• No pre-existing condition limitation

We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.

• Minimum essential coverage (MEC)

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

• Minimum value standard

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

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

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

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

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

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

• Types of coverage available for you and your family

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

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

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

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

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

• Family Member Coverage

Family members covered under your Self and Family enrollment are your spouse (including a valid common law marriage) and children as described below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described below.

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

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

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

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

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

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

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

• Children's Equity Act

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

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

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

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

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

• When benefits and premiums start

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

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

• When you retire

• When FEHB coverage ends

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

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

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

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

• Upon divorce

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

• Temporary Continuation of Coverage (TCC)

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

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

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

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

• Finding Replacement Coverage

We will provide you with assistance in finding a non-group contract available inside or outside the Marketplace if:

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

You must contact us in writing within 31 days after you are no longer eligible for coverage. For assistance in finding coverage, please contact us at 202-833-4910 or visit our website at
www.AFSPA.org/FSBP.

Benefits and rates under the replacement coverage will differ from benefits and rates under the FEHB Program. However, you will not have to answer questions about your health and we will not impose a waiting period or limit your coverage due to pre-existing conditions.

• Health Insurance Marketplace

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

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 202-833-4910 (M-F 8:30 a.m. - 5:30 p.m. ET) or write to us at Foreign Service Benefit Plan, 1620 L Street, NW, Suite 800, Washington, DC 20036-5629. You may also request replacement cards by secure e-mail through our secure Member Portal at www.myafspa.org. Login to the Member Portal with your username and password.

Where you get covered care

You can get care from any “covered provider” or “covered facility.” We do not require referrals to see a specialist. How much we pay – and you pay – depends on the type of covered provider or facility you use. If you use our in-network providers, you will pay less.

• Covered providers

We provide benefits for the services of covered professional providers, as required by Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not determined by your state’s designation as a medically underserved area.

Covered professional providers are medical practitioners who perform covered services when acting within the scope of their license or certification under applicable state law and who furnish, bill, or are paid for their health care services in the normal course of business. Covered services must be provided in the state in which the practitioner is licensed or certified.

• Covered facilities

Covered facilities include:

• Birthing Center — A licensed facility that is equipped and operated solely to provide prenatal care, to perform uncomplicated spontaneous deliveries and to provide immediate postpartum care.
• Convenient Care Clinic — A small health care facility, usually located in a high-traffic retail outlet, with a limited pharmacy, that provides non-emergency, basic health care services on a walk-in basis. Examples include Minute Clinic^® in CVS retail stores and Take Care Clinic^SM at Walgreens. Convenient care clinics are different from urgent care centers (see Urgent Care Center, next page).
• Hospice Care Facility — A facility providing hospice care services that is appropriately licensed or certified as such under the law of the jurisdiction in which it is located, and that:
  • Is certified (or is qualified and could be certified) under Medicare;
  • Is accredited by the Joint Commission on Accreditation of Healthcare Organizations;
  • Meets the standards established by the National Hospice Organization.
• Hospital
  • An institution that is accredited as a hospital under the hospital accreditation program of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO); or
  • Any other institution that is operated pursuant to law, under the supervision of a staff of doctors and with 24-hour-a-day nursing services, and that is engaged primarily in providing: (a) General inpatient care and treatment of sick and injured persons through medical, diagnostic and major surgical facilities, all of which facilities must be provided on its premises or under its control; or (b) Specialized inpatient medical care and treatment of sick or injured persons through medical and diagnostic facilities (including X-ray and laboratory) on its premises, under its control, or through a written agreement with a hospital (as defined above) or with a specialized provider of those facilities.
  • In no event shall the term hospital include a convalescent nursing home or institution or part thereof that: (a) Is used principally as a convalescent facility, rest facility, nursing facility or facility for the aged; (b) Furnishes primarily domiciliary or custodial care, including training in the routines of daily living; or (c) Is operated as a school.
• Residential Treatment Center — Residential treatment centers (RTCs) are accredited by a nationally recognized organization and licensed by the state, district, or territory to provide residential treatment for medical conditions, mental health conditions, and/or substance use disorder. RTCs provide 24-hour residential evaluation, treatment and comprehensive specialized services relating to the individual’s medical, physical, mental health, and/or substance use disorder therapy needs, all under the active participation and direction of a licensed physician who is participating within the scope of the physician’s license. RTCs offer programs for persons who need short-term transitional services designed to achieve predicted outcomes focused on fostering improvement or stability in functional, physical and/or mental health, recognizing the individuality, strengths, and needs of the persons served. 
• Skilled Nursing Facility — An institution or that part of an institution, which provides convalescent skilled nursing care 24-hours-a-day and is classified as a skilled nursing facility under Medicare.
• Urgent Care Center — A free-standing ambulatory care center, outside of a hospital emergency department, that provides emergency treatment for medical conditions that are not life-threatening, but need prompt attention, on a walk-in basis.

• Transitional care

Specialty care: If you have a chronic or disabling condition and

• lose access to your specialist because we drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan,
• lose access to your in-network specialist because we terminate our contract with your specialist for reasons other than for cause, or
• lose access to your in-network specialist because your specialist terminates their contract with us.

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

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist and your in-network benefits continue until the end of your postpartum care, even if it is beyond the 90 days.

• If you are hospitalized when your enrollment begins

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 202-833-4910.  If you are new to the FEHB Program, we will reimburse you for your covered services while you are in the hospital beginning on the effective date of your coverage.

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

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

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

You need prior Plan approval for certain services

The pre-service claim approval processes for inpatient hospital admissions (called precertification) and for other services, are detailed in this Section. A pre-service claim is any claim, in whole or in part, that requires approval from us in advance of obtaining medical care or services. In other words, a pre-service claim for benefits (1) requires precertification, prior approval or a referral and (2) will result in a reduction of benefits if you do not obtain precertification, prior approval or a referral.

You must get prior approval for certain services. Failure to do so may result in a $500 penalty to be taken from any inpatient or Skilled Nursing Facility benefits provided by the Plan. Please see Warning below. In addition, we may deny benefits for services listed in this Section, under Other services.

• Inpatient hospital and skilled nursing facility admissions

Precertification is the process by which – prior to your inpatient hospital or Skilled Nursing Facility admission – we evaluate the medical necessity or to confirm coverage of your proposed stay and the number of days required to treat your condition. Unless we are misled by the information given to us, we will not change our decision on medical necessity.

Warning:

Your in-network physician, hospital, or skilled nursing facility will take care of requesting precertification. You should always ask your physician, hospital, or skilled nursing facility whether or not they have contacted us for precertification. For out-of-network hospitals and Skilled Nursing Facility admissions, we will reduce our benefits for the out-of-network inpatient hospital or Skilled Nursing Facility stay by $500 if no one contacts us for precertification (see page 61). If the stay is not medically necessary, we will only pay for any covered medical services and supplies that are otherwise payable on an outpatient basis.

Exceptions:

You do not need precertification in these cases:

• You are admitted to a hospital, Skilled Nursing Facility or residential treatment center outside the 50 United States. However, the Plan will review all services to establish medical necessity or to confirm coverage. We may request medical records in order to determine medical necessity.
• You have another group health insurance policy that is the primary payor for the hospital stay.
• Medicare Part A is the primary payor for the hospital stay. Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare lifetime reserve days or you have no Medicare lifetime reserve days left, then we will become the primary payor and you must precertify.

• Other services

When you see an in-network physician, that physician must obtain precertification or prior approval for certain services such as inpatient hospitalization and the following services. If you see an out-of-network physician, you must obtain precertification or prior approval.

For a complete list of services that require precertification or prior approval, refer to
www.aetna.com/health-care-professionals/precertification/precertification-lists.html.

• Ambulance – prior approval required for transportation by fixed-wing aircraft (plane)
• Autologous chondrocyte implantation, Carticel
• BRCA genetic testing
• Cardiac rhythm implantable devices
• Certain mental health services, inpatient admissions, Residential treatment center (RTC) admissions, Partial hospitalization programs (PHPs), Transcranial magnetic stimulation (TMS) and Applied Behavior Analysis (ABA - even if rendered outside the 50 United States)
• Chiari malformation decompression surgery
• Cochlear device and/or implantation
• Covered transplant surgeries
• Dialysis visits – when request is initiated by an in-network provider, and dialysis to be performed at an out-of-network facility
• Dorsal column (lumbar) neurostimulators: trial or implantation
• Electric or motorized wheelchairs and scooters
• Endoscopic nasal balloon dilation procedures
• Gender reassignment surgery, even if rendered outside the 50 United States
• Gene therapy, gene editing and gene silencing, even if rendered outside the 50 United States
• Hip and knee arthroplasties
• Hip surgery to repair impingement syndrome
• Hyperbaric oxygen therapy
• Inpatient confinements (except hospice). For example, surgical and non-surgical stays; stays in a skilled nursing or rehabilitation facility; and maternity and newborn stays that exceed the standard length of stay (LOS)
• Lower limb prosthetics
• Observation stays more than 24 hours
• Orthognathic surgery procedures, bone grafts, osteotomies and surgical management of the temporomandibular joint (TMJ)
• Osseointegrated implant
• Osteochondral allograft/knee
• Out-of-network freestanding ambulatory surgical facility services, when referred by an in-network provider
• Pain management such as facet and spinal injections
• Pediatric congenital heart surgery
• Polysomnography (attended sleep studies)
• Power morcellation with uterine myomectomy, with hysterectomy or for removal of uterine fibroids
• Private duty nursing
• Proton beam radiotherapy
• Radiation oncology
• Radiology imaging such as CT scans, MRIs, MRAs, and nuclear stress tests
• Reconstructive or other procedures that may be considered cosmetic, such as:
• Blepharoplasty/canthoplasty
• Breast reconstruction/breast enlargement
• Breast reduction/mammoplasty
• Cervicoplasty
• Excision of excessive skin due to weight loss
• Gastroplasty/gastric bypass
• Lipectomy or excess fat remova
• Surgery for varicose veins, except stab phlebectomy

• Shoulder arthroplasty

• Spinal procedures, such as:

• Artificial intervertebral disc surgery
• Cervical, lumbar and thoracic laminectomy/laminotomy procedure
• Spinal fusion surgery
• Uvulopalatopharyngoplasty, including laser-assisted procedures
• Ventricular assist devices
• Video electroencephalographic (EEG)

Note: Chemotherapy also requires prior approval. See Section 5(a), Medical Services and supplies provided by physicians and other health care professionals.

Note: We only cover medically necessary services, drugs or supplies. Services, drugs or supplies that are not medically necessary, are not accepted standards of medical, dental, or psychiatric practice, or are experimental or investigational are not covered. We encourage you to contact the Plan to confirm coverage for proposed treatment prior to incurring services.

Note: Prescription drugs - Some medications and injectables are not covered unless you receive prior authorization. See Section 5(f), Prescription drug benefits. You are required to obtain all specialty drugs used for long term therapy from Accredo. To speak to an Accredo representative, please call 800-922-8279.

Note: We do not require precertification, prior approval or concurrent review if you receive treatment outside the 50 United States (including Guam), except as noted on the previous pages. However, the Plan will review all services to establish medical necessity or to confirm coverage. We may request medical records from you or your provider in order to determine medical necessity.

Note: We do not require precertification, prior approval or concurrent review when Medicare Part A and/or Part B or another group health insurance policy is the primary payor.  Precertification, prior approval and concurrent review are required, however, when Medicare or the other group health insurance policy stops paying benefits for any reason.

Note: We do not require prior authorization for the purchase of certain prescription drugs when Medicare Part B or Part D is the primary payor for the drugs or you are outside the 50 United States and purchase them from a retail pharmacy outside the 50 United States.

How to request precertification for an admission or get prior approval or prior authorization for Other services

First, you, your representative, your physician, or your hospital must call us at 800-593-2354 before admission or medical/surgical services requiring prior approval or prior authorization are rendered.

Next, provide the following information:

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

For prescription medications that require prior authorization, you, your representative, your physician, or your hospital must call Express Scripts (ESI), the Plan’s Pharmacy Benefit Manager at 800-818-6717 (TDD: 1-800-759-1089 for the hearing impaired).

