15% of the Plan allowance (deductible applies)

Member facilities: 35% of the Plan allowance (deductible applies)

Non-member facilities: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.

Preferred facilities: 30% of the Plan allowance

Note: You may also be responsible for paying a copayment per day per facility for outpatient services. See above and pages 81-84 for specific coverage information.

Member/Non-member facilities: You pay all charges

We provide enhanced benefits for covered inpatient facility services related to the surgical procedures listed below, when the surgery is performed at a facility designated as a Blue Distinction Center for Knee and Hip Replacement, Blue Distinction Center for Spine Surgery, or Blue Distinction Center for Comprehensive Bariatric Surgery.

• Bariatric surgeries covered are:
  • Roux-en-Y
  • Gastric bypass
  • Laparoscopic adjustable gastric banding
  • Sleeve gastrectomy
  • Biliopancreatic bypass with duodenal switch
• Total hip replacement or revision
• Total knee replacement or revision
• Spine surgery, limited to:
  • Cervical discectomy
  • Thoracic discectomy
  • Laminectomy
  • Laminoplasty
  • Spinal fusion

Note: You must precertify your hospital stay and verify your facility’s designation as a Blue Distinction Center for the type of surgery being scheduled. Contact us prior to your admission at the customer service phone number listed on the back of your ID card for assistance.

Note: Members are responsible for regular cost-sharing amounts for the surgery and related professional services as described in Section 5(b).

Note: These benefit levels do not apply to inpatient facility care related to other services or procedures, or to outpatient facility care, even if the services are performed at a Blue Distinction Center. See pages 78-80 for regular inpatient hospital benefits and pages 81-85 for outpatient facility benefit levels.

Note: See pages 18-19 for more information about Blue Distinction Centers.

Outpatient facility services related to specific covered bariatric surgical procedures, when the surgery is performed at a designated Blue Distinction Center for Bariatric Surgery.

Outpatient facility services related to specific covered hip and knee replacement or revision surgeries and certain spine surgery procedures, when performed at a designated Blue Distinction Center for hip/knee/spine surgery.

Note: You must meet the pre-surgical requirements listed on pages 65-66 for bariatric surgeries.

Note: In addition, you must obtain prior approval and verify the facility’s designation as a Blue Distinction Center for the type of surgery being scheduled. Contact us prior to the procedure at the customer service phone number listed on the back of your ID card for assistance.

Note: Members are responsible for regular cost-sharing amounts for the surgery and related professional services as described in Section 5(b).

Note: These benefits do not apply to other types of outpatient surgical services, even when performed at a Blue Distinction Center. See pages 81-82 for the benefits we provide.

Note: See pages 18-19 for more information about Blue Distinction Centers.

Precertification prior to admission is required.

A preliminary treatment plan and discharge plan must be developed and agreed to by the member, provider (residential treatment center (RTC)), and case manager in the Local Plan where the RTC is located prior to admission.

We cover inpatient care provided and billed by an RTC for members enrolled and participating in case management through the Local Plan, when the care is medically necessary for treatment of a medical, mental health, and/or substance use disorder:

• Room and board, such as semiprivate room, nursing care, meals, special diets, ancillary charges, and covered therapy services when billed by the facility (see page 39 for services billed by professional providers).

Note: RTC benefits are not available for facilities licensed as a skilled nursing facility, group home, halfway house, or similar type facility.

Preferred facilities: $350 per admission copayment for unlimited days (no deductible)

Member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible)

Non-member facilities: 35% of the Plan allowance (no deductible), and any remaining balance after our payment

Note: Non-member RTCs must, prior to admission, agree to abide by the terms established by the Local Plan for the care of the particular member and for the submission and processing of related claims.

Preferred facilities: $175 per day copayment up to $875 per admission for unlimited days

Member/Non-member facilities: You pay all charges

Note: Benefits are not available for non-covered services, including: respite care; outdoor residential programs; services provided outside of the provider’s scope of licensure; recreational therapy; educational therapy; educational classes; biofeedback; Outward Bound programs; equine/hippotherapy provided during the approved stay; personal comfort items, such as guest meals and beds, phone, television, beauty and barber services; custodial or long term care (see Definitions); and domiciliary care provided because care in the home is not available or is unsuitable.

Note: For outpatient residential treatment center services, see page 101.

See previous page

See previous page

When Medicare Part A is not your primary payor:

For members who do not have Medicare Part A, we cover skilled nursing facility (SNF) inpatient care for a maximum of 30 days annually, when the member can be expected to benefit from short-term SNF services with a goal of returning home.

The following criteria must also be met:

• Member is enrolled in case management prior to admission to the SNF (signed consent required), and actively participates in case management both prior to and during admission to the SNF.
• Precertification is obtained prior to admission (including overseas care).
• We approve the preliminary treatment plan prior to admission (plan must include proposed therapies and document the need for inpatient care).
• Member participates in all treatment and care planning activities, including discharge planning/transition to home.

Benefits are not available for inpatient SNF care solely for management of tube feedings, for home level dialysis treatment, as an interim transition to long term care placement, or for any other non-covered services.

Note: No inpatient benefits (such as room and board) will be provided if precertification is not obtained prior to admission (see page 21). Members are responsible for enrolling in case management (see page 21).

Preferred facilities: $175 (no deductible) per admission

Member facilities: $275 plus 35% of the Plan allowance (no deductible) per admission

Non-member facilities: $275 plus 35% of the Plan allowance (no deductible), and any remaining balance after our payment, per admission

All charges

When Medicare Part A is your primary payor:

When Medicare Part A is the primary payor (meaning it pays first) and has made a payment, Standard Option provides limited secondary benefits.

We pay the applicable Medicare Part A copayments incurred in full during the first through the 30th day of confinement for each benefit period (as defined by Medicare) in a qualified skilled nursing facility.

Note: See https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ge101c03.pdf for complete Medicare benefit period definition.

If Medicare pays the first 20 days in full, Plan benefits will begin on the 21st day (when Medicare Part A copayments begin) and will end on the 30th day.

Note: See page 84 for benefits provided for outpatient physical, occupational, speech, and cognitive rehabilitation therapy, and manipulative treatment services when billed by a skilled nursing facility. See Section 5(f) for benefits for prescription drugs.

Note: If Medicare Part A is your primary payor, we will only provide benefits if Medicare provided benefits for the admission.

Preferred facilities: Nothing (no deductible)

Member facilities: Nothing (no deductible)

Non-member facilities: Nothing (no deductible)

Note: You pay all charges not paid by Medicare after the 30th day.

All charges

Not covered:

Phone, television, personal comfort items, such as guest meals and beds, beauty and barber services, recreational outings/trips, stretcher or wheelchair transportation, non-emergent ambulance transport that is requested, beyond the nearest facility adequately equipped to treat the member’s condition, by patient or physician for continuity of care or other reason, custodial or long term care (see Definitions), and domiciliary care provided because care in the home is not available or is unsuitable

All charges

All charges

See pages 90-92. Traditional Home Hospice Care, Continuous Home Hospice Care, Inpatient Hospice Care and Professional ambulance transport services

See pages 90-92. Traditional Home Hospice Care, Continuous Home Hospice Care, Inpatient Hospice Care and Professional ambulance transport services

Pre-Hospice Enrollment Benefits

Prior approval is not required.