• Non-urgent care claims

For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the pre-service claim.

If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

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

• Urgent care claims

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

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

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

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision or by calling us at 202-833-4910 between 8:30 a.m. and 5:30 p.m. Eastern Time.  You may also call OPM’s FEHB II at 202-606-3818 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at 202-833-4910. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

• Concurrent care claims

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

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

• The Federal Flexible Spending Account Program – FSAFEDS

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

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

• Emergency inpatient admission

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must phone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital. If you do not phone the Plan within two business days, penalties may apply - see Warning under Inpatient hospital and skilled nursing facility admissions earlier in this Section and If your hospital stay needs to be extended on the next page.

• Maternity care

You do not need precertification of a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 3 days after admission for a vaginal delivery or 5 days after admission for a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, your physician or the hospital must contact us for precertification of additional days for your baby.

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

• If your hospital stay needs to be extended

If your hospital stay – including for maternity care – needs to be extended, you, your representative, your doctor or the hospital must ask us to approve the additional days. If you remain in the hospital beyond the number of days we approved and did not get the additional days precertified, then

• For the part of the admission that was medically necessary, we will pay inpatient benefits, but
• For the part of the admission that was not medically necessary, we will pay only medical services and supplies otherwise payable on an outpatient basis and will not pay inpatient benefits.

• If your treatment needs to be extended

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

If you disagree with our pre-service claim decision

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

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

• To reconsider a non-urgent care claim

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

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

1. Precertify your hospital stay or, if applicable, arrange for the health care provider to give you the care or grant your request for prior approval for a service, drug, or supply; or
2. Ask you or your provider for more information.
   • You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.
   • If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision; or
3. Write to you and maintain our denial.

• To reconsider an urgent care claim

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

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

• To file an appeal with OPM

Cost-sharing

Copayment

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

Example:

• When you purchase prescriptions from the Express Scripts Pharmacy^SM (home delivery), you pay a copayment of $15 for generic, or $60 for preferred brand name.
• When you go into an out-of-network hospital, you pay $200 per person, per hospital stay.

We do not reimburse you for copayments.

Note:  If the billed amount (or the Plan allowance that providers we contract with have agreed to accept as payment in full) is less than your copayment, you pay the lower amount.

Deductible

A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them. We do not reimburse you for the deductible. Benefits paid by us do not count towards the deductible. Copayments and coinsurance amounts do not count toward any deductible. When a covered service or supply is subject to a deductible, only the Plan allowance for the service or supply counts toward the deductible. Expenses are “incurred” on the date on which the service or supply is received.

The calendar year deductible is $300 per person for in-network providers (including Guam) and providers outside the 50 United States or $400 per person for out-of-network providers (including Guam). Any expenses incurred that apply toward deductibles for in-network or out-of-network apply toward both in and out-of-network limits.

Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $300 for in-network providers (including Guam) and providers outside the 50 United States or $400 for out-of-network providers (including Guam).

Under a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $600 for in-network providers (including Guam) and providers outside the 50 United States or $800 for out-of-network providers (including Guam).

Under a Self and Family enrollment, the deductible is satisfied for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $600 for in-network providers (including Guam) and providers outside the 50 United States or $800 for out-of-network providers (including Guam).

If the billed amount (or the Plan allowance that providers we contract with have agreed to accept as payment in full) is less than the remaining portion of your deductible, you pay the lower amount.

Example: If the billed amount is $100, the provider has an agreement with us to accept $80, and you have not paid any amount toward meeting your calendar year deductible, you must pay $80. We will apply $80 to your deductible.  We will begin paying benefits once the remaining portion of your calendar year deductible ($300 for in-network (including Guam) and providers outside the 50 United States or $400 for out-of-network providers (including Guam)) has been satisfied.

Note: If you change plans during Open Season and the effective date of your new plan is after January 1 of the next year, you do not have to start a new deductible under your prior plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.

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

Coinsurance

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

Example: You pay 10% of the Plan allowance for surgery performed by an in-network provider.

If your provider routinely waives (does not require you to pay) your copayments, deductibles, or coinsurance, the provider is misstating the fee and may be violating the law.  In this case, when we calculate our share, we will reduce the provider’s fee by the amount waived.

For example, if your out-of-network physician or other health care professional ordinarily charges $100 for a service but routinely waives your 30% coinsurance, the actual charge is $70.  We will pay $49 (70% of the actual charge of $70).

Waivers

In some instances, an in-network provider may ask you to sign a “waiver” prior to receiving care. This waiver may state that you accept responsibility for the total charge, including any charges above the negotiated amount, for any care that is not covered by your health plan. If you sign such a waiver, whether or not you are responsible for the total charge depends on the contracts that the Plan has with its providers. If you are asked to sign this type of waiver, please be aware that, if benefits are denied for the services, you could be legally liable for the related expenses. If you would like more information about waivers, please contact us at 202-833-4910.

Differences between our allowance and the bill

Our “Plan allowance” is the amount we use to calculate our payment for covered services. Fee-for-service plans arrive at their allowances in different ways, so their allowances vary. For more information about how we determine our Plan allowance, see the definition of Plan allowance in Section 10, Definitions.

Often, the provider’s bill is more than a fee-for-service plan’s allowance. Whether or not you have to pay the difference between our allowance and the bill will depend on the provider you use.

You should use an in-network provider. The following two examples explain how we will handle your bill when you go to an in-network provider and when you go to an out-of-network provider.  When you use an in-network provider, the amount you pay is much less.

• In-network providers (including Guam) agree to limit what they will bill you. Because of that, when you use an in-network provider, your share of covered charges consists only of your deductible and coinsurance. Here is an example about coinsurance:  You see an in-network physician or other health care professional who charges $150, but our allowance is $100. If you have met your deductible, you are only responsible for your coinsurance. That is, you pay just 10% of our $100 allowance ($10). Because of the agreement, your in-network physician or other health care professional will not bill you for the $50 difference between our allowance and his/her bill. Follow these procedures when you use an in-network provider in order to receive in-network benefits:
  • Verify that the provider is in the network when you make your appointment. Confirm that the address for your appointment is the same location as on our website. Providers may choose to be an in-network provider at one location but not at another;   
  • Present your Foreign Service Benefit Plan Identification (ID) card at the time you visit your health care provider, confirming in-network participation in order to receive in-network benefits and the provider’s continued participation in our network.  If you do not present your ID card, the provider may not give you the in-network discount; and
  • Generally, you do not pay an in-network provider at the time of service. In-network providers must bill us directly. We must reimburse the provider directly. In-network providers will bill you for any balance after our payment to them.

• Out-of-network providers, on the other hand, have no agreement to limit what they will bill you.  For instance:

  • When you use an out-of-network provider, you will pay your deductible and coinsurance plus any difference between our allowance and charges on the bill.  Here is an example: You see an out-of-network physician or other health care professional who charges $150 and our allowance is again $100.  If you have met your deductible, you are responsible for your coinsurance, so you pay 30% of our $100 allowance ($30).  Plus, because there is no agreement between the out-of-network physician or other health care professional and us, the physician or other health care professional can bill you for the $50 difference between our allowance and his/her bill.
• Other participating providers (See Section 1, How This Plan Works) agree to limit what they will bill you. You still will have to pay your deductible and the out-of-network benefit level.  These providers have agreed not to bill you for the difference between the billed charges and the discounted amount.  
• Providers outside the 50 United States charges generally are not subject to a Plan allowance, that is, our Plan allowance is the amount billed by the provider or as part of our Direct Billing Arrangements.  Similar to the in-network example above, when you use a provider outside the 50 United States and you have met your deductible, you are responsible for your coinsurance. You will pay just 10% of the charge ($15).  Generally, you do not pay a provider in our Direct Billing Arrangement. We must reimburse the provider directly for any covered expenses. You are responsible, however, for any deductible and coinsurance, which we do not reimburse. See Section 7 for more information.

The table on the next page illustrates the examples of how much you have to pay out-of-pocket for medical services from an in-network provider vs. an out-of-network provider (including Guam) vs. a provider outside the 50 United States.  The table uses our example of a service for which the provider charges $150 and our allowance is $100.  The table shows the amount you pay if you have met your calendar year deductible.

Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments

We protect you against catastrophic out-of-pocket expenses for covered services. The IRS limits annual out-of-pocket expenses for covered services, including deductibles and copayments, to no more than $6,900 for Self Only enrollment, and $13,800 for a Self Plus One or Self and Family. The out-of-pocket limit for this Plan may differ from the IRS limit, but cannot exceed that amount.

For those benefits where copayments, coinsurance or deductibles apply, we pay 100% of the Plan allowance for the rest of the calendar year after your expenses total to:

• For Self Only enrollment $5,000 and for Self Plus One or Self and Family enrollment $7,000 for in-network providers (including Guam) and providers outside the 50 United States and when you use the Plan’s network retail pharmacy through Express Scripts (ESI), or home delivery (mail order) through the Express Scripts Pharmacy^SM, or purchase prescriptions outside the 50 United States from a retail pharmacy or Military Treatment Facility (including Guam);
• For Self Only enrollment $7,000 and for Self Plus One or Self and Family enrollment $9,000 for in- and out-of-network providers combined (including Guam) and when you use the Plan’s network retail pharmacy through Express Scripts or home delivery (mail order) through the Express Scripts Pharmacy^SM or purchase prescriptions outside the 50 United States from a retail pharmacy or Military Treatment Facility (including Guam).

For Self Plus One and Self and Family enrollments, once any individual family member reaches the Self Only catastrophic protection out-of-pocket maximum during the calendar year, that member’s claims will no longer be subject to associated cost-sharing amounts for the rest of the year. All other family members will be required to meet the balance of the catastrophic protection out-of-pocket maximum.

Any expenses incurred that apply toward the catastrophic out-of-pocket maximum for in-network or out-of-network apply toward both in and out-of-network limits.

This catastrophic protection out-of-pocket maximum is combined for medical/surgical, mental health/substance use disorder, and pharmacy.

The following cannot be counted toward catastrophic protection out-of-pocket expenses:

• Expenses in excess of Plan allowances, maximum benefit or visit limitations;
• Expenses for a transplant above the $400,000 maximum in-network benefit or expenses at an out-of-network facility;
• Expenses for dental care;
• Any amounts you pay because benefits have been reduced for non-compliance with precertification, prior approval, prior authorization requirements (see Section 3, How you get care);
• Expenses for prescriptions purchased at pharmacies in the 50 United States without using the Plan’s identification card or purchased from a source other than the Plan's mail order pharmacy;
• Expenses for maintenance prescription medications (drugs you take regularly for ongoing conditions) not purchased through the Express Scripts Home Delivery Pharmacy or through a participating Smart90^® Retail Network pharmacy; and
• Non-covered services and supplies.

Carryover

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

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

                                                                                                                                                                                       .

Flexible benefits option

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

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

Electronic Funds Transfer (EFT) of claim reimbursements

You can elect to receive your benefit reimbursement via Electronic Funds Transfer (EFT) and have payments deposited directly into your U.S. bank account.

Some important things to know about signing up for EFT service:

• Enrolling for EFT service is easy. Simply complete the Authorization Form in full and return it to the address on the form with a voided check or savings withdrawal slip attached to it.
• The Authorization Form can be found on Aetna's secure member website:
  • Visit www.AFSPA.org/FSBP
  • Select the "Helpful Links" tab and then click on "Aetna's secure member website"
  • Log on to Aetna's secure member website
  • Select "Forms"
  • Select "Electronic Funds Transfer (EFT)/Direct Deposit Authorization Form"
• When you receive benefit reimbursement via EFT, your Explanation of Benefits (EOB) will be available to you on Aetna's secure member website and will no longer be mailed to you. Instead, visit the Plan's website at www.AFSPA.org/FSBP  and select “Aetna's secure member website”. Log on to Aetna's secure member website to view your EOB.
• Only one bank account per family is permitted.
• The Plan cannot retrieve funds from your bank account. The Electronic Funds Transfer (EFT)/Direct Deposit Authorization Form only allows the Plan to deposit funds into your bank account.
• The Plan does not charge a fee for EFT service but your bank may charge a small transaction fee. We recommend that you verify with your bank if they will charge you any banking service fees.
• You may opt to have a paper copy of your EOB mailed to you by checking the box at the bottom of the enrollment form indicating your desire to continue to receive a paper EOB.
• You have the option to receive benefit reimbursement via check. There is nothing you need to do if you choose this option.

Scanned claim submission via secure Internet connection

The Plan provides a secure method for you to submit claims to us via the Internet. Visit our website
(www.myafspa.org), enter your username and password and click “Sign In”. Once inside the portal, select “Submit A Claim” under the "Secure Forms" tab. Follow the screen prompts to upload your PDF claim documents. You have the options to include questions or comments and send your secure claims to a specific customer service representative. Please ensure your name and member ID number appear on the claim. Make sure the image quality of your electronic documents is clear and legible.  Any unclear or illegible supporting documentation may cause your claim to be delayed or denied. In addition, you may correspond with us via secure e-mail through this process.

Electronic copies of Explanations of Benefits (EOBs)

Call the Plan’s customer service department at 202-833-4910 and request to stop receiving a paper copy of your EOB. Follow these easy steps to view and print your EOB on Aetna's secure member website:

• Visit www.AFSPA.org/FSBP
• Select the "Helpful Links" tab and then click on "Aetna's secure member website"
• Log on to Aetna's secure member website
• Select "Explanation of Benefits"

You will continue to receive your claim reimbursement checks unless you want to take advantage of our Electronic Funds Transfer (EFT) option (see previous page).

24-Hour Nurse Advice Line and Healthwise Knowledgebase

Informed Health^® Line (the Plan's 24-Hour Nurse Advice Line) provides you with telephone access to registered nurses experienced in providing information on a variety of health topics. Informed Health Line is available 24 hours a day, 7 days a week by phone at 855-482-5750 or 704-834-6782. We provide TDD service for the hearing and speech-impaired. We also offer foreign language translation for non-English speaking members.

You may e-mail a nurse by clicking on the “Stay Healthy” icon and selecting "e-mail a nurse" on Aetna's secure member website. A nurse will respond to your inquiry within 24 hours. To access Aetna's secure member website, visit the Plan’s website (www.AFSPA.org/FSBP), select the "Helpful Links” tab and then click on "Aetna's secure member website."

Healthwise Knowledgebase is an online education support resource available to you through Aetna's secure member website. It is a user-friendly decision-support tool that provides clinical information on 6,000 health topics, 600 medical tests and procedures, 500 support groups and 3,000 medications. The tool promotes informed health decision-making and helps members learn about their treatment options. Once you log on to Aetna's secure member website, select the "Stay Healthy" icon and then select "Healthwise Knowledgebase."

Informed Health Line nurses also have access to the Healthwise video library and can relay video links to you upon request or to provide further education/support of the health topic you discussed.

FSBP 24-Hour Translation Line

When you are overseas you have access to a translation service, 24 hours a day, 7 days a week to assist you in discussing your urgent health related conditions (such as accidents and medical emergencies that require immediate attention) with a foreign health care professional. You may call 855-482-5750 or 704-834-6782.

Simple Steps to Living Well Together Program and Wellness Incentives

Foreign Service Benefit Plan (FSBP) is committed to helping you achieve your best health. Members (over 18 years of age) who take simple steps to a healthier lifestyle can earn up to a maximum of $400 in incentives to be deposited in a Wellness Incentive Fund Account for participating in the Simple Steps to Living Well Together Program.

Complete the Health Risk Assessment (HRA) and earn a $75 wellness incentive. Completing your HRA annually is an important first step to guiding your personal health goals.

Note: See elsewhere in this Section for information on how to complete the HRA.

Complete a Biometric Screening through Quest Diagnostics and have a Routine Physical Examination and earn a $100 incentive. You must pass 3 out of 5 metabolic syndrome criteria (HDL Cholesterol, Triglycerides, Blood Pressure, Waist Circumference, and Glucose) from the Biometric Screening to earn the incentive.

If you do not pass 3 out of 5 metabolic syndrome criteria, you will receive the incentive if one of the following is completed:

• Mediterranean Wellness Program (see elsewhere in this Section)
• Health Coaching Program (Weight Management, Exercise, Nutrition, Stress Management) (see elsewhere in this Section)
• Dietary and nutritional counseling (obtain three counseling visits, which includes individual and group behavioral counseling) (see Section 5(a))

Note: See elsewhere in this Section for information on how to complete the Biometric Screening through Quest Diagnostics.

Complete a Healthy Action (non-condition specific) by participating in one of the Plan’s wellness programs outlined below and earn additional incentives.

• Participate in our Digital Coach Programs (see elsewhere in this Section)
  • Complete level 3 and earn $75
  • Complete level 4 and earn an additional $75
• Participate in our Health Coaching Program (Tobacco Cessation, Weight Management, Exercise, Nutrition, Stress Management) (see elsewhere in this Section)
  • Complete 6 Health Coaching sessions and earn $75
  • Complete 8 Health Coaching sessions and earn an additional $75
• Get your breast cancer screening and earn $25
• Get your cervical cancer screening (pap smear) and earn $25
• Get a flu shot and earn $25

Note: For benefit information for the breast cancer screening, cervical cancer screening and flu shot, see Section 5(a), Preventive care, adult.

Members identified with the following conditions may be eligible to complete the Healthy Actions outlined below and earn a $75 incentive for each one completed.

(Simple Steps to Living Well Together Program and Wellness Incentives continued next page)

Simple Steps to Living Well Together Program and Wellness Incentives

(cont.)

1. Controlling Blood Pressure for members with high blood pressure

• The Plan will reach out to you if you are identified through claims data as having high blood pressure and will provide you a form for your provider to complete. On the form, your provider must document two (2) controlled blood pressure readings below 140/90 on separate visits during the current calendar year for you to earn the incentive.

• If you are unable to meet this goal, you will receive the incentive if one of the following is completed:

  • Mediterranean Wellness Program (see elsewhere in this Section)
  • Health Coaching Program (Weight Management, Exercise, Nutrition, Stress Management) (see elsewhere in this Section)
  • Livongo Remote Hypertension Monitoring Program (Enroll in the Program and check blood pressure using the Livongo connected blood pressure cuff on two different days per continuous calendar month for four months) (see elsewhere in this Section).

2. Controlling Metabolic Syndrome/Pre-Diabetes levels for members with pre-diabetes

• The Plan will reach out to you if you are identified through claims data as having metabolic syndrome/pre-diabetes and ask you to have your provider submit documentation of the following results. To receive the $75 incentive reward, your results must show:
  • You have reduced your weight by 5%; or
  • You have lowered your triglycerides by at least 10%; or
  • You have raised your HDL by 5%
• If you are unable to meet these goals, you will receive the incentive if one of the following is completed:
  • Dietary and nutritional counseling (obtain three counseling visits, which includes individual and group behavioral counseling) (see Section 5(a))
  • Mediterranean Wellness Program (see elsewhere in this Section)

3. Controlling A1c Hemoglobin (HbA1c) levels for members with diabetes

• The Plan will reach out to you if you are identified through claims data as having diabetes and ask you to have your provider submit your HbA1c laboratory results. To receive the $75 incentive reward, your test results must show:
  • Your HbA1c must be less than 8%
• If your HbA1c is greater than or equal to 8 percent, you will receive the incentive if one of the following is completed:
  • Dietary and nutritional counseling (obtain three counseling visits, which includes individual and group behavioral counseling) (see Section 5(a))
  • Mediterranean Wellness Program (see elsewhere in this Section)
  • Diabetic Education or Training (see Section 5(a))
  • Livongo Remote Diabetes Monitoring Program (Enroll in the Program and check blood glucose using the Livongo meter four times per continuous calendar month for four months) (see elsewhere in this Section). Note: You always should follow directions from your health care provider with respect to the frequency of use and glucose testing.

(Simple Steps to Living Well Together Program and Wellness Incentives continued next page)

Simple Steps to Living Well Together Program and Wellness Incentives

(cont.)

Healthy actions that make you eligible to earn $75 (continued):

4. Eliminating tobacco use for tobacco users

• The Plan will reach out to you if you self-identified as a tobacco user on your HRA and ask you to participate in the Plan’s Tobacco Cessation Program (see Section 5(a)). To receive the $75 incentive reward, you must complete:
  • At least two quit attempts as part of our Tobacco Cessation Program. The quit attempt must include four tobacco cessation counseling sessions of at least 30 minutes each.

5. Prenatal Care for members who are pregnant

• If you are pregnant, your provider must submit documentation of a prenatal care visit during the first trimester. The documentation submitted must include a copy of the prenatal care medical record including Obstetric Panel testing, ultrasound, or prenatal exam from your provider for you to earn the incentive.

Note: To earn an incentive for the completed Healthy Actions above, mail your documentation to: Aetna, C/O FEHB QM, 4400 NW Loop 410, Suite 101, San Antonio, TX 78229.

Note: Please keep the following in mind when participating in the Simple Steps to Living Well Together Program:

• Allow up to 4 weeks after completion of a wellness activity or reaching a goal for the incentive to be deposited into your Wellness Incentive Fund Account
• You can earn each incentive only once per calendar year
• You can earn up to a total maximum of $400 combined incentives per calendar year
• You must complete all incentives by December 31^st of the calendar year, except for the Biometric Screening. The Biometric Screening must be completed by December 1^st of the calendar year.
• You can use incentives only for “Eligible Medical Expenses” as defined below

Eligible Medical Expenses, as defined by Internal Revenue Code Section 213(d), include your deductible, coinsurance, and copayments (e.g., prescription drug copayments) incurred by you or your covered dependents.

You and your dependents' medical claims and prescription claims submitted for non-network retail pharmacies outside the 50 United States will transfer automatically to the Wellness Incentive Fund Account after processing. Reimbursement for your deductible and coinsurance will be sent to you or your provider if there are funds available. Other expenses, like dental, vision, and prescriptions purchased through the Plan’s retail pharmacy network or home delivery program cannot be reimbursed automatically. You will need to submit a copy of your receipt with a completed claim form (Wellness Incentive Claim Form) found on Aetna's secure member website.

• Visit www.AFSPA.org/FSBP
• Select the "Helpful Links" tab and then click on “Aetna's secure member website”
• Log on to Aetna's secure member website 
• Select “Forms”
• Select “Wellness Incentive Claim Form"

If you are enrolled in a Flexible Spending Account (FSA) and wellness incentives have been deposited into your Wellness Incentive Fund Account, you may not receive reimbursement for the same medical expense from both your Wellness Incentive Fund Account and your FSA. If a medical expense is covered under both your Wellness Incentive Fund Account and your FSA, you must use the funds in your Wellness Incentive Fund Account first. Enrollees may receive reimbursements from their FSAs for medical expenses that are covered by both their Wellness Incentive Fund Account and their FSA only after the funds in the Wellness Incentive Fund Account have been exhausted. In order to receive reimbursement from your Wellness Incentive Fund Account for Eligible Medical Expenses, you must complete and sign a Wellness Incentive Claim Form certifying that you have not received reimbursement for the applicable Eligible Medical Expense and that you will not seek such reimbursement under any other plan or arrangement. If you receive reimbursements from more than one plan or arrangement for the same Eligible Medical Expense, the amount received in excess of the Eligible Medical Expense may be taxable to you as income.

Any unused funds in your Wellness Incentive Fund Account at the end of the calendar year will remain in the Wellness Incentive Fund Account for Eligible Medical Expenses in the next Plan year as long as you remain enrolled in the Plan.

To monitor the availability of funds in your Wellness Incentive Fund Account, visit the Plan's website
(www.AFSPA.org/FSBP), select the "Helpful Links" tab and then click on “Aetna's secure member website”. Once you log on to Aetna's secure member website, look for the "Stay Healthy" icon, select “Discover a Healthier You” and proceed. If you would like to contact the Plan for more information about this Program, please call 202-833-4910.