Before home hospice care begins, members may be evaluated by a physician to determine if home hospice care is appropriate. We provide benefits for pre-enrollment visits when provided by a physician who is employed by the home hospice agency and when billed by the agency employing the physician. The pre-enrollment visit includes services such as:

• Evaluating the member’s need for pain and/or symptom management; and
• Counseling regarding hospice and other care options

Prior approval from the Local Plan is required for all hospice services. Our prior approval decision will be based on the medical necessity of the hospice treatment plan and the clinical information provided to us by the primary care provider (or specialist) and the hospice provider. We may also request information from other providers who have treated the member. All hospice services must be billed by the approved hospice agency. You are responsible for making sure the hospice care provider has received prior approval from the Local Plan (see page 22 for instructions). Please check with your Local Plan, and/or visit www.fepblue.org/provider to use our National Doctor & Hospital Finder, for listings of Preferred hospice providers.

Note: If Medicare Part A is the primary payor for the member’s hospice care, prior approval is not required. However, our benefits will be limited to those services listed on this page and on pages 91-92.

Members with a terminal medical condition (or those acting on behalf of the member) are encouraged to contact the Case Management Department at their Local Plan for information about hospice services and Preferred hospice providers.

Covered services

We provide benefits for the hospice services listed below when the services have been included in an approved hospice treatment plan and are provided by the home hospice program in which the member is enrolled:

• Advanced care planning (see Section 10, page (Applies to printed brochure only))
• Dietary counseling
• Durable medical equipment rental
• Medical social services
• Medical supplies
• Nursing care

Nothing

• Oxygen therapy
• Periodic physician visits
• Physical therapy, occupational therapy, and speech therapy related to the terminal medical condition
• Prescription drugs and medications
• Services of home health aides (certified or licensed, if the state requires it, and provided by the home hospice agency)

See pages 90-92. Traditional Home Hospice Care, Continuous Home Hospice Care, Inpatient Hospice Care and Professional ambulance transport services

See pages 90-92. Traditional Home Hospice Care, Continuous Home Hospice Care, Inpatient Hospice Care and Professional ambulance transport services

Traditional Home Hospice Care

Periodic visits to the member’s home for the management of the terminal medical condition and to provide limited patient care in the home. An episode of care is one home hospice treatment plan per calendar year. See page 90 for prior approval requirements.

Preferred facilities: Nothing (no deductible)

Member/Non-member facilities: $450 copayment per episode (no deductible)

Preferred facilities: Nothing

Member/Non-member facilities: You pay all charges

Continuous Home Hospice Care

Services provided in the home to members enrolled in home hospice during a period of crisis, such as frequent medication adjustments to control symptoms or to manage a significant change in the member’s condition, requiring a minimum of 8 hours of care during each 24-hour period by a registered nurse (R.N.) or licensed practical nurse (L.P.N.).

Note: Members must receive prior approval from the Local Plan for each episode of continuous home hospice care (see page 90). An episode consists of up to seven consecutive days of continuous care. The member must be enrolled in a home hospice program in order to receive benefits for subsequent continuous home hospice care, and the services must be provided by the home hospice program in which the member is enrolled.

Preferred facilities: Nothing (no deductible)

Member facilities: $450 per episode copayment (no deductible)

Non-member facilities: $450 per episode copayment, plus 35% of the Plan allowance (no deductible), and any remaining balance after our payment

Preferred facilities: Nothing

Member/Non-member facilities: You pay all charges

Inpatient Hospice Care

Benefits are available for inpatient hospice care when provided by a facility that is licensed as an inpatient hospice facility and when:

• Inpatient services are necessary to control pain and/or manage the member’s symptoms;
• Death is imminent; or
• Inpatient services are necessary to provide an interval of relief (respite) to the caregiver

Note: Benefits are provided for up to 30 consecutive days in a facility licensed as an inpatient hospice facility. The member does not have to be enrolled in a home hospice care program to be eligible for the first inpatient stay. However, the member must be enrolled in a home hospice care program in order to receive benefits for subsequent inpatient stays.

Preferred facilities: Nothing (no deductible)

Member facilities: $450 per admission copayment, plus 35% of the Plan allowance (no deductible)

Non-member facilities: $450 per admission copayment, plus 35% of the Plan allowance (no deductible), and any remaining balance after our payment

Preferred facilities: Nothing

Member/Non-member facilities: You pay all charges

Not covered:

• Advanced care planning, except when provided as part of a covered hospice care treatment plan (see page 90)
• Homemaker services
• Home hospice care (e.g., care given by a home health aide) that is provided and billed for by other than the approved home hospice agency when the same type of care is already being provided by the home hospice agency

Professional ambulance transport services to or from the nearest hospital equipped to adequately treat your condition, when medically necessary, and:

• Associated with covered hospital inpatient care
• Related to medical emergency
• Associated with covered hospice care

Note: We also cover medically necessary emergency care provided at the scene when transport services are not required.

$100 copayment per day for ground ambulance transport services (no deductible)

$150 copayment per day for air or sea ambulance transport services

$100 copayment per day for ground ambulance transport services

$150 copayment per day for air or sea ambulance transport services

Professional ambulance transport services to or from the nearest hospital equipped to adequately treat your condition, when medically necessary, and when related to accidental injury

Note: We also cover medically necessary emergency care provided at the scene when transport services are not required.

Note: Prior approval is required for all non-emergent air ambulance transport.

Nothing (no deductible)

Note: These benefit levels apply only if you receive care in connection with, and within 72 hours after, an accidental injury. For services received after 72 hours, see above.

$100 copayment per day for ground ambulance transport services

$150 copayment per day for air or sea ambulance transport services

Medically necessary emergency ground, air and sea ambulance transport services to the nearest hospital equipped to adequately treat your condition if you travel outside the United States, Puerto Rico and the U.S. Virgin Islands

Note: If you are traveling overseas and need assistance with emergency evacuation services to the nearest facility equipped to adequately treat your condition, please contact the Overseas Assistance Center (provided by GMMI, Inc.) by calling the center collect at 804-673-1678. See page 130 for more information.

$100 copayment per day for ground ambulance transport services (no deductible)

$150 copayment per day for air or sea ambulance transport services

$100 copayment per day for ground ambulance transport services

$150 copayment per day for air or sea ambulance transport services

Not covered:

• Wheelchair van services and gurney van services
• Ambulance and any other modes of transportation to or from services including but not limited to physician appointments, dialysis, or diagnostic tests not associated with covered inpatient hospital care
• Ambulance transport that is requested, beyond the nearest facility adequately equipped to treat the member’s condition, by patient or physician for continuity of care or other reason
• Commercial air flights
• Repatriation from an international location back to the United States. See definition of repatriation in Section 10. Members traveling overseas should consider purchasing a travel insurance policy that covers repatriation to your home country.
• Costs associated with overseas air or sea transportation to other than the closest hospital equipped to adequately treat your condition.

• Professional provider services in the emergency room, hospital outpatient department, or provider’s office, including professional care, diagnostic studies, radiology services, laboratory tests, and pathology services, when billed by a professional provider

Preferred: Nothing (no deductible)

Participating: Nothing (no deductible)

Non-participating: Any difference between our allowance and the billed amount (no deductible)

Preferred: Nothing

Participating: Nothing

Non-participating: You pay any difference between our allowance and the billed amount

Note: These benefit levels apply only to professional provider services performed in the emergency room. Regular benefit levels apply to covered services provided in all other settings. See Sections 5(a) and 5(b) for those benefits.

• Outpatient hospital services and supplies, including professional provider services, diagnostic studies, radiology services, laboratory tests, and pathology services, when billed by the hospital

Preferred: Nothing (no deductible)

Member: Nothing (no deductible)

Non-member: Nothing (no deductible)

Preferred emergency room: $175 copayment per day per facility

Member emergency room: $175 copayment per day per facility

Non-member emergency room: $175 copayment per day per facility

Note: If you are admitted directly to the hospital from the emergency room, you do not have to pay the $175 emergency room copayment. However, the $175 per day copayment for Preferred inpatient care still applies.

Note: Regular benefit levels apply to covered outpatient hospital services provided in settings other than an emergency room. See Section 5(c) for those benefits.

• Urgent care center services and supplies, including professional providers’ services, diagnostic studies, radiology services, laboratory tests and pathology services, when billed by the provider

Preferred urgent care center: Nothing (no deductible)

Participating urgent care center: Nothing (no deductible)

Non-participating urgent care center: Any difference between our allowance and the billed amount (no deductible)

Preferred urgent care center: $35 copayment per visit

Participating/Non-participating urgent care center: You pay all charges

Note: If you are treated by a non-PPO professional provider in a PPO facility, you will be responsible for your cost-share for the services, plus any difference between our allowance and the billed amount.

Note: We pay inpatient benefits if you are admitted. See Sections 5(a), 5(b), and 5(c) for those benefits.

Note: See Section 5(g) for dental benefits for accidental injuries.

Note: The benefits described on page 95 apply only if you receive care in connection with, and within 72 hours after, an accidental injury. For services received after 72 hours, regular benefits apply. See Sections 5(a), 5(b), and 5(c) for the benefits we provide.

Note: For drugs, services, supplies, and/or durable medical equipment billed by a provider other than a hospital, urgent care center, or physician, see Sections 5(a) and 5(f) for the benefit levels that apply.

Note: All follow-up care must be performed and billed for by Preferred providers to be eligible for benefits.

Not covered:

• Oral surgery except as shown in Section 5(b)
• Injury to the teeth while eating
• Emergency room professional charges for shift differentials

• Professional provider services in the emergency room, including professional care, diagnostic studies, radiology services, laboratory tests, and pathology services, when billed by a professional provider

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 15% of the Plan allowance (deductible applies)

Non-participating: 15% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred: Nothing

Participating: Nothing

Non-participating: You pay any difference between our allowance and the billed amount

• Outpatient hospital emergency room services and supplies, including professional provider services, diagnostic studies, radiology services, laboratory tests, and pathology services, when billed by the hospital

Note: We pay inpatient benefits if you are admitted as a result of a medical emergency. See Section 5(c).

Note: Regular benefit levels apply to covered services provided in settings other than the emergency room. See Section 5(c) for those benefits.

Preferred: 15% of the Plan allowance (deductible applies)

Member: 15% of the Plan allowance (deductible applies)

Non-member: 15% of the Plan allowance (deductible applies)

Preferred emergency room: $175 copayment per day per facility

Member emergency room: $175 copayment per day per facility

Non-member emergency room: $175 copayment per day per facility

Note: If you are admitted directly to the hospital from the emergency room, you do not have to pay the $175 emergency room copayment. However, the $175 per day copayment for Preferred inpatient care still applies.

Note: All follow-up care must be performed and billed for by Preferred providers to be eligible for benefits.

• Urgent care center services and supplies, including professional providers’ services, diagnostic studies, radiology services, laboratory tests and pathology services, when billed by the provider
  
  Note: Benefits for crutches, splints, braces, etc. when billed by a provider other than the urgent care center are stated in Section 5(a), pages 57-58.

Preferred urgent care center: $30 copayment per visit (no deductible)

Participating urgent care center: 35% of the Plan allowance (deductible applies)

Non-participating urgent care center: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred urgent care center: $35 copayment per visit

Participating/Non-participating urgent care center: You pay all charges

Note: If you are treated by a non-PPO professional provider in a PPO facility, you will be responsible for your cost-share for the services, plus any difference between our allowance and the billed amount.

Note: We pay inpatient benefits if you are admitted. See Sections 5(a), 5(b), and 5(c) for those benefits.

Note: These benefit levels do not apply if you receive care in connection with, and within 72 hours after, an accidental injury. See pages 95-96 for the benefits we provide.

Note: All follow-up care must be performed and billed for by Preferred providers to be eligible for benefits.

Not covered:  Emergency room professional charges for shift differentials

See Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services (pages 92-93) for complete ambulance benefit and coverage information.

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

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

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

We cover professional services by licensed professional mental health and substance use disorder practitioners when acting within the scope of their license.

Services provided by licensed professional mental health and substance use disorder practitioners when acting within the scope of their license

• Individual psychotherapy
• Group psychotherapy
• Pharmacologic (medication) management
• Psychological testing
• Office visits
• Clinic visits
• Home visits
• Phone consultations and online medical evaluation and management services (telemedicine)

Note: To locate a Preferred provider, visit www.fepblue.org/provider to use our National Doctor & Hospital Finder, or contact your Local Plan at the mental health and substance use disorder phone number on the back of your ID card.

Note: See pages 61 and 117 for our coverage of smoking and tobacco cessation treatment.

Note: See page 47 for our coverage of mental health visits to treat postpartum depression and depression during pregnancy.

Note: We cover outpatient mental health and substance use disorder services or supplies provided and billed by residential treatment centers at the levels shown here.

Preferred: $25 copayment for the visit (no deductible)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus the difference between our allowance and the billed amount

Preferred: $30 copayment per visit

Participating/Non-participating: You pay all charges

Telehealth professional services for:

• Behavioral health counseling
• Substance use disorder counseling

Note: Refer to Section 5(h), Wellness and Other Special Features, for information on telehealth services and how to access our telehealth provider network.

Note: Benefits are combined with telehealth services listed in Section 5(a), page 39.

Preferred Telehealth provider: Nothing (no deductible) for the first 2 visits per calendar year for any covered telehealth service

$10 copayment per visit (no deductible) after the 2^nd visit

Participating/Non-participating: You pay all charges

Preferred Telehealth provider: Nothing for the first 2 visits per calendar year for any covered telehealth service

$15 copayment per visit after the 2^nd visit

Participating/Non-participating: You pay all charges

• Inpatient professional services

Preferred: Nothing (no deductible)

Participating: 35% of the Plan allowance (no deductible)

Non-participating: 35% of the Plan allowance (no deductible), plus the difference between our allowance and the billed amount

Preferred: Nothing

Participating/Non-participating: You pay all charges

• Professional charges for facility-based intensive outpatient treatment
• Professional charges for outpatient diagnostic tests

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus the difference between our allowance and the billed amount

Preferred: Nothing

Participating/Non-participating: You pay all charges

Inpatient services provided and billed by a hospital or other covered facility (See below for residential treatment center care.)

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

Note: Inpatient care to treat substance use disorder includes room and board and ancillary charges for confinements in a hospital/treatment facility for rehabilitative treatment of alcoholism or substance use disorder.

Note: You must get precertification of inpatient hospital stays; failure to do so will result in a $500 penalty.

Preferred facilities: $350 per admission copayment for unlimited days (no deductible)

Member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible)

Non-member facilities: 35% of the Plan allowance for unlimited days (no deductible), and any remaining balance after our payment

Preferred facilities: $175 per day copayment up to $875 per admission for unlimited days

Member/Non-member facilities: You pay all charges

Precertification prior to admission is required.