Health Risk Assessment (HRA)*

Health Risk Assessment (HRA)

Make a difference in your health in just a few minutes by completing a simple health risk assessment (HRA) about your health history and habits. The HRA can:

• Help you learn more about your health risks
• Provide strategies to improve your health and well-being
• Give you personalized health results to share with your doctor

You can complete the HRA on-line or over the telephone with a Health Coach. To complete the on-line HRA, visit www.AFSPA.org/FSBP

• Select the "Helpful Links" tab and then click on "Aetna's secure member website"
• Log on to Aetna's secure member website
• Look for the "Stay Healthy" icon, select "Discover a Healthier You" and proceed

To schedule an appointment to complete the HRA over the telephone, contact a Health Coach at 855-406-5122 or 479-973-7168. Coaches are available Monday through Thursday from 8:00 a.m. - 10:00 p.m. Eastern Time (ET) and Friday from 8:00 a.m. - 6:00 p.m. ET. You may also schedule an appointment online at
http://enroll.trestletree.com and use passcode: FSBP.

*This is part of the Plan’s Simple Steps to Living Well Together Program. Participate in this Program and you are eligible to earn an incentive reward. See this Section, Simple Steps to Living Well Together Program and Wellness Incentives.

Quest Diagnostics Biometric Screening*

You can obtain a Biometric Screening at a Quest Diagnostics Patient Service Center (PSC) or you can obtain the screening from your physician by having your physician complete a Biometric Screening Physician Results Form and submit it to Quest Diagnostics. A Biometric Screening obtained through your physician is done generally during a routine physical examination. Visit my.questforhealth.com and enter the registration key "FSBP" to register for your screening, locate a PSC location or print a copy of the Biometric Screening Physician Results Form to take to your physician. You also can register by calling 855-623-9355. Quest Diagnostics will send you your biometric screening results and a personalized action plan to help you better understand your health risks.

*This is part of the Plan’s Simple Steps to Living Well Together Program. Participate in this Program and you are eligible to earn an incentive reward.  See this Section, Simple Steps to Living Well Together Program and Wellness Incentives.

Mediterranean Wellness Program*

Mediterranean Wellness Program

You can receive up to 100% reimbursement for the Mediterranean Wellness Program once you complete at least 80% of the Program. Once you complete at least 80% of the Program, the Plan will automatically reimburse you for the cost of the program under the Plan’s Nutritional counseling benefit.

The Mediterranean Wellness Program assists you in maintaining a desirable weight and keeping healthy by eating nutritious, appealing, and hearty food. The interactive, on-line, 8-week program provides you with the flexibility to enroll at any time. You will have access to an 80-page support manual and access to your own Registered Dietician.

To learn more about the Program, visit www.AFSPA.org/FSBP, select the "Helpful Links" tab and then click on “Aetna's secure member website". Once you log on to Aetna's secure member website, look for the "Stay Healthy" icon, select "Discover a Healthier You" and proceed.

If you would like to contact the Plan for more information about this Program, please call 202-833-4910.

*Completion of this Program can earn you a Healthy Action Incentive in the Simple Steps to Living Well Together Program (condition specific). See this Section, Simple Steps to Living Well Together Program and Wellness Incentives.

Health Coaching Program*

The Health Coaching Program provides you and your covered dependents the opportunity to work one-on-one with a Health Coach to improve your health. A Health Coach is a health care professional who partners with you to transform your health goals into action. Your Health Coach will provide guidance, support, and resources to help you overcome obstacles that may be keeping you from realizing optimal health. You can talk to a Health Coach about the following health-related matters:

• Tobacco cessation
• Weight management
• Exercise
• Nutrition
• Stress management

How does health coaching work?

• You talk with your Health Coach over the telephone through conveniently scheduled appointments and create a plan that is right for you to meet your health goals. Everything in the program is tailored to you.
• You explore ways to make changes in your behavior that will last.
• You receive written materials from your Health Coach that can help you decide where you want to go with your health and how to get there.
• Appointments can range from 15 minutes to an hour. How long and how often you meet with your Health Coach depends on your individual needs.

To enroll in a program, contact a Health Coach at 855-406-5122 or 479-973-7168. Coaches are available Monday through Thursday from 8:00 a.m.– 10:00 p.m. Eastern Time (ET) and Friday from 8:00 a.m.– 6:00 p.m. ET. You may also enroll online at http://enroll.trestletree.com (passcode: FSBP).

Note: See Section 5(a), Educational classes and programs for more information.

*This is part of the Plan’s Simple Steps to Living Well Together Program. Participate in this Program and you are eligible to earn an incentive reward. See this Section, Simple Steps to Living Well Together Program and Wellness Incentives.

Healthy Pregnancy Program

You have access to the Plan's Healthy Pregnancy Program, which provides educational material and support to pregnant women during healthy and high risk pregnancies. Contact the Plan at 800-593-2354 for more information.

Digital Coach Programs*

Digital coach programs — These include nine base programs for weight management, smoking cessation, stress management, nutrition, physical activity, cholesterol management, blood pressure, depression management, and sleep improvement. Programs are prioritized based on a member’s health risk assessment to help create a personalized plan for successful behavior change. Members can engage and participate through personalized messaging with tools and resources to help track their progress and stay on the path to wellness.

Access the Plan’s website tool on Aetna's secure member website through our link at www.AFSPA.org/FSBP, select the "Helpful Links" tab and then click on “Aetna's secure member website”. Once you log on to Aetna's secure member website, look for the "Stay Healthy" icon, select "Discover a Healthier You" and proceed. This provides you secure access to a broad range of your personal health information after you register.

*This is part of the Plan’s Simple Steps to Living Well Together Program. Participate in this Program and you are eligible to earn an incentive reward. See this Section, Simple Steps to Living Well Together Program and Wellness Incentives.

In Touch Care (ITC) Program

In Touch Care (ITC) Program provides you and your dependents personal support to manage health events or chronic conditions at no additional cost. This combined service formerly fell under three programs, Case Management, Disease Management and Advanced Illness Program. It also broadens the scope of the Program to include a Social Work Program and a Pain Management Program.

ITC Program offers you:

• Ongoing, one-on-one phone calls with a nurse or social worker who serves as a trusted resource for you and your family. To begin one-on-one nurse or social worker support, call 800-593-2354;
• Digital support that provides a variety of resources to help you manage your health better. To begin using the digital support of ITC, log in to Aetna's secure member website. First-time users will need to register and then go to your health dashboard; and
• Customized health action plans based on your needs and preferences.

We are committed to giving you all the support you deserve. That is why we offer both digital and nurse support, and you can move easily between the two.

You will benefit from many digital health and wellness related programs and resources:

• Personal health record – organize and store your health history and information, plus get health alerts and notifications.

• Health evaluation – get a custom, step-by-step plan based on questions about your health and habits.
• Health decision support – learn about your health care and treatment options.
• Digital Coach Programs – find dynamic health coaching programs that give you personalized support.(see elsewhere in this Section)
• Health dashboard – view your health information and find entry points for health and wellness programs and resources.

Social Work Program:

ITC also includes a Social Work Program designed to improve the quality of life by taking steps to help members locate the right resources. Social workers help connect you with community resources that can provide services to you in times of need. Some examples include:

• Local food pantries
• Utility or rental assistance programs
• Home-delivered meal services
• Support groups
• Counseling services

In addition, social workers can refer you to Federal and state programs, such as:

• Social Security
• Medicare
• Medicaid

Our social workers are licensed and degreed professionals who work in a variety of settings, including government and non-profit organizations, hospitals, schools and clinics. Social workers also help treat mental, emotional and behavioral issues in clinical settings.

Pain Management Program:

The Pain Management Program is designed for members with chronic pain and either taking opioids or trying to avoid opioids. Members enrolled will receive coaching and support, which includes assisting with identifying the availability of other treatment plans that may include non-pharmacologic modalities for the treatment of pain such as, but not limited to: injection therapies, cognitive therapies, psychosocial supports, medical devices (e.g. nerve stimulators) and additional chiropractic, acupuncture, massage therapy, or physical therapy visits as applicable. The program also provides assistance with psychological effects of chronic pain, reduction of opioid use, avoiding opioid use and resources for those who are dependent on opioid medications.

Compassionate Care Program (formerly Advanced Illness Program):

The Compassionate Care Program is designed to improve the quality of life through health condition management and to reduce costs for members with advanced illness, including those facing imminent end-of-life decisions. It provides tools and information to encourage advance planning for the kind of issues often associated with an advanced illness, such as living wills, advance directives and tips on how to begin conversations about these issues with loved ones. This program is designed to provide quality of life improvement through health condition management and to reduce costs for members at the end of life through timely member and caregiver education. It encourages better use of community-based services and resources, systemic palliative care integration and enhanced hospice utilization and retention. This program is a voluntary program provided to you and your dependents at no additional cost.

If you would like to contact the Plan for more information about the ITC Program, please call 800-593-2354. We are available to assist you Monday-Friday from 6:00 a.m. - 5:00 p.m. Mountain Standard Time (MST).

Cancer Support Program

The Plan's Cancer Support Program is designed to provide education and support to members.

We will contact candidates and ask them to participate in the Program. Participation is voluntary. The participant and his/her physician or other health care professional remain in charge of the treatment plan.

If you would like to contact the Plan for more information about this Program, please call 800-593-2354. We are available to assist you Monday-Friday from 6:00 a.m. - 5:00 p.m. Mountain Standard Time (MST).

See Section 5(a), Treatment therapies for our benefits for chemotherapy and radiation therapy. See below for information on TherapEase Cuisine, the Plan’s cancer nutrition benefit.

TherapEase Cuisine

TherapEase Cuisine, a nutritional program through the Express Scripts Pharmacy^SM, the Plan’s home delivery pharmacy, offers an easy-to-use online program providing cancer patients access to nutritional information that follows the Academy of Nutrition and Dietetics guidelines for cancer nutrition. TherapEase Cuisine helps answer the question, “What should I be eating?” for those diagnosed with cancer.

Simply visit www.therapeasecuisine.com, click on “Sign Up” and then enter your first name, last name, full prescription number from one of your oncology medication bottles, and date of birth. You then can create your free account and access online nutrition information.

Note: See Section 5(a), Medical services and supplies, Educational classes and programs and above in Cancer Support Program for more information on how you can take advantage of the Plan’s Cancer Support Program that provides education and nursing support for cancer patients.

myStrength^TM - on-line mental health support program

The myStrength™ program provides you and your covered dependents age 13 and older, evidence-based resources to help overcome obstacles of depression, anxiety, and substance use disorder while improving overall well-being through a personalized evidence based internet-enabled program.  This program focuses on the management of depression, anxiety, and substance use disorder through easy to use tools, weekly exercises, informational articles and daily inspiration in a safe and confidential environment. 

The program uses interactive web and mobile applications that deliver evidence-based psychotherapy models like:

• Cognitive behavioral therapy (CBT)
• Acceptance and commitment therapy (ACT)
• Mindfulness acceptance

Personalized inspirational and wellness approaches increase personal relevance, improve outcomes and focus on total well-being.

If you would like to enroll in the program visit www.mystrength.com, select “Sign-up”, enter the access code “FSBP” and complete the myStrength sign-up process with a brief Wellness Assessment and personal profile.

AbleTo – on-line treatment support program

AbleTo is a web-based video conferencing personalized 8-week treatment support program designed to address the unique emotional and behavioral health needs of individuals learning to live with conditions like heart disease, type 2 diabetes, chronic pain or life events such as losing a loved one or having a baby. Members work with the same therapist and coach each week to set reasonable goals toward healthier lifestyle changes.

There are several ways we identify members who may benefit from the AbleTo support such as:

• Your nurses or clinicians may refer you to AbleTo as they work directly with you and can refer you if it is determined that you can benefit from AbleTo support.
• If identified, an Engagement Specialist from AbleTo will contact you to introduce the treatment option.
• If you feel you would benefit from this program, would like more information, or would like to enroll in this program please call 866-287-1802 or visit AbleTo’s website at www.AbleTo.com/enroll.

Note: AbleTo is not available to members outside the 50 United States.

The Pre-Diabetic Alert Program is focused to provide education and support for members "at risk" for developing diabetes.

We will contact those individuals identified at risk and offer them the opportunity to participate in the Program. Participation is voluntary. The participant and his/her physician or other health care professional remain in charge of the participant's treatment plan.

See Section 5(a), Medical services and supplies for the Plan’s Diabetic Education or training benefit.