A preliminary treatment plan and discharge plan must be developed and agreed to by the member, provider (residential treatment center (RTC)), and case manager in the Local Plan where the RTC is located prior to admission.

Preferred facilities: $350 per admission copayment for unlimited days (no deductible)

Member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible)

Preferred facilities: $175 per day copayment up to $875 per admission for unlimited days

Member/Non-member facilities: You pay all charges

We cover inpatient care provided and billed by an RTC for members enrolled and participating in case management through the Local Plan, when the care is medically necessary for treatment of a medical, mental health, and/or substance use disorder:

• Room and board, such as semiprivate room, nursing care, meals, special diets, ancillary charges, and covered therapy services when billed by the facility (see page 99 for services billed by professional providers)

Note: RTC benefits are not available for facilities licensed as a skilled nursing facility, group home, halfway house, or similar type facility.

Note: Benefits are not available for non-covered services, including: respite care; outdoor residential programs; services provided outside of the provider’s scope of practice; recreational therapy; educational therapy; educational classes; biofeedback; Outward Bound programs; hippotherapy/equine therapy provided during the approved stay; personal comfort items, such as guest meals and beds, phone, television, beauty and barber services; custodial or long term care (see Definitions, page (Applies to printed brochure only)); and domiciliary care provided because care in the home is not available or is unsuitable.

Note: For outpatient residential treatment center services, see the next Section.

Non-member facilities: 35% of the Plan allowance (no deductible), and any remaining balance after our payment

Note: Non-member facilities must, prior to admission, agree to abide by the terms established by the Local Plan for the care of the particular member and for the submission and processing of related claims.

See previous page

Outpatient services provided and billed by a covered facility

Note: We cover outpatient mental health and substance use disorder services or supplies provided and billed by residential treatment centers at the levels shown here.

• Individual psychotherapy
• Group psychotherapy
• Pharmacologic (medication) management
• Partial hospitalization
• Intensive outpatient treatment

Preferred: 15% of the Plan allowance (deductible applies)

Member: 35% of the Plan allowance (deductible applies)

Non-member: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.

Preferred: $30 copayment per day per facility

Member/Non-member: You pay all charges

Outpatient services provided and billed by a covered facility

• Diagnostic tests
• Psychological testing

Note: A residential treatment center is a covered facility for outpatient care (see Section 10, Definitions, for more information). We cover inpatient mental health and substance use disorder services or supplies provided and billed by residential treatment centers, other than room and board and inpatient physician care, at the levels shown here.

Preferred: 15% of the Plan allowance (deductible applies)

Member: 35% of the Plan allowance (deductible applies)

Non-member: 35% of the Plan allowance (deductible applies). You may also be responsible for any difference between our allowance and the billed amount.

Preferred: Nothing

Member/Non-member: Nothing

• Marital, family, educational, or other counseling or training services
• Services performed by a non-covered provider
• Testing for and treatment of learning disabilities and intellectual disability
• Inpatient services performed or billed by residential treatment centers, except as described on pages 87-88 and 100-101
• Services performed or billed by schools, halfway houses, group homes or members of their staffs
  
  Note: We cover professional services as described on pages 99-100 when they are provided and billed by a covered professional provider acting within the scope of his or her license.
• Psychoanalysis or psychotherapy credited toward earning a degree or furtherance of education or training regardless of diagnosis or symptoms that may be present
• Services performed or billed by residential therapeutic camps (e.g., wilderness camps, Outward Bound, etc.)
• Hippotherapy/equine therapy (exercise on horseback)
• Light boxes
• Custodial or long term care (see Definitions)
• Costs associated with enabling or maintaining providers’ telehealth (telemedicine) technologies, non-interactive telecommunication such as email communications, or store-and-forward telehealth services

Asthma Medications

Preferred Retail Pharmacies:

Note: See page 24 for information about drugs and supplies that require prior approval.

Tier 1 (generic drug): $5 copayment (no deductible)

Tier 2 (preferred brand-name drug): 20% of the Plan allowance (no deductible)

Tier 1 (generic drug): $5 copayment for each purchase of up to a 90-day supply

Tier 2 (preferred brand-name drug): $35 copayment for each purchase of up to a 30-day supply ($105 copayment for a 31 to 90-day supply)

When Medicare Part B is primary, you pay the following:

Tier 1 (generic drug): $5 copayment

Tier 2 (preferred brand-name drug): $30 copayment for each purchase of up to a 30-day supply ($90 copayment for a 31 to 90-day supply)

Asthma Medications

Mail Service Prescription Drug Program:

Note: See page 24 for information about drugs and supplies that require prior approval. You must obtain prior approval before Mail Service will fill your prescription. See pages 24 and 107.

Note: See pages 114-116 for Tier 3, 4 and 5 prescription drug benefits.

Tier 1 (generic drug): $5 copayment (no deductible)

Tier 2 (preferred brand-name drug): $65 copayment (no deductible)

When Medicare Part B is primary, you pay the following:

Tier 1 (generic drug): $5 copayment

Tier 2 (preferred brand-name drug): $75 copayment

Anti-hypertensive Medications
Preferred Retail Pharmacies:

Note: See page 24 for information about drugs and supplies that require prior approval.

Tier 1 (generic drug): $3 copayment (no deductible)

Tier 1 (generic drug): $5 copayment for each purchase of up to a 90-day supply

Anti-hypertensive Medications
Mail Service Prescription Drug Program:

Note: See page 24 for information about drugs and supplies that require prior approval. You must obtain prior approval before Mail Service will fill your prescription. See pages 24 and 107.

Note: See pages 114-116 for Tier 2, 3, 4, and 5 prescription drug benefits.

Tier 1 (generic drug): $3 copayment (no deductible)

When Medicare Part B is primary, you pay the following:

Tier 1 (generic drug): $5 copayment

• Drugs, vitamins and minerals, and nutritional supplements that by Federal law of the United States require a prescription for their purchase
  
  Note: See pages 112-113 for our coverage of medications to promote better health as recommended under the Affordable Care Act.
• Medical foods, as defined by the U.S. Food and Drug Administration, that are consumed or administered enterally and are intended for the specific dietary management of a disease or condition for which there are distinctive nutritional requirements.
  
  The Plan covers medical food formulas and enteral nutrition products that are ordered by a healthcare provider, and are medically necessary to prevent clinical deterioration in members at nutritional risk. (See Coverage below)
• Must meet the definition of medical food (see definition on page (Applies to printed brochure only))
• Must be receiving active, regular, and ongoing medical supervision and must be unable to manage the condition by modification of diet alone

Coverage is provided as follows:

• Inborn errors of amino acid metabolism up to age 22
• Food allergy with atopic dermatitis, gastrointestinal symptoms, IgE mediation, malabsorption disorder, seizure disorder, failure to thrive, or prematurity, when administered orally and is the sole source (100%) of nutrition. This once per lifetime benefit is limited to one year following the date of the initial prescription or physician order for the medical food (e.g., Neocate, in a formula form or powders mixed to become formulas)
• Medical foods and nutritional supplements when administered by catheter or nasogastric tubes

Note: A prescription and prior approval are required for medical foods provided under the pharmacy benefit. Renewals of the prior authorization are required every benefit year for inborn errors of metabolism and tube feeding.

Note: See Section 5(a), page (Applies to printed brochure only), for our coverage of medical foods and nutritional supplements when administered by catheter or nasogastric tube under the medical benefit.