If you would like to contact the Plan for more information about this Program, please call 800-593-2354.

Institutes of Excellence for tissue and organ transplants

The Plan has special arrangements with facilities to provide services for tissue and organ transplants only. The transplant network was designed to give you an opportunity to access providers that demonstrate high quality medical care for transplant patients.

Note: If a qualified tissue/organ transplant is medically necessary and performed at one of the transplant network facilities, you may be eligible for reimbursement of some expenses for travel and lodging for the transplant recipient and one family member or caregiver. We also may assist you and one family member or caregiver with travel and lodging arrangements.

Reimbursement is subject to IRS regulations.

Note: Receipts are required for reimbursement of travel and lodging costs.

See Section 5(b), Organ/tissue transplants for the Plan’s Organ/Tissue transplants benefit.

Contact the Plan at 800-593-2354 for more information. We are available to assist you Monday-Friday from 6:00 a.m. - 5:00 p.m. Mountain Standard Time (MST).

Livongo – remote diabetes monitoring program*

Livongo is a remote diabetes monitoring program powered by Livongo Health that empowers those with diabetes to live a better life. Livongo provides personalized support through a cellular enabled meter, mobile app, and personalized interventions to help you make better decisions about diabetes management. Candidates will be contacted and asked to participate in the program based on claims data. Participation is voluntary. The participant and his/her physician or healthcare professional remain in charge of the participant’s treatment plan. 

The program provides:

• Unlimited blood glucose test strips and lancets
• A glucose meter that tracks strip usage and prompts members to reorder supplies
• Real-time interventions by Certified Diabetes Educators for members with dangerous (high and/or low) blood sugar levels

Note: The Livongo for Diabetes Program offers an advanced blood glucose meter that uses cellular technology to upload blood glucose readings automatically and provides real-time insights in the United States. Due to the unique cellular network infrastructure in certain countries, the Livongo advanced blood glucose meter may have limited cellular connectivity. Blood glucose readings may not upload automatically, real-time insights may not be received, and other features linked to connectivity may be limited. Members still receive the blood glucose meter, unlimited test strips, and coaching at no cost.

Note: The Livongo advanced blood glucose meter will not have cellular connectivity in the following countries: British Indian Ocean Territory, Central African Republic, Cote D'Ivoire, Cuba, Djibouti, East Timor, Eritrea, Ethiopia, Federated States of Micronesia, Grenada, Japan, Lebanon, Liberia, Mauritius, Palau, Singapore, South Korea, Suriname, Togo, Turkmenistan.

For more information visit get.livongo.com/FSBP or call 800-945-4355.

*Participation in this Program can earn you a Healthy Action Incentive in the Simple Steps to Living Well Together Program (condition specific). See this Section, Simple Steps to Living Well Together Program and Wellness Incentives.

Livongo – remote hypertension monitoring program*

Livongo for hypertension provides support to members living with high blood pressure through remote hypertension monitoring. Remote hypertension monitoring combines technology to empower members living with high blood pressure with evidence based digital clinical interventions. Candidates will be contacted and invited to participate in the Program based on claim data. Participation is voluntary. The participant and his/her physician or healthcare professional remain in charge of the participant’s treatment plan.

The program provides:

• A connected blood pressure monitor
• Counseling by Livongo’s clinical coaching team
• Livongo mobile app that provides real-time readings

The hypertension cuff and monitor are Bluetooth enabled. With each blood pressure reading, you receive instant in-app feedback and coaching to drive you closer to your goal. In addition, you have access to Livongo’s clinical coaching team who provide counseling on ways to keep your blood pressure well controlled, adhere to your medications and generally manage your hypertension through lifestyle changes.

Note: The Livongo mobile app is available only on the U.S. Apple Store or U.S. Google Play Store.

For more information visit get.livongo.com/FSBP or call contact 800-945-4355.

*Participation in this Program can earn you a Healthy Action Incentive in the Simple Steps to Living Well Together Program (condition specific). See this Section, Simple Steps to Living Well Together Program and Wellness Incentives.

Express Scripts Specialist Pharmacists Program

For those who need the highest degree of clinical support, Express Scripts enables members and their caregivers to engage with highly trained specialist pharmacists and nurses. The specialist pharmacists specialize in caring for patients with the most complex and costly conditions, including cardiovascular disease, diabetes, cancer, HIV, asthma, depression, and many rare and specialty conditions.

For direct access to a specialist pharmacist, call 800-818-6717 or log on to express-scripts.com and send your question via secure email.

Overseas Second Opinion

The Plan has a special arrangement with the Cleveland Clinic to provide patients who receive treatment in foreign countries a second opinion for certain diagnoses through the e-Cleveland Clinic. Patients who receive treatment in foreign countries and with qualifying diagnoses as determined by the Plan will have convenient access to the Cleveland Clinic’s nationally-recognized specialists for a second opinion. This second opinion program is available in most locations throughout the world.

To determine if you are an appropriate candidate for this second opinion benefit, e-mail the Plan at secondopinion@aetna.com. If your diagnosis qualifies for this program, you will be asked to submit medical history information and answer questions specific to the diagnosis. You also may need to gather information from your local physician or hospital, such as pathology (biopsy) slides or X-rays and mail them to the Plan as instructed.

The appropriate physician will review the medical history and original tests before rendering a second opinion. You will be notified by e-mail within three to five days that the opinion is ready and can be viewed online at a secure website. Once a second opinion is obtained, you may proceed with the treatment that was originally recommended by your own physician or you may decide you want to seek another opinion or arrange care with another physician.

Aetna's secure member website – web based customer service – and Aetna Health^SM App

Aetna's secure member website - web based customer service

Access Aetna's secure member website through our link at www.AFSPA.org/FSBP, select the "Helpful Links" tab and then click on “Aetna's secure member website”. This provides you secure access to a broad range of your personal health information after you register.

Aetna's secure member website provides tools to become an optimal health care consumer. Services such as the following are available:

• Interactive personal health record — The Plan will build your health record with information from your claims. You also can add other personal health information such as blood pressure, weight, vital statistics, immunization records, and more.
• Robust claims information — You can view and organize your claims the way you want: sort by date range, health care provider etc.
• Explanation of benefits (EOBs) — You can access and print your EOBs.
• Decision support tools — You can check the average cost of medical procedures or view hospital quality information before you receive care.
• Health information — You can obtain health information and news that is relevant to you.
• Interactive health tools — You can assess, understand, and manage conditions and health risks. Easy to use content helps members navigate common, but sometimes complex conditions.
• KidsHealth Library — You can access an online resource that educates families and helps them make informed decisions about children's health. KidsHealth is an engaging way to encourage preventive behaviors and motivate kids and teens to become more involved in their health. 

Aetna Health^SM App

You can use the Aetna Health app to:

• Find doctors and facilities using location and see maps for directions
• Locate urgent care - walk-in clinics, urgent care clinics, emergency rooms
• View claims and claim details
• View benefits and balances
• Track out-of-pocket dollars
• View ID card information
• Store ID card offline
• Get cost estimates before you receive care
• View your Health History
• Share your opinion (feedback)

The app can be downloaded for free onto your mobile device. Text “Aetna” to 90156 to receive a link to download the Aetna Health app (message and date rates may apply).

Express Scripts (ESI) – prescription benefits web based customer service and mobile app

Express Scripts web based customer service

Access the Plan's website tool for managing your Prescription benefits (see Section 5(f), Prescription drug benefits) through our link at www.AFSPA.org/FSBP. Click on the “Prescription” tab on the right. This provides you secure access to the Express Scripts Pharmacy and a broad range of prescription management tools. Services such as the following are available:

• Refill and renew home delivery prescriptions;
• Verify home delivery prescription status;
• View retail and home delivery prescription claim histories, expenses, and balances;
• Locate a pharmacy including Smart90^® pharmacies;
• Compare plan-specific pricing and drug coverage information with all lower cost, clinically appropriate alternatives identified;
• Review drug information (interactions, side effects, precautions, guidelines for use, etc.);
• Review benefit highlights, including days supply and copayments;
• Transfer retail prescriptions to mail; and
• Receive automated e-mail refill and renewal reminders to help ensure continuous therapy and late-to-fill messages that indicate when you are late to fill an important medication.

Express Scripts Mobile App

You can use the Express Scripts Mobile App to:

• Register for online access directly (no need to already have an account at Express-Scripts.com in order to use the app);
• Order refills and renewals and check delivery status on home delivery prescriptions;
• Locate a pharmacy including Smart90^® pharmacies;
• Access Price a Medication to find and compare medication costs;
• Transfer existing prescriptions to home delivery;
• Find all your detailed drug information by medication name, dosage condition or drug category and see potential side effects, drug interactions, pill images, proper usage;
• Set dosage and refill reminders; and
• Receive pharmacy care alerts.

The app can be downloaded for free onto your mobile device.

Aexcel Designated Providers

A guide to the Aexcel specialist performance designation

Aexcel is our designation for high-performing specialty physicians and physician groups in 12 medical specialty areas:

• Cardiology
• Cardiothoracic surgery
• Gastroenterology
• General surgery
• Neurology
• Neurosurgery
• Obstetrics and gynecology
• Orthopedics
• Otolaryngology/ENT
• Plastic surgery
• Urology
• Vascular surgery

Physicians with the Aexcel specialist designation have met added standards for volume, clinical performance, and efficiency. Aetna evaluates these providers using specific standards and, based on the results, gives them the Aexcel specialty designation.

Visit www.fsbphealth.com, select "Find a Provider" and look for the blue star next to the provider’s name for an Aexcel designated provider. If a specialist does not have a blue star, this does not mean the physician does not provide quality services. It could be that Aetna does not have enough information available to evaluate a particular physician or the physician’s specialty is not one of the 12 specialty categories. The Aexcel information is only a guide. There are many ways to evaluate doctor practices. You should talk with your primary care physician and the specialist you are considering before making a decision. Please note that ratings have a chance for error. An Aexcel designation is not a guarantee of service quality or treatment outcome. Therefore, the Aexcel designation should not be the only reason for choosing a specialty doctor.

Dental Insurance

AFSPA offers four (4) dental plans, including a true international plan. Dependent children are covered up to age 26.

Discount Care Programs

Save on dental, vision, and LASIK services. Available to U.S. Residents only. This plan is not insurance.

Hearing Aid Discounts

Save 30-60% on digital hearing aids and batteries. Complimentary service for all AFSPA members. This plan is not insurance.

Life Insurance

AFSPA offers three (3) life insurance options:

• Accidental Death & Dismemberment (AD&D) protects worldwide, up to $600,000, against loss due to accidental injury or death.
• Group Enhanced Life (GEL) is a term life plan that covers up to $600,000. A portion of your benefit may be used while living including assistance with long term care costs.
• For select agencies only, the Immediate Benefit Plan (IBP) covers immediate expenses, upon an employee’s death. This term life plan pays the beneficiary within 48 hours of AFSPA’s notification.

Group Disability Income Protection Insurance

AFSPA’s two (2) disability plans pay 60% of your salary (up to $5,000/month), if you cannot work for an extended period, due to illness or injury.

Members of Household Insurance

AFSPA offers three travel medical insurance plans for members of your household who are traveling outside of their home country and are not eligible for FEHB.

Professional Services

Receive discounted legal, taxes, long term care, and financial planning advice.

Travel Insurance

AFSPA offers travel insurance that covers pre-trip, medical, and travel assistance benefits including medical evacuation, repatriation of remains, trip cancellation, baggage loss, etc.

Enroll/Apply at any time for all of the above programs. No Open Season is required.

Learn more at www.AFSPA.org/AIP.

Institutes of Excellence™ (IOE) Infertility Providers

Access infertility providers with proven outcomes through Aetna’s Institutes of Excellence (IOE) Infertility network. Learn more at www.aetnainfertilitycare.com.

How to claim benefits

To obtain claim forms, visit our website at www.AFSPA.org/FSBP. To obtain claim filing advice or answers about our benefits, contact us by e-mail through our secure Member Portal at www.myafspa.org. Submit your claims by mail to the Foreign Service Benefit Plan, 1620 L Street, NW, Suite 800, Washington, DC 20036-5629 or through the secure Member Portal. Login to the Member Portal with your username and password. Once inside the portal, select “Submit A Claim” under the “Secure Forms” tab. Follow the screen prompts to upload your PDF claim documents. You have the options to include questions or comments and send your secure claims to a specific customer service representative. Please ensure your name and member ID number appear on the claim. Make sure the image quality of your electronic documents is clear and legible. Any unclear or illegible supporting documentation may cause your claim to be delayed or denied. In addition, you may contact us by phone (M-F 8:30 a.m. - 5:30 p.m. ET) at 202-833-4910 (members) or 202-833-5751 (health care providers).

In most cases, providers and facilities file claims for you. Your provider must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form.

When you must file a claim – such as for out-of-network providers or when another group health plan is primary – submit it on the CMS-1500 or a claim form that includes the information shown below. Overseas claims do not need to be filed on a CMS-1500; however, the information below still is required to receive reimbursement (see Overseas Claims on next page). Bills and receipts should be itemized and show:

• Patient’s name, date of birth, address, phone number and relationship to enrollee
• Patient’s Plan identification number
• Name, address, and tax identification number of the person or company providing the services or supplies. We do not need the tax identification number for providers outside the United States.
• Dates that services or supplies were furnished
• Diagnosis
• Type of each service or supply
• Charge for each service or supply
• Valid medical or ADA dental code (not required for overseas claims) or description of each service or supply

Note: If you paid for the services, we may ask you for proof of payment in the form of your receipt of payment or provider proof of payment stamp.

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills. In addition, the Plan cannot accept a claim from you as an e-mail attachment. You may submit claims as described above through our secure Member Portal.

In addition:

• Generally, you need to fill out only one claim form per year. You should fill out a claim form if you submit a claim due to accidental injury, you have changed your address, or if the member’s other insurance/Medicare status has changed.
• If another health plan is your primary payor, you must send a copy of the explanation of benefits (EOB) form you received from your primary payor (such as the Medicare Summary Notice (MSN)) with your claim.
• Claims for massage therapy must include an itemized bill and the provider’s Federal Tax I.D. Number and/or Massage Therapy License Number (if a United States provider).
• Bills for private duty nursing care must show that the nurse is a Registered Nurse (R.N.) or Licensed Practical Nurse (L.P.N.). You also should include the initial history and physical, treatment plan indicating expected duration and frequency from your attending physician or other health care professional and the nurse's notes from the nurse.
• Claims for rental or purchase of durable medical equipment must include the purchase price, a prescription, and a statement of medical necessity including the diagnosis and estimated length of time needed.
• Claims for dental services must include a copy of the dentist’s itemized bill (including the information required on the previous page) and the dentist’s Federal Tax ID Number. We do not have separate dental claim forms.

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

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

Records

Keep a separate record of the medical expenses of each covered family member as deductibles and maximum allowances apply separately to each person. Save copies of all medical bills, including those you accumulate to satisfy a deductible. In most instances they will serve as evidence of your claim.

We will provide you with a record of expenses you submit and benefits we paid for each claim that you file (explanation of benefits (EOB)). You are responsible for keeping these. We will not provide duplicate or year-end statements. If you need duplicate copies, please refer to Section 5(h), Wellness and other Special Features under Aetna's secure member website (Web based customer service).

Deadline for filing your claim

Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you receive the service. If you could not file on time because of Government administrative operations or legal incapacity, you must submit your claim as soon as reasonably possible. We void uncashed reimbursement checks two years from the date they were issued. Once we pay benefits, there is a three-year limitation on the reissuance of uncashed checks.

Overseas Claims

The Foreign Service Benefit Plan pays claims for providers outside the 50 United States at the same in-network coinsurance rate as in-network providers in the 50 United States, except in Guam which is part of the Plan’s network and subject to in- and out-of-network benefits.

If you are posted outside the 50 United States and both the Medical and Health Program of the Department of State – Bureau of Medical Services (MED) – and we cover you, submit claims to us as described below or as directed by MED, through your Management Office.

If the Medical and Health Program of the Department of State does not cover you, you should submit claims directly to us as described on the previous page.

You do not need to file overseas claims on CMS-1500 or UB-04 forms; however, the information referenced below still is required to receive reimbursement.

When filing a claim for services rendered by an overseas provider, bills and receipts should be itemized and show:

• Patient’s name, date of birth, address, phone number and relationship to enrollee
• Patient’s Plan identification number
• Full name and address of the provider, including city, postal code and country
• Dates that services or supplies were furnished
• Diagnosis/reason for visit
• Type of each service or supply
• Charge for each service or supply

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills. Submissions of only a credit card or cash register receipt will result in a request for additional information. In addition, the Plan cannot accept a claim from you as an e-mail attachment. You may submit claims through our secure Member Portal as described below.

Note: We will provide translation and currency conversion services for claims for overseas (foreign) services.

Note: Members receiving services in countries under sanction by the Office of Foreign Assets Control (OFAC) of the U.S. Department of the Treasury may be requested to provide additional information. For more information see https://www.treasury.gov/resource-center/sanctions/pages/default.aspx.

We use the following methods to process your foreign claims: 

• We will translate your claim, if you do not provide a translation.
• We will use the U.S. dollar exchange rate, benchmarked against the rate reported by Oanda
  (www.oanda.com), applicable on the date the service was incurred, if you do not supply us with a currency exchange rate supported by documentation.
• If you receive services from a provider who is part of our Direct Billing Arrangements, we will use the exchange rate on the date the service was incurred if the provider does not supply us with a currency exchange rate.
• Generally, you do not pay a provider in our Direct Billing Arrangement. We must reimburse the provider directly for any covered expenses. You are responsible, however, for any deductible and coinsurance, which we do not reimburse.
• If you have paid a direct billing provider prior to your claim submission, we request that you provide us with a copy of your paid receipt along with the exchange rate you used to convert the currency.

We have Direct Billing Arrangements with providers in many countries, including China, Colombia, France, Germany, Great Britain, Italy, Japan, Korea, Panama, Russia, Switzerland and Turkey. In addition, overseas Seventh-day Adventist Hospitals and Clinics participate in our Direct Billing Arrangement. Please see our website (www.AFSPA.org/FSBP) for the most up-to-date information.

The Plan provides a secure electronic method for you to submit claims to us via the Internet. Visit our secure Member Portal (www.myafspa.org), enter your username and password. Once inside the portal, select “Submit A Claim” under the "Secure Forms" tab. Follow the screen prompts to upload your PDF claim documents. You have the options to include questions or comments and send your secure claims to a specific customer service representative. Please ensure your name and member ID number appear on the claim. Make sure the image quality of your electronic documents is clear and legible.  Any unclear or illegible supporting documentation may cause your claim to be delayed or denied. In addition, you may correspond with us via secure e-mail through this process.

If you are unable to submit your claim electronically via the secure Member Portal, you may send your claim via mail to Foreign Service Benefit Plan, 1620 L Street, NW, Suite 800, Washington, DC 20036-5629.

Do not send your claims in care of Department of State (Pouch Mail). It will delay your claim substantially.

Plan telephone numbers (M-F 8:30 a.m. - 5:30 p.m. ET): 202-833-4910 (members); 202-833-5751 (health care providers)

When we need more information

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

Notice Requirements

The Secretary of Health and Human Services has identified counties where at least 10 percent of the population is literate only in certain non-English languages. The non-English languages meeting this threshold in certain counties are Spanish, Chinese, Navajo and Tagalog. If you live in one of these counties, we will provide language assistance in the applicable non-English language. You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

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

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

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

b) Send your request to us at: Foreign Service Benefit Plan, 1620 L Street, NW, Suite 800, Washington, DC 20036-5629; and

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

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

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

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

2

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

a) Pay the claim; or

b) Write to you and maintain our denial; or

c) Ask you or your provider for more information.

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

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

3

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

You must write to OPM within:

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

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

Send OPM the following information:

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

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

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

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

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

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

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

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

When you have other health coverage

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

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

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

When we are the secondary payor, we will determine our allowance. You must send us your primary plan’s explanations of benefits (EOBs) if we ask for them. After the primary plan pays, we will pay what is left of our allowance, up to the lesser of:

• Our benefits in full; or
• A reduced amount that, when added to the benefits payable by the primary plan, does not exceed 100% of covered expenses.

We will not pay more than our allowance. The combined payments from both plans might not equal the entire amount billed by the provider.

Please see Section 4, Your costs for covered services, for more information about how we pay claims.

• TRICARE and CHAMPVA

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

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

• Workers’ Compensation

We do not cover services that:

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

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

• Medicaid

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

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

When other Government agencies are responsible for your care

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

When others are responsible for injuries

Our subrogation and reimbursement rights are both a condition of, and a limitation on, the benefit payments that you are eligible to receive from us. By accepting Plan benefits, you agree to the terms of this provision.

If you receive (or are entitled to) a monetary recovery from any source as the result of an injury or illness, you are required to reimburse us out of that recovery for any and all of our benefits paid to diagnose and treat that illness or injury to the full extent of the benefits paid or provided. The Plan’s right of reimbursement extends to all benefit payments for related treatment incurred up to and including the date of settlement or judgement, regardless of the date that those expenses were submitted to the Plan for payment. Additionally, if your representatives (heirs, estate, administrators, legal representatives, successors, or assignees) receive (or are entitled to) a monetary recovery from any source as a result of an injury or illness to you, they are required to reimburse us out of that recovery. This is known as our reimbursement right.

We may also, at our option, pursue recovery as successor to the rights of the enrollee or any covered family member who suffered an illness or injury, which includes the right to file suit and make claims in your name, and to obtain reimbursement directly from the responsible party, liability insurer, first party insurer, or benefit program. This is known as our subrogation right.

Examples of situations to which our reimbursement and subrogation rights apply include, but are not limited to, when you become ill or are injured due to (1) an accident on the premises owned by a third party, (2) a motor vehicle accident, (3) a slip and fall, (4) an accident at work, (5) medical malpractice, or (6) a defective product.

Our reimbursement and subrogation rights extend to all benefits available to you under any law or under any type of insurance or benefit program, including but not limited to:

• When you are entitled to the payment of healthcare expenses under automobile insurance, including no-fault insurance and other insurance that pays without regard to fault, your automobile insurance is the primary payor and we are the secondary payor;
• Third party liability coverage;
• Personal or business umbrella coverage;
• Uninsured and underinsured motorist coverage;
• Workers’ Compensation benefits;
• Medical reimbursement or payment coverage;
• Homeowners or property insurance;
• Payments directly from the responsible party; and
• Funds or accounts established through settlement or judgment to compensate injured parties.

Our reimbursement right applies even if the monetary recovery may not compensate you fully for all of the damages resulting from the injuries or illness. In other words, we are entitled to be reimbursed for those benefit payments even if you are not “made whole” for all of your damages by the compensation you receive.

Our reimbursement right is not subject to reduction for attorney’s fees under the “common fund” or any other doctrine. We are entitled to be reimbursed for 100% of the benefits we paid on account of the injuries or illness unless we agree in writing to accept a lesser amount.

We enforce our reimbursement right by asserting a first priority lien against any and all recoveries you receive by court order or out-of-court settlement, insurance or benefit program claims, or otherwise, regardless of whether medical benefits are specifically designated in the recovery and without regard to how it is characterized (for example as “pain and suffering"), designated, or apportioned. Our subrogation or reimbursement interest shall be paid from the recovery before any of the rights of any other parties are paid. 

You agree to cooperate with our enforcement of our reimbursement right by:

• Telling us promptly whenever you have filed a claim for compensation resulting from an accidental injury or illness and responding to our questionnaires;
• Pursuing recovery of our benefit payments from the third party or available insurance company;
• Accepting our lien for the full amount of our benefit payments;
• Signing our Reimbursement Agreement when requested to do so;
• Agreeing to assign any proceeds or rights to proceeds from third party claims or any insurance to us;
• Keeping us advised of the claim's status;
• Agreeing and authorizing us to communicate directly with any relevant insurance carrier regarding the claim related to your injury or illness;
• Advising us of any recoveries you obtain, whether by insurance claim, settlement or court order; and
• Agreeing that you or your legal representative will hold any funds from settlement or judgment in trust until you have verified our lien amount, and reimbursed us out of any recovery received to the full extent of our reimbursement right.