• Insulin, diabetic test strips, and lancets
  
  Note: See page 57 for our coverage of insulin pumps.
• Needles and disposable syringes for the administration of covered medications
• Clotting factors and anti-inhibitor complexes for the treatment of hemophilia

See page 108 and pages 110-116

See page 108 and pages 110-116

• Drugs to aid smoking and tobacco cessation that require a prescription by Federal law
  
  Note: We provide benefits for over-the-counter (OTC) smoking and tobacco cessation medications only as described on page 117.
  
  Note: You may be eligible to receive smoking and tobacco cessation medications at no charge. See page 117 for more information.
• Drugs for the diagnosis and treatment of infertility, except as described on pages 118-119
• Drugs to treat gender dysphoria (gonadotropin-releasing hormone (GnRH) antagonists and testosterones)
• Contraceptive drugs and devices, limited to:
  • Diaphragms and contraceptive rings
  • Injectable contraceptives
  • Intrauterine devices (IUDs)
  • Implantable contraceptives
  • Oral and transdermal contraceptives

Note: We waive your cost-share for generic contraceptives and for brand-name contraceptives that have no generic equivalent or generic alternative, when you purchase them at a Preferred retail pharmacy or, for Standard Option members and Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program. See pages 115 and 116 for details.

See below and pages 111-117

See below and pages 111-117

• Over-the-counter (OTC) contraceptive drugs and devices, for women only, limited to:
  • Emergency contraceptive pills
  • Female condoms
  • Spermicides

Preferred retail pharmacy: Nothing (no deductible)

Non-preferred retail pharmacy: You pay all charges

Preferred retail pharmacy: Nothing

Non-preferred retail pharmacy: You pay all charges

• Sponges

Note: We provide benefits in full for OTC contraceptive drugs and devices for women only when the contraceptives meet U.S. FDA standards for OTC products. To receive benefits, you must use a retail pharmacy and present the pharmacist with a written prescription from your physician.

See previous page

See previous page

Immunizations when provided by a Preferred retail pharmacy that participates in our vaccine network (see below) and administered in compliance with applicable state law and pharmacy certification requirements. See pages 43 and 45 for specific coverage.

Note: Our vaccine network is a network of Preferred retail pharmacies that have agreements with us to administer one or more routine immunizations. Check with your pharmacy or call our Retail Pharmacy Program at 800-624-5060, TTY: 800-624-5077, to find out which vaccines your pharmacy can provide.

Preferred retail pharmacy: Nothing (no deductible)

Non-preferred retail pharmacy: You pay all charges (except as noted below)

Note: You pay nothing for influenza (flu) vaccines obtained at Non-preferred retail pharmacies.

Preferred retail pharmacy: Nothing

Non-preferred retail pharmacy: You pay all charges (except as noted below)

Note: You pay nothing for influenza (flu) vaccines obtained at Non-preferred retail pharmacies.

Diabetic Meter Program

Members with diabetes may obtain one glucose meter kit every 365 days at no cost through our Diabetic Meter Program. To use this program, you must call the phone number listed below and request one of the eligible types of meters. The types of glucose meter kits available through the program are subject to change.

To order your free glucose meter kit, call us toll-free at 855-582-2024, Monday through Friday, from
9 a.m. to 7 p.m., Eastern Time, or visit our website at www.fepblue.org. The selected meter kit will be sent to you within 7 to 10 days of your request.

Note: Contact your physician to obtain a new prescription for the test strips and lancets to use with the new meter. See page 112 for more information.

Nothing for a glucose meter kit ordered through the Diabetic Meter Program

Nothing for a glucose meter kit ordered through the Diabetic Meter Program

Metformin and metformin extended release (excluding osmotic and modified release generic drugs)

Preferred Retail Pharmacies:

Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply (no deductible)

Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply

Mail Service Prescription Drug Program:

Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply (no deductible)

When Medicare Part B is primary, you pay the following:

Tier 1 (generic drug): $1 copayment for each purchase of up to a 90-day supply

Other Preferred Diabetic Medications, Test Strips, and Supplies

Preferred Retail Pharmacies:

Tier 2 (preferred diabetic medications and supplies): 20% of the Plan allowance for each purchase of up to a 90-day supply (no deductible)

Non-preferred retail pharmacies: You pay all charges

Tier 2 (preferred diabetic medications and supplies): $35 copayment for each purchase of up to a 30-day supply ($65 copayment for a 31 to 90-day supply)

When Medicare Part B is primary, you pay the following:

Tier 2 (preferred brand-name drugs): $30 copayment for each purchase of up to a 30-day supply ($60 copayment for a 31 to 90-day supply)

Mail Service Prescription Drug Program:

Tier 2 (preferred brand-name drug): $40 copayment for each purchase of up to a 90-day supply (no deductible)

When Medicare Part B is primary, you pay the following:

Tier 2 (preferred brand-name drugs) $50 copayment for each purchase of up to a 90-day supply

Note: See pages 115-116 for Tier 2, 3, 4, and 5 prescription drug benefits.

Benefits will be provided for syringes, pens and pen needles and test strips at Tier 2 (diabetic medications and supplies) for Standard Option members, and Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program. See pages 115-116 for more information.

Medications to promote better health as recommended under the Patient Protection and Affordable Care Act (the “Affordable Care Act”), limited to:

• Iron supplements for children from age 6 months through 12 months
• Oral fluoride supplements for children from age 6 months through 5 years
• Folic acid supplements, 0.4 mg to 0.8 mg, for women capable of pregnancy
• Low-dose aspirin (81 mg per day) for pregnant members at risk for preeclampsia
• Aspirin for men age 45 through 79 and women age 50 through 79
• Generic cholesterol-lowering statin drugs

Note: Benefits are not available for acetaminophen, ibuprofen, naproxen, etc.

Note: Benefits for the medications listed on the previous page are subject to the dispensing limitations described on page 106 and are limited to recommended prescribed limits.

Note: To receive benefits, you must use a Preferred retail pharmacy and present a written prescription from your physician to the pharmacist.

Note: A complete list of USPSTF-recommended preventive care services is available online at: www.healthcare.gov/preventive-care-benefits. See pages 42-46 in Section 5(a) for information about other covered preventive care services.

Note: See page 117 for our coverage of smoking and tobacco cessation medications.

Preferred retail pharmacy: Nothing (no deductible)

Non-preferred retail pharmacy: You pay all charges

Preferred retail pharmacy: Nothing

Non-preferred retail pharmacy: You pay all charges

Generic medications to reduce breast cancer risk for women, age 35 or over, who have not been diagnosed with any form of breast cancer

Note: Your physician must send a completed Coverage Request Form to CVS Caremark before you fill the prescription. Call CVS Caremark at 800-624-5060, TTY: 800-624-5077, to request this form. You can also obtain the Coverage Request Form through our website at www.fepblue.org.

Preferred retail pharmacy: Nothing (no deductible)

Non-preferred retail pharmacy: You pay all charges

Mail Service Prescription Drug Program: Nothing (no deductible)

Preferred retail pharmacy: Nothing

Non-preferred retail pharmacy: You pay all charges

When Medicare Part B is primary, you pay the following:

Mail Service Prescription Drug Program: Nothing

We cover the first prescription filled for certain bowel preparation medications for colorectal cancer screenings with no member cost-share. We also cover certain antiretroviral therapy medications for HIV for those at risk but who do not have HIV. You can view the list of covered medications on our website at www.fepblue.org or call 800-624-5060, TTY: 800-624-5077, for assistance.