You further agree to cooperate fully with us in the event we exercise our subrogation right.

Failure to cooperate with these obligations may result in the temporary suspension of your benefits and/or offsetting of future benefits.

For more information about this process, please call our Third Party Recovery Services unit at 202-683-9140 or 855-661-7973 (toll free).  You also can email them at info@elgtprs.com.

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

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

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

If you are a participant in a clinical trial, this health plan will cover related care costs only as follows, if they are not provided by the clinical trial:

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

When you have Medicare

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

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

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

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

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. We do not require precertification, prior approval, or concurrent review when Medicare Part A and/or Part B is the primary payor. Precertification, prior approval, and concurrent review are required, however, when Medicare stops paying benefits for any reason. We do not require prior authorization for the purchase of certain prescription drugs when Medicare Part B or Part D is the primary payor for the drugs or you are outside the 50 United States and purchase them from a retail pharmacy outside the 50 United States. However, when Medicare stops paying benefits for any reason, you must follow our precertification, prior approval, prior authorization, and concurrent review procedures.

We limit our payment to an amount that supplements the benefits that Medicare would pay under Medicare Part A (Hospital insurance) and Medicare Part B (Medical insurance), regardless of whether Medicare pays. Note: We pay our regular benefits for emergency services to an institutional provider, such as a hospital that does not participate with Medicare and is not reimbursed by Medicare.

Claims process when you have the Original Medicare Plan – Send us a copy of your Medicare Card when we are secondary to Medicare. We need this information in order to start electronic crossover of your claims. Electronic crossover is a process that assures, in most cases, you do not have to file a claim when Medicare is primary. Call us at 202-833-4910 or contact us through our secure Member Portal at www.myafspa.org.  Login to the Member Portal with your username and password to find out if your claims are being electronically filed or you have questions about the process described below. You probably will not need to file a claim form when you have both our Plan and the Original Medicare Plan.

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

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, we will coordinate your claim automatically and provide secondary benefits for covered charges. There are exceptions:

• If you have not sent us a copy of your Medicare Card as stated above, you will need to send us your claims and Medicare Summary Notices (MSNs) until you have sent us a copy of your Medicare Card and we have had time to set up electronic crossover.
• If Medicare rejects your claim completely, send us your claim and your MSN. You must send them in order for us to begin processing your claim.
• If Medicare rejects a part of your claim or pays a reduced amount, you may need to send us your claim and MSN. In that case, we will ask you for a copy of them. You must send them to us in order for us to continue processing your claim.

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

• Medical services and supplies provided by physicians and other health care professionals in Section 5(a).
  • If you are enrolled in Medicare Part B, we will waive your calendar year deductible and coinsurance.
• Surgical and anesthesia services provided by physicians and other health care professionals in Section 5(b).
  • If you are enrolled in Medicare Part B, we will waive your coinsurance.
• Services provided by a hospital or other facility, and ambulance services in Section
  5(c).
  • If you are enrolled in Medicare Part A, we will waive your inpatient hospital copayment and coinsurance for inpatient admissions.
  • If you are enrolled in Medicare Part B, we will waive the deductible and coinsurance for outpatient hospital, ambulatory surgical center, and ambulance.
• Services provided by facilities and providers covered under Emergency services/ accidents in Section 5(d).
  • If you are enrolled in Medicare Part B, we will waive the deductible, coinsurance and copay.
• Services provided by mental health and substance use disorder facilities and providers in Section 5(e).
  • If you are enrolled in Medicare Part A, we will waive the inpatient hospital copayment and coinsurance for inpatient admissions.
  • If you are enrolled in Medicare Part B, we will waive the deductible and coinsurance.
• Services provided under Prescription benefits in Section 5(f).
  • If you are enrolled in Medicare Part B and Medicare Part B is primary, the Plan will coordinate benefits and waive the deductible, coinsurance, and/or copayment for prescription drugs covered under Medicare Part B that you purchase only at Network pharmacies.
  • If you are enrolled in Medicare Part B and Medicare Part B is primary, the Plan will coordinate benefits and waive the deductible, coinsurance and/or copayment for colostomy, ostomy, and diabetic supplies covered under Medicare Part B that you purchase from any Medicare Part B provider.
• Services provided under Dental benefits in Section 5(h).
• We do not waive the coinsurance under Dental benefits.

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

Benefit Description: Deductible
High Option You Pay without Medicare: In-Network: $300 self only/$600 family
High Option You Pay without Medicare: Out-of-Network: $400 self only/$800 family
High Option You Pay with Medicare Part B: In Network: $0
High Option You Pay with Medicare Part B: Out-of-Network: $0

Benefit Description: Catastrophic Protection Out-of-Pocket Maximum
High Option You Pay without Medicare: In-Network: $5,000 self only/$7,000 family
High Option You Pay without Medicare: Out-of-Network: $7,000 self only/$9,000 family
High Option You Pay with Medicare Part B: In Network: $5,000 self only/$7,000 family
High Option You Pay with Medicare Part B: Out-of-Network: $7,000 self only/$9,000 family

Benefit Description: Part B Premium Reimbursement Offered
High Option You Pay without Medicare: In-Network: N/A
High Option You Pay without Medicare: Out-of-Network: N/A
High Option You Pay with Medicare Part B: In Network: N/A
High Option You Pay with Medicare Part B: Out-of-Network: N/A

Benefit Description: Primary Care Physician
High Option You Pay without Medicare: In-Network: 10% of the Plan allowance
High Option You Pay without Medicare: Out-of-Network: 30% of the Plan allowance and any difference between our allowance and the billed amount
High Option You Pay with Medicare Part B: In Network: $0
High Option You Pay with Medicare Part B: Out-of-Network: $0

Benefit Description: Specialist
High Option You Pay without Medicare: In-Network: 10% of the Plan allowance
High Option You Pay without Medicare: Out-of-Network: 30% of the Plan allowance and any difference between our allowance and the billed amount
High Option You Pay with Medicare Part B: In Network: $0
High Option You Pay with Medicare Part B: Out-of-Network: $0

Benefit Description: Inpatient Hospital
High Option You Pay without Medicare: In-Network: $0
High Option You Pay without Medicare: Out-of-Network: $200 per admission and 20% of the Plan allowance and any difference between our allowance and the billed amount
High Option You Pay with Medicare Part B: In Network: $0
High Option You Pay with Medicare Part B: Out-of-Network: $200 per admission and 20% of the Plan allowance and any difference between our allowance and the billed amount

Benefit Description: Outpatient Hospital
High Option You Pay without Medicare: In-Network: 10% of the Plan allowance
High Option You Pay without Medicare: Out-of-Network: 30% of the Plan allowance and any difference between our allowance and the billed amount
High Option You Pay with Medicare Part B: In Network: $0
High Option You Pay with Medicare Part B: Out-of-Network: $0

Benefit Description: Incentives Offered
High Option You Pay without Medicare: In-Network: N/A
High Option You Pay without Medicare: Out-of-Network: N/A
High Option You Pay with Medicare Part B: In Network: N/A
High Option You Pay with Medicare Part B: Out-of-Network: N/A

• Tell us about your Medicare coverage

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

• Private contract with your physician

If you are enrolled in Medicare Part B, a physician may ask you to sign a private contract agreeing that you can be billed directly for services ordinarily covered by Original Medicare, that is, the physician may have opted out of the entire Medicare Program. Should you sign an agreement, neither you nor the physician may bill Medicare. Medicare will not pay any portion of the charges and we will not increase our payment. We will limit our payment to the coordinated amount we would have paid after Original Medicare’s payment. You may be responsible for paying the difference between the billed amount and the amount we paid.

If the physician did not inform you of his/her “Opt Out” status or did not ask you to sign a private contract, we will process your initial claim for that physician using our regular in-network/out-of-network benefit coinsurance. We will inform you and your physician in a letter that future claims will be processed per the above paragraph. If you continue receiving services from the physician, you will be responsible for paying the difference between the billed amount and the amount we paid as described above.

• Medicare Advantage
  (Part C)

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private health care choices (like HMOs and regional PPOs) in some areas of the country.

To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048) or at their website, www.medicare.gov.

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

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

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

• Medicare prescription drug coverage (Part D)

If your physician:

Then you are responsible for:

Participates with Medicare or accepts Medicare assignment for the claim and is a member of our network,

your in-network deductibles and coinsurance.

Opts-out of Medicare via private contract

your deductibles, coinsurance, copayments, and any balance your physician charges

When you have the Original Medicare Plan (Part A, Part B, or both)

We limit our payment to an amount that supplements the benefits that Medicare would pay under Medicare Part A (Hospital insurance) and Medicare Part B (Medical insurance), regardless of whether Medicare pays. Note: We pay our regular benefits for emergency services to an institutional provider, such as a hospital, that does not participate with Medicare and is not reimbursed by Medicare.

We use the Department of Veterans Affairs (VA) Medicare-equivalent Remittance Advice (MRA) when the statement is submitted to determine our payment for covered services provided to you if Medicare is primary, when Medicare does not pay the VA facility.

If you are covered by Medicare Part B and it is primary, your out-of-pocket costs for services that both Medicare Part B and we cover depend on whether your physician accepts Medicare assignment for the claim.

If your physician accepts Medicare assignment, you pay nothing for covered charges.

If your physician does not accept Medicare assignment, you pay nothing because we supplement Medicare's payment up to the “limiting charge”.

It is important to know that a physician who does not accept Medicare assignment may not bill you for more than 115% of the amount Medicare bases its payment on, called the “limiting charge.” The Medicare Summary Notice (MSN) that Medicare will send you will have more information about the limiting charge. If your physician tries to collect more than allowed by law, ask the physician to reduce the charges. If the physician does not, report the physician to the Medicare carrier that sent you the MSN form. Call us if you need further assistance.

Please see this section, The Original Medicare Plan (Part A or Part B), for more information about how we coordinate benefits with Medicare.

Cardiac rehabilitation

A comprehensive exercise, education, and behavioral modification program designed to improve the physical and emotional condition of patients with heart disease.  Heart attack survivors, bypass and angioplasty patients, cardiac valvular surgery patients, and individuals with angina, congestive heart failure, and heart transplants are all candidates for a cardiac rehabilitation program. Cardiac rehabilitation is prescribed to control symptoms, improve exercise tolerance, and improve the overall quality of life in these patients.

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

If you are a participant in a clinical trial, this health Plan will cover related care costs as follows, if they are not provided by the clinical trial:

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

Coinsurance

See Section 4, Coinsurance.

Copayment

See Section 4, Copayment.

Cost-Sharing

See Section 4, Cost-sharing.

Treatment or services, regardless of who recommends them or where they are provided, that a person not medically skilled could render safely and reasonably, or that help you mainly with daily living activities. These activities include but are not limited to:

1. Personal care, such as help in: walking; getting in and out of bed; bathing; eating by spoon, tube, or gastrostomy; exercising; dressing;
2. Homemaking, such as preparing meals or special diets;
3. Moving you;
4. Acting as companion or sitter;
5. Supervising medication that you can usually take yourself; or
6. Treatment or services that you may be able to perform with minimal instruction including, but not limited to, recording temperature, pulse, respirations, or administration and monitoring of feeding systems.

We determine which services are custodial care.

Deductible

See Section 4, Deductible.

The date the benefits described in this brochure become effective:

1. January 1 for all continuing enrollments;
2. The first day of the first full pay period of the new year if you change plans or options or elect FEHB coverage during the Open Season for the first time; or
3. The date determined by your employing or retirement system if you enroll during the calendar year, but not during the Open Season.

The cost incurred for a covered service or supply ordered or prescribed by a covered provider. You incur an expense on the date the service or supply is received. Expense does not include any charge:

1. For a service or supply that is not medically necessary; or
2. That is in excess of the Plan’s allowance for the service or supply.

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

A medical treatment or procedure, or a drug, device, or biological product is experimental or investigational if 1) reliable evidence shows that it is the subject of ongoing phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or 2) reliable evidence shows that the consensus of opinion among experts regarding the drug, device, or biological product or medical treatment or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis.

Reliable evidence means only: the published reports and articles in the authoritative medical and scientific literature; the written protocol or protocols used by the treating facility or the  protocol(s) of another facility studying substantially the same drug, device or medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device or medical treatment or procedure.

Genetic counseling

A process of communication between you and trained professionals intended to provide you with information about a genetic disease, or risk of such a disease, and its effect on you and your family.

Health care coverage that you are eligible for because of employment, membership in, or connection with, a particular organization or group that provides payment for any health care services or supplies, or that pays a specific amount for each day or period of hospitalization if the specified amount exceeds $200 per day, including extension of any of these benefits through COBRA.

Intensive day treatment

Outpatient treatment of mental conditions or substance use disorder rendered at and billed by a facility that meets the definition of a hospital. Treatment program must be established which consists of individual or group psychotherapy and/or psychological testing.

Services, drugs, supplies, or equipment provided by a hospital or covered provider of the health care services that we determine:

1. Are appropriate to diagnose or treat your condition, illness, or injury;
2. Are consistent with standards of good medical practice in the United States;
3. Are not primarily for your, a family member’s, or a provider’s personal comfort or convenience;
4. Are not a part of or associated with your scholastic education or vocational training; and
5. In the case of inpatient care, cannot be provided safely on an outpatient basis.

The fact that a covered provider has prescribed, recommended, or approved a service, supply, drug, or equipment does not, in itself, make it medically necessary.

Mental health conditions/substance use disorder

Conditions and diseases listed in the most recent edition of the International Classification of Diseases (ICD) as mental, behavioral, and neurodevelopmental disorders.

Observation Care

Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment, that are provided while a decision is being made regarding whether a patient will require further treatment as a hospital inpatient or whether a patient will be able to be discharged from the hospital. Observation services are commonly ordered for a patient who presents to the emergency room department and who then requires a significant period of treatment or monitoring in order to make a decision regarding their inpatient admission or discharge. Some hospitals will bill for observation room status (hourly) and hospital incidental services. See pages 61 and 62 for more information.

This Plan uses National Standardized Criteria Sets and other nationally recognized clinical guidelines and resources in making determinations to evaluate the appropriateness of observation care services.

Plan allowance

The amount we use to determine our payment and your coinsurance for covered services. Fee-for-service plans determine their allowances in different ways. We determine our allowance as follows:

In-network Providers (includes Guam) – Our Plan allowance is a negotiated amount between the Plan and the provider. We base our coinsurance on this negotiated amount, and the provider has agreed to accept the negotiated amount as full payment for any covered services rendered. This applies to all benefits in Section 5 of this brochure.

Out-of-network Providers (includes Guam) – Our Plan allowance is the lesser of: (1) the provider’s billed charge; or (2) the Plan’s out-of-network fee schedule amount. The Plan’s out-of-network fee schedule amount is equal to the 90^th percentile amount for the charges listed in the Prevailing Healthcare Charges System, or the Medicare Data Resources System administered by Fair Health, Inc., if such a charge does not exist for the service or supply. The out-of-network fee schedule amounts vary by geographic area in which services are furnished. We base our coinsurance on this out-of-network fee schedule amount. This applies to all benefits in Section 5 of this brochure. For urine drug testing services, the out-of-network allowance is the maximum Medicare allowance for such services.

For certain services, exceptions may exist to the use of the out-of-network fee schedule to determine the Plan’s allowance for out-of-network providers, including, but not limited to, the use of Medicare fee schedule amounts. For claims governed by the Omnibus Budget Reconciliation Act (OBRA) of 1990 and 1993, the Plan allowance will be based on Medicare allowable amounts as is required by law. For claims where the Plan is the secondary payer to Medicare (Medicare COB situations), the Plan allowance is the Medicare allowable charge.

Other Participating Providers (includes Guam) – Our Plan allowance is the amount that the provider has negotiated and agreed to accept for the services and/or supplies. Benefits will be paid at out-of-network benefit levels, subject to any applicable deductibles, coinsurance, and copayments. This applies to all benefits in Section 5 of this brochure.

Providers outside the 50 United States  (does not include Guam) – We generally do not reduce claims from providers outside the 50 United States to a Plan allowance, that is, our Plan allowance is the amount billed by the provider or as part of our Direct Billing Arrangements. However, we reserve the right to request information from you or your provider that will enable us to determine medical necessity or an allowance on charges that we deem to be excessive.

For more information, see Section 4, Differences between our allowance and the bill.

Pre-service claims

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

Routine preventive services and immunizations

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

Also visit:

• HHS: www.healthcare.gov/preventive-care-benefits/
• CDC: www.cdc.gov/vaccines/schedules/index.html
• www.healthcare.gov/preventive-care-women/

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

For additional information: healthfinder.gov/myhealthfinder/default.aspx

If our preventive services, counseling and screenings benefits are more generous than the ACA or USPSTF, we pay under the appropriate benefit without cost sharing when delivered by an in-network provider (including Guam) or provider outside the 50 United States.

Routine testing/screening

Urgent care claims

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

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

Urgent care claims usually involve pre-service claims and not post-service claims.  We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine. If you believe your claim qualifies as an urgent care claim, please contact the Plan through our Customer Service Department at the Foreign Service Benefit Plan, 1620 L Street, NW, Suite 800, Washington, DC 20036-5629, by phone at 202-833-4910 (M-F 8:30 a.m. - 5:30 p.m. ET), or e-mail through our secure Member Portal at www.myafspa.org. Login to the Member Portal with your username and password. We also have a fax number: 202 833-4918. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

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

In-network (includes Guam): 10% of our allowance*

Out-of-network (includes Guam): 30% of our allowance and any difference between our allowance and the billed amount*

Providers outside the 50 United States (does not include Guam): 10% of our allowance*

31-35

Surgical and Anesthesia Services provided by physicians:

In-network (includes Guam): 10% of our allowance

Out-of-network (includes Guam): 30% of our allowance and any difference between our allowance and the billed amount

Providers outside the 50 United States (does not include Guam): 10% of our allowance

51-60

Services provided by a hospital: Inpatient

In-network (includes Guam): Nothing

Out-of-network (includes Guam): $200 per hospital admission and 20% of charges and any difference between our allowance and the billed amount

Providers outside the 50 United States (does not include Guam): Nothing

62-63

Services provided by a hospital: Outpatient

Surgical:

In-network (includes Guam): 10% of our allowance*

Out-of-network (includes Guam): 30% of our allowance and any difference between our allowance and the billed amount*

Providers outside the 50 United States (does not include Guam): 10% of our allowance*

Medical:

In-network (includes Guam): 10% of our allowance*

Out-of-network (includes Guam): 30% of our allowance and any difference between our allowance and the billed amount*

Providers outside the 50 United States (does not include Guam): 10% of our allowance*

63

Emergency benefits: Accidental injury: emergency room charges (ER) or urgent care facility charges, ER, urgent care physician's or other health care professional charges and ancillary services performed at the time of the ER visit or initial urgent care facility visit; or office visit and ancillary services performed at the time of the initial office visit

In-network (includes Guam): Nothing

Out-of-network (includes Guam): Only the difference between our allowance and the billed amount

Providers outside the 50 United States (does not include Guam): Nothing

66

Emergency benefits: Medical emergency

In-network (includes Guam): 10% of our allowance*

Out-of-network (includes Guam): 10% of our allowance and any difference between our allowance and the billed amount*

Providers outside the 50 United States (does not include Guam): 10% of our allowance*

66

Emergency benefits: Outpatient care in an urgent care facility because of a medical emergency

In-network (includes Guam): $35 copayment per occurrence

Out-of-network (includes Guam): $35 copayment per occurrence and any difference between our allowance and the billed amount

Providers outside the 50 United States (does not include Guam): $35 copayment per occurrence

67

Mental health and substance use disorder treatment:

In-network (includes Guam): Regular cost-sharing*

Out-of-network (includes Guam): Regular cost-sharing*

Providers outside the 50 United States (does not include Guam): Regular cost-sharing*

68-72

Prescription drugs: Retail pharmacy

(NOTE: After two courtesy fills of non-specialty maintenance medication at network retail, you must use network home delivery or a Smart90^® retail network pharmacy. See next page.)

(NOTE: See Section 5(f) for restrictions on specialty drugs.)

Network pharmacies in the 50 United States: Note – You must show your Plan ID card:

• Tier I (Generic Drug): $10 copay for up to a 30-day supply
• Tier II (Preferred Brand Name Drug): 25% ($30 minimum; $100 maximum) for up to a 30-day supply
• Tier III (Non-Preferred Brand Name Drug): 35% ($60 minimum; $200 maximum) for up to a 30-day supply
• Tier IV (Generic Specialty Drugs): 25% up to a maximum of $150 for up to a 30-day supply
• Tier V (Preferred Brand Name Specialty Drugs): 25% up to a maximum of $200 for up to a 30-day supply
• Tier VI (Non-Preferred Brand Name Specialty Drugs): 35% up to a maximum of $300 for up to a 30-day supply

Out-of-network pharmacies in the 50 United States: 100% and cannot claim reimbursement from the Plan (no coverage)

Retail pharmacies outside of the 50 United States: 10% (claim reimbursement from the Plan)

81

Prescription drugs (cont.): Network home delivery and Smart90 retail network pharmacy

(NOTE: After two courtesy fills of non-specialty maintenance medication at network retail, you must use network home delivery or a Smart90 retail network pharmacy.)

Network home delivery through the Express Scripts Pharmacy^SM or through a Smart90 retail network pharmacy

• Tier I (Generic Drug): $15 for up to a 90-day supply
• Tier II (Preferred Brand Name Drug): $60 for up to a 90-day supply
• Tier III (Non-Preferred Brand Name Drug): 35% ($80 minimum; $500 maximum) for up to a 90-day supply
• Tier IV (Generic Specialty Drugs): 25% up to maximum of $150 for up to a 90-day supply
• Tier V (Preferred Brand Name Specialty Drugs): 25% up to a maximum of $200 for up to a 90-day supply
• Tier VI (Non-Preferred Brand Name Specialty Drugs): 35% up to a maximum of $300 for up to a 90-day supply

82

Dental care: Routine preventive care and surgical procedures

The difference between our scheduled allowances and the actual billed amounts

87

Dental care: Orthodontics

50% of our allowance up to $1,000 per course of treatment, per person and 100% after our maximum payment of $1,000

87

Wellness and other special features:

• Flexible benefits option
• Electronic Funds Transfer (EFT) of claim reimbursements
• Scanned claim submission via secure Internet connection
• Electronic copies of Explanations of Benefits
• 24-hour Nurse Advice Line and Healthwise Knowledgebase
• FSBP 24-Hour Translation Line
• Simple Steps to Living Well Together Program and Wellness Incentives
• Mediterranean Wellness Program
• Health Coaching Program
• Healthy Pregnancy Program
• Digital Coach Programs

• In Touch Care (ITC) Program
• Cancer Support Program
• TherapEase Cuisine
• myStrength™ on-line mental health support program
• AbleTo on-line treatment support
• Pre-Diabetic Alert Program
• Institutes of Excellence for tissue and organ transplants
• Livongo remote diabetes monitoring program
• Livongo remote hypertension monitoring program
• Express Scripts Specialist Pharmacists Program
• Overseas Second Opinion
• Aetna's secure member website, web-based customer service/Aetna Health^SM app
• Express Scripts (ESI) Prescription benefits web based customer service and mobile app
• Aexcel Designated Providers

88-
101

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

In-network only (including Guam): Nothing after $5,000 for Self Only enrollment and $7,000 for Self Plus One or Self and Family enrollment per year (includes prescriptions purchased at a network retail pharmacy and through network home delivery)

In- and out-of-network (including Guam): Nothing after $7,000 for Self Only enrollment and $9,000 for Self Plus One or Self and Family enrollment per year (includes prescriptions purchased at a network retail pharmacy and through network home delivery)

Providers outside the 50 United States: Nothing after $5,000 for Self Only enrollment and $7,000 for Self Plus One or Self and Family enrollment per year (includes prescriptions purchased outside the 50 United States and through network home delivery)

Note: Benefit maximums still apply and some costs do not count toward this protection.

26-27