Preferred retail pharmacy: Nothing (no deductible)

Non-preferred retail pharmacy: You pay all charges

Mail Service Prescription Drug Program: Nothing (no deductible)

Preferred retail pharmacy: Nothing

Non-preferred retail pharmacy: You pay all charges

When Medicare Part B is primary, you pay the following:

Mail Service Prescription Drug Program: Nothing

Opioid Reversal Agents: Tier 1 medications limited to Narcan nasal spray and naloxone generic injectable

Preferred Retail Pharmacies

Tier 1: Nothing for the purchase of up to a 90-day supply per calendar year (no deductible)

Note: Once you have purchased amounts of these medications in a calendar year that are equivalent to a 90-day supply combined, all Tier 1 fills thereafter are subject to the corresponding cost-share.

Tier 1: Nothing for the purchase of up to a 90-day supply per calendar year

Note: Once you have purchased amounts of these medications in a calendar year that are equivalent to a 90-day supply combined, all Tier 1 fills thereafter are subject to the corresponding cost-share.

Non-preferred Retail Pharmacies

You pay all charges

You pay all charges

Opioid Reversal Agents (cont.)
Mail Service Prescription Drug Program

Tier 1: Nothing for the purchase of up to a 90-day supply per calendar year (no deductible)

Note: Once you have purchased amounts of these medications in a calendar year that are equivalent to a 90-day supply combined, all Tier 1 fills thereafter are subject to the corresponding cost-share.

When Medicare Part B is primary, you pay the following:

Tier 1: Nothing for the purchase of up to a 90-day supply per calendar year

Note: Once you have purchased amounts of these medications in a calendar year that are equivalent to a 90-day supply combined, all Tier 1 fills thereafter are subject to the corresponding cost-share.

Here is how to obtain your prescription drugs and supplies:

Preferred Retail Pharmacies

• Make sure you have your Plan ID card when you are ready to purchase your prescription.
• Go to any Preferred retail pharmacy, or
• Visit the website of your retail pharmacy to request your prescriptions online and delivery, if available.
• For a listing of Preferred retail pharmacies, call the Retail Pharmacy Program at 800-624-5060, TTY: 800-624-5077, or visit our website, www.fepblue.org.
  
  Note: Retail pharmacies that are Preferred for prescription drugs are not necessarily Preferred for durable medical equipment (DME) and medical supplies. To receive Preferred benefits for DME and covered medical supplies, you must use a Preferred DME or medical supply provider. See Section 5(a) for the benefit levels that apply to DME and medical supplies.

Note: Benefits for Tier 4 and Tier 5 specialty drugs purchased at a Preferred pharmacy are limited to one purchase of up to a 30-day supply for each prescription dispensed. All refills must be obtained through the Specialty Drug Pharmacy Program. See page 116 for more information.

Note: For prescription drugs billed for by a skilled nursing facility, nursing home, or extended care facility, we provide benefits as shown on this page for drugs obtained from a Preferred retail pharmacy, as long as the pharmacy supplying the prescription drugs to the facility is a Preferred pharmacy. For benefit information about prescription drugs supplied by Non-preferred retail pharmacies, please refer to page 115.

Tier 1 (generic drug): $7.50 copayment for each purchase of up to a 30-day supply ($22.50 copayment for a 31 to 90-day supply) (no deductible)

Note: You pay a $5 copayment for each purchase of up to a 30-day supply ($15 copayment for a 31 to 90-day supply) when Medicare Part B is primary.

Note: You may be eligible to receive your first 4 generic prescriptions filled (and/or refills ordered) at no charge when you change from certain brand-name drugs to a corresponding generic drug replacement. See page 107 for information.

Tier 2 (preferred brand-name drug): 30% of the Plan allowance for each purchase of up to a 90-day supply (no deductible)

Tier 3 (non-preferred brand-name drug): 50% of the Plan allowance for each purchase of up to a 90-day supply (no deductible)

Tier 4 (preferred specialty drug): 30% of the Plan allowance (no deductible), limited to one purchase of up to a 30-day supply

Tier 5 (non-preferred specialty drug): 30% of the Plan allowance (no deductible), limited to one purchase of up to a 30-day supply

Tier 1 (generic drug): $10 copayment for each purchase of up to a 30-day supply ($30 copayment for a 31 to 90-day supply)

Tier 2 (preferred brand-name drug): $55 copayment for each purchase of up to a 30-day supply ($165 copayment for a 90-day supply)

Tier 3 (non-preferred brand-name drug): 60% of the Plan allowance ($75 minimum) for each purchase of up to a 30-day supply ($210 minimum for a 31 to 90-day supply)

Tier 4 (preferred specialty drug): $65 copayment limited to one purchase of up to a 30-day supply

Tier 5 (non-preferred specialty drug): $90 copayment limited to one purchase of up to a 30-day supply

When Medicare Part B is primary, you pay the following:

Tier 1 (generic drug): see above

Tier 2 (preferred brand-name drug): $50 copayment for each purchase of up to a 30-day supply ($150 copayment for a 31 to 90-day supply)

Tier 3 (non-preferred brand-name drug): 50% of the Plan allowance ($60 minimum) for each purchase of up to a 30-day supply ($175 minimum for a 31 to 90-day supply)

Tier 4 (preferred specialty drug): $60 copayment limited to one purchase of up to a 30-day supply

Note: For a list of the Preferred Network Long Term Care pharmacies, call 800-624-5060, TTY: 800-624-5077.

Note: For coordination of benefits purposes, if you need a statement of Preferred retail pharmacy benefits in order to file claims with your other coverage when this Plan is the primary payor, call the Retail Pharmacy Program at 800-624-5060, TTY: 800-624-5077, or visit our website at www.fepblue.org.

Note: We waive your cost-share for available forms of generic contraceptives and for brand-name contraceptives that have no generic equivalent or generic alternative.

See previous page

Continued from previous page:

Tier 5 (non-preferred specialty drug): $80 copayment limited to one purchase of up to a 30-day supply

Non-preferred Retail Pharmacies

45% of the Plan allowance (Average wholesale price – AWP), plus any difference between our allowance and the billed amount (no deductible)

Note: If you use a Non-preferred retail pharmacy, you must pay the full cost of the drug or supply at the time of purchase and file a claim with the Retail Pharmacy Program to be reimbursed. Please refer to Section 7 for instructions on how to file prescription drug claims.

All charges

Mail Service Prescription Drug Program

For Standard Option and Basic Option members when Medicare Part B is Primary, if your doctor orders more than a 21-day supply of covered drugs or supplies, up to a 90-day supply, you can use this service for your prescriptions and refills.

Please refer to Section 7 for instructions on how to use the Mail Service Prescription Drug Program.

Note: See page 24 for information about drugs and supplies that require prior approval. You must obtain prior approval before Mail Service will fill your prescription. See pages 24 and 107.

Note: Not all drugs are available through the Mail Service Prescription Drug Program. There are no specialty drugs available through the Mail Service Program.

Note: Please refer to page 116 for information about the Specialty Drug Pharmacy Program.

Tier 1 (generic drug): $15 copayment (no deductible)

Note: You pay a $10 copayment per generic prescription filled (and/or refill ordered) when Medicare Part B is primary.

Note: You may be eligible to receive your first 4 generic prescriptions filled (and/or refills ordered) at no charge when you change from certain brand-name drugs to a corresponding generic drug replacement. See page 107 for information.

Tier 2 (preferred brand-name drug): $90 copayment (no deductible)

Tier 3 (non-preferred brand-name drug): $125 copayment (no deductible)

When Medicare Part B is primary, you pay the following:

Tier 1 (generic drug): $20 copayment

Tier 2 (preferred brand-name drug): $100 copayment

Tier 3 (non-preferred brand-name drug): $125 copayment

When Medicare Part B is not primary: No benefits

Note: Although you do not have access to the Mail Service Prescription Drug Program, you may request home delivery of prescription drugs you purchase from Preferred retail pharmacies offering options for online ordering. See page 108 of this Section for our payment levels for drugs obtained through Preferred retail pharmacies.

Note: We waive your cost-share for available forms of generic contraceptives and for brand-name contraceptives that have no generic equivalent or generic alternative.

Contact Us: If you have any questions about this program, or need assistance with your Mail Service drug orders, please call 800-262-7890, TTY: 800-216-5343.

Note: If the cost of your prescription is less than your copayment, you pay only the cost of your prescription. The Mail Service Prescription Drug Program will charge you the lesser of the prescription cost or the copayment when you place your order. If you have already sent in your copayment, they will credit your account with any difference.

See previous page

See previous page

Specialty Drug Pharmacy Program

We cover specialty drugs that are listed on the Service Benefit Plan Specialty Drug List. This list is subject to change. For the most up-to-date list, call the phone number below or visit our website, www.fepblue.org. (See page (Applies to printed brochure only) for the definition of “specialty drugs.”)

Each time you order a new specialty drug or refill, a Specialty Drug pharmacy representative will work with you to arrange a delivery time and location that are most convenient for you, as well as ask you about any side effects you may be experiencing. See page 138 for more details about the Program.

Note: Benefits for the first three fills of each Tier 4 or Tier 5 specialty drug are limited to a 30-day supply. Benefits are available for a 31 to 90-day supply after the third fill.

Note: Due to manufacturer restrictions, a small number of specialty drugs may only be available through a Preferred retail pharmacy. You will be responsible for paying only the copayments shown here for specialty drugs affected by these restrictions.

Contact Us: If you have any questions about this program, or need assistance with your specialty drug orders, please call 888-346-3731, TTY: 877-853-9549.

Specialty Drug Pharmacy Program:

Tier 4 (preferred specialty drug): $65 copayment for each purchase of up to a 30-day supply ($185 copayment for a 31 to 90-day supply) (no deductible)

Tier 5 (non-preferred specialty drug): $85 copayment for each purchase of up to a 30-day supply ($240 copayment for a 31 to 90-day supply) (no deductible)

Specialty Drug Pharmacy Program:

Tier 4 (preferred specialty drug): $85 copayment for each purchase of up to a 30-day supply ($235 copayment for a 31 to 90-day supply)

Tier 5 (non-preferred specialty drug): $110 copayment for each purchase of up to a 30-day supply ($300 copayment for a 31 to 90-day supply)

When Medicare Part B is primary, you pay the following:

Tier 4 (preferred specialty drug): $80 copayment for each purchase of up to a 30-day supply ($210 copayment for a 31 to 90-day supply)

Tier 5 (non-preferred specialty drug): $100 copayment for each purchase of up to a 30-day supply ($255 copayment for a 31 to 90-day supply)

Smoking and Tobacco Cessation Medications

If you are a covered member, you may be eligible to obtain specific prescription generic and brand-name smoking and tobacco cessation medications at no charge. Additionally, you may be eligible to obtain over-the-counter (OTC) smoking and tobacco cessation medications, prescribed by your physician, at no charge. These benefits are only available when you use a Preferred retail pharmacy. To qualify, create a Tobacco Cessation Quit Plan using our Online Health Coach. For more information, see page 125.

Note: There may be age-restrictions based on U.S. FDA guidelines for these medications.

The following medications are covered through this program:

• Generic medications available by prescription:
  • Bupropion ER 150 mg tablet
  • Bupropion SR 150 mg tablet
• Brand-name medications available by prescription:
  • Chantix 0.5 mg tablet
  • Chantix 1 mg continuing monthly pack
  • Chantix 1 mg tablet
  • Chantix starting monthly pack
  • Nicotrol cartridge inhaler
  • Nicotrol NS Spray 10 mg/ml
• Over-the-counter (OTC) medications

Note: To receive benefits for over-the-counter (OTC) smoking and tobacco cessation medications, you must have a physician’s prescription for each OTC medication that must be filled by a pharmacist at a Preferred retail pharmacy.

Note: These benefits apply only when all of the criteria listed above are met. Regular prescription drug benefits will apply to purchases of smoking and tobacco cessation medications not meeting these criteria. Benefits are not available for over-the-counter (OTC) smoking and tobacco cessation medications except as described above.

Note: See page 61 for our coverage of smoking and tobacco cessation treatment, counseling, and classes.

Preferred retail pharmacy: Nothing (no deductible)

Non-preferred retail pharmacy: You pay all charges

Preferred retail pharmacy: Nothing

Non-preferred retail pharmacy: You pay all charges

Not covered:

• Remicade, Renflexis, and Inflectra are not covered for prescriptions obtained from a retail pharmacy, Mail Service Prescription or through the Specialty Drug Program
• Medical foods administered orally are not covered if not obtained at a retail pharmacy or through the Mail Service Prescription Drug Program
• Medical supplies such as dressings and antiseptics
• Drugs and supplies for cosmetic purposes
• Drugs and supplies for weight loss
• Drugs for orthodontic care, dental implants, and periodontal disease
• Drugs used in conjunction with assisted reproductive technology (ART) and assisted insemination procedures
• Insulin and diabetic supplies except when obtained from a retail pharmacy or through the Mail Service Prescription Drug Program, or except when Medicare Part B is primary (see pages 58 and 110)
• Medications and orally taken nutritional supplements that do not require a prescription under Federal law even if your doctor prescribes them or if a prescription is required under your state law
• Products and foods other than liquid formulas or powders mixed to become formulas; foods and formulas readily available in a retail environment and marketed for persons without medical conditions; low-protein modified foods (e.g., pastas, breads, rice, sauces and baking mixes); nutritional supplements, energy products; and similar items
  
  Note: See page 112 for our coverage of medications recommended under the Affordable Care Act and page 117 for smoking and tobacco cessation medications.
  
  Note: See Section 5(a), page 58 for our coverage of medical foods and nutritional supplements when administered by catheter or nasogastric tube.
• Infant formula other than described on pages 58 and 109
• Drugs for which prior approval has been denied or not obtained
• Drugs and supplies related to sexual dysfunction or sexual inadequacy
• Drugs and covered-drug-related supplies for the treatment of gender dysphoria if not obtained from a retail pharmacy or through the Mail Service Prescription Drug Program or Specialty Drug Pharmacy Program as described on page 110
• Drugs purchased through the mail or internet from pharmacies outside the United States by members located in the United States
• Over-the-counter (OTC) contraceptive drugs and devices, except as described on page 110
• Drugs used to terminate pregnancy
• Sublingual allergy desensitization drugs, except as described on page 51

All charges

All charges

Covered prescription drugs and supplies not obtained at a retail pharmacy, through the Specialty Drug Pharmacy Program, or, for Standard Option members and Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program. This includes drugs and supplies covered only under the medical benefit.

Note: We cover drugs and supplies purchased overseas as shown here, as long as they are the equivalent to drugs and supplies that by Federal law of the United States require a prescription. Please refer to page 131 in Section 5(i) for more information.

Note: For covered prescription drugs and supplies purchased outside of the United States, Puerto Rico, and the U.S. Virgin Islands, please submit claims on an Overseas Claim Form. See Section 5(i) for information on how to file claims for overseas services.

• Please refer to the Sections indicated for additional benefit information related to drugs obtained from other sources:
  • Physician’s office – Section 5(a)
  • Facility (inpatient or outpatient) – Section 5(c)
  • Hospice agency – Section 5(c)
• Please refer to page 114 for prescription drugs obtained from a Preferred retail pharmacy, that are billed for by a skilled nursing facility, nursing home, or extended care facility.

Preferred: 15% of the Plan allowance (deductible applies)

Participating professional provider: 35% of the Plan allowance (deductible applies)

Non-participating professional provider: 35% of the Plan allowance (deductible applies) plus any difference between our allowance and the billed amount

Member: 35% of the Plan allowance (deductible applies)

Non-member: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Preferred: 30% of the Plan allowance

Participating professional provider: You pay all charges

Non-participating professional provider: You pay all charges

Member or Non-member: You pay all charges

• Auto-immune infusion medications: Remicade, Renflexis and Inflectra

Note: Benefits for certain auto-immune infusion medications (limited to Remicade, Renflexis and Inflectra) are covered only when they are obtained by a non-pharmacy provider, such as a physician or facility (hospital or ambulatory surgical center).

Preferred: 10% of the Plan allowance (deductible applies)

Participating professional provider: 15% of the Plan allowance (deductible applies)

Non-participating professional provider: 15% of the Plan allowance (deductible applies) plus any difference between our allowance and the billed amount

Member: 15% of the Plan allowance (deductible applies)

Non-member: 15% of the Plan allowance (deductible applies), plus any difference between our allowance and billed amount.

Preferred: 15% of the Plan allowance

Participating professional provider: You pay all charges

Non-participating professional provider: You pay all charges

Member or Non-member: You pay all charges

We provide benefits for services, supplies, or appliances for dental care necessary to promptly repair injury to sound natural teeth required as a result of, and directly related to, an accidental injury. To determine benefit coverage, we may require documentation of the condition of your teeth before the accidental injury, documentation of the injury from your provider(s), and a treatment plan for your dental care. We may request updated treatment plans as your treatment progresses.

Note: An accidental injury is an injury caused by an external force or element such as a blow or fall and that requires immediate attention. Injuries to the teeth while eating are not considered accidental injuries.

Note: A sound natural tooth is a tooth that is whole or properly restored (restoration with amalgams or resin-based composite fillings only); is without impairment, periodontal, or other conditions; and is not in need of the treatment provided for any reason other than an accidental injury. For purposes of this Plan, a tooth previously restored with a crown, inlay, onlay, or porcelain restoration, or treated by endodontics, is not considered a sound natural tooth.

Preferred: 15% of the Plan allowance (deductible applies)

Participating: 35% of the Plan allowance (deductible applies)

Non-participating: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Note: Under Standard Option, we first provide benefits as shown in the Schedule of Dental Allowances on the following pages. We then pay benefits as shown here for any balances.

$30 copayment per visit

Note: We provide benefits for accidental dental injury care in cases of medical emergency when performed by Preferred or non-preferred providers. See Section
5(d) for the criteria we use to determine if emergency care is required. You are responsible for the applicable copayment as shown above. If you use a non-preferred provider, you may also be responsible for any difference between our allowance and the billed amount.

Note: All follow-up care must be performed and billed for by Preferred providers to be eligible for benefits.

Clinical oral evaluations

Periodic oral evaluation (up to 2 per person per calendar year)

Limited oral evaluation

Comprehensive oral evaluation

Detailed and extensive oral evaluation

$12
 

$14

$14

$14

$8
 

$9

$9

$9

All charges in excess of the scheduled amounts listed to the left

Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed to the left and the Maximum Allowable Charge (MAC).

Diagnostic imaging

Intraoral complete series

$36

$22

All charges in excess of the scheduled amounts listed to the left

Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed to the left and the Maximum Allowable Charge (MAC).

Palliative treatment

Palliative treatment of dental pain – minor procedure

Protective restoration

$24
 

$24

$15
 

$15

All charges in excess of the scheduled amounts listed to the left

Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed to the left and the Maximum Allowable Charge (MAC).

Preventive

Prophylaxis – adult (up to 2 per person per calendar year)

Prophylaxis – child (up to 2 per person per calendar year)

Topical application of fluoride or fluoride varnish (up to 2 per person per calendar year)

---
 

$22
 

$13

$16
 

$14
 

$8

All charges in excess of the scheduled amounts listed to the left

Note: For services performed by dentists and oral surgeons in our Preferred Dental Network, you pay the difference between the amounts listed to the left and the Maximum Allowable Charge (MAC).

Not covered: Any service not specifically listed above

Nothing

Nothing

All charges

Clinical oral evaluations

Periodic oral evaluation*

Limited oral evaluation

Comprehensive oral evaluation*

*Benefits are limited to a combined total of 2 evaluations per person per calendar year

Preferred: All charges in excess of your $30 copayment

Participating/Non-participating: Nothing

Preferred: $30 copayment per evaluation

Participating/Non-participating: You pay all charges

Diagnostic imaging

Intraoral – complete series including bitewings (limited to 1 complete series every 3 years)

Preferred: All charges in excess of your $30 copayment

Participating/Non-participating: Nothing

Preferred: $30 copayment per evaluation

Participating/Non-participating: You pay all charges

Preventive

Prophylaxis – adult (up to 2 per calendar year)

Prophylaxis – child (up to 2 per calendar year)

Topical application of fluoride or fluoride varnish – for children only (up to 2 per calendar year)

Sealant – per tooth, first and second molars only (once per tooth for children up to age 16 only)

Preferred: All charges in excess of your $30 copayment

Participating/Non-participating: Nothing

Preferred: $30 copayment per evaluation

Participating/Non-participating: You pay all charges

Not covered: Any service not specifically listed above

Nothing

All charges

• You have FEHB coverage on your own or through your spouse who is also an active employee

• You have FEHB coverage through your spouse who is an annuitant

• It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)

• It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD

• This Plan was the primary payor before eligibility due to ESRD (for 30-month coordination period)

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

• Medicare based on ESRD (for the 30-month coordination period)

• Medicare based on ESRD (after the 30-month coordination period)

Participates with Medicare or accepts Medicare assignment and is not in our Preferred network

your deductibles, coinsurance, and copayments, and any balance up to the Medicare-approved amount.

Does not participate with Medicare and is in our Preferred network

Note: In many cases, your payment will be less because of our Preferred agreements. Contact your Local Plan for information about what your specific Preferred provider can collect from you.

your deductibles, coinsurance, and copayments, and any balance up to 115% of the Medicare-approved amount.

your copayments and coinsurance, and any balance up to 115% of the Medicare-approved amount.

Does not participate with Medicare and is not in our Preferred network

your deductibles, coinsurance, copayments, and any balance up to 115% of the Medicare-approved amount.

Opts-out of Medicare via private contract

your deductibles, coinsurance, copayments, and any balance your physician charges.

your deductibles, coinsurance, copayments, and any balance your physician charges.