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

Coverage under this plan qualifies as minimum essential coverage. 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.

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, give you other plans’ brochures and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

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

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

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

Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and one eligible family member. Self and Family coverage is for the enrollee and one or more eligible family members. Family members include your spouse and your 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.

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

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

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member 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 members covered under your Self and Family enrollment are your spouse (including your spouse by a valid common-law marriage from a state that recognizes common-law marriages) and children as described below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described below.

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

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

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

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

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

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

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

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

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

• If you have no FEHB coverage, your employing office will enroll you 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.

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 2025 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 2024 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.

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 Temporary Continuation of Coverage (TCC), or a conversion policy (a non-FEHB individual policy).

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

If you were married to an enrollee and your divorce or annulment is final, you may not remain covered as a family member under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices, https://www.opm.gov/healthcare-insurance/life-events/memy-family/im-separated-or-im-getting-divorced/#url=Health. We may request that you verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal job, or if you are a covered 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. 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  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.

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.

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.

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.

FEHB Carriers must have clauses in their in-network (participating) provider agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount. If an in-network provider bills you for covered services over your normal cost share (deductible, copay, co-insurance) contact your Carrier to enforce the terms of its provider contract.

Covered 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 healthcare services in the normal course of business. Covered services must be provided in the state in which the practitioner is licensed or certified.

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

We list network-contracted covered providers in our network provider directory, which we update periodically, and make available on our website.

This Plan recognizes that transgender, non-binary, and other gender diverse members require health care delivered by healthcare providers experienced in gender affirming health. Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender. This Plan provides Care Coordinators for complex conditions and can be reached at 800-593-2354.

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.
• Walk-in Clinic — A medical facility that accepts patients on a walk-in basis, which provides non-emergency, basic healthcare services and does not require an appointment. Examples include Minute Clinic^® at CVS Pharmacy locations and Walgreens Walk-In Clinics. Walk-in 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.

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.

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.

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.

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.

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 70). 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.

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.

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.

• Advanced Reproductive Technology (ART) services, even if rendered outside the 50 United States
• Ambulance – prior approval required for transportation by fixed-wing aircraft (plane)
• Autologous chondrocyte implantation, Carticel
• Bariatric Surgery
• 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 affirming 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 removal
• Surgery for varicose veins, except stab phlebectomy

• Shoulder arthroplasty

• Specialty drugs

• Spinal procedures, such as:

• Artificial intervertebral disc surgery
• Cervical, lumbar and thoracic laminectomy/laminotomy procedure
• Sacroiliac joint fusions 
• Spinal fusion surgery
• Vertebral corpectomy
• Uvulopalatopharyngoplasty, including laser-assisted procedures
• Ventricular assist devices

Note: Chemotherapy also requires prior approval. See Section 5(a), Medical Services and supplies provided by physicians and other healthcare 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 - Certain 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.

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).

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

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

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

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

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

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

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision or by calling us at 202-833-4910 between 8:30 a.m. and 5:30 p.m. Eastern Time.  You may also call OPM’s FEHB 2 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).

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

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

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

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 hospital stay, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

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

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below. If your claim is in reference to a contraceptive, call 800-841-2734.

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

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

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

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

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

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

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. The $200 does not apply to out-of-network hospital stays for mental health and/or substance use disorders.

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.

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 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 healthcare 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).

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.

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 healthcare 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 healthcare professional will not bill you for the $50 difference between our allowance and the 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 healthcare 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 healthcare 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 healthcare professional and us, the physician or other healthcare professional can bill you for the $50 difference between our allowance and the 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 information 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. Specifically listed, is an example of a service for which the provider charges $150 and our allowance is $100. The example shows the amount you pay if you have met your calendar year deductible.

You should also see Important Notice About Surprise Billing – Know Your Rights this Section that describes your protections against surprise billing under the No Surprises Act.

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 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.

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.

We will make diligent efforts to recover benefit payments we made in error but in good faith. We may reduce subsequent benefit payments to offset overpayments.

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.

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

A surprise bill is an unexpected bill you receive for:

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

Balance billing happens when you receive a bill from the nonparticipating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan.

Your health plan must comply with the NSA protections that hold you harmless from surprise bills. Please note: there are certain circumstances under the law where a provider can give you notice that they are out of network and you can consent to receiving a balance bill. 

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.AFSPA.org/FSBP or contact the health plan at 202-833-4910.

• Healthcare FSA (HCFSA) – Reimburses an FSA participant for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, over-the-counter drugs and medications, vision and dental expenses, and much more) for their tax dependents, and their adult children (through the end of the calendar year in which they turn 26).
• FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans.  This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.

• Professional services of physicians or other healthcare professionals during a hospital or skilled nursing facility stay (except when billed by the hospital or skilled nursing facility), in the physician’s or other healthcare professional's office, at home, or consultations
• Office consultation including second opinion
• Telemedicine consultations
• Psychological tests and pharmacological visits
• Office visits by a dentist in relation to covered oral and maxillofacial surgical procedures
• Non-specialty drugs and medical supplies billed by a physician or other healthcare professional
• Hearing treatment related to non-auditory illness or disease
• Office consultations and non-compound hormone treatment for menopause and perimenopause
  

Note: Telemedicine consultations are covered when your provider uses a Health Insurance Portability and Accountability Act (HIPAA) compliant tool such as Vidyo or Bluejeans for facilitating telehealth consultations.

Note: See Section 5(h), Compassionate Care under Care Management Programs, for information on advance care planning.

Note: See Section 5(f), Prescription drug benefits, for information on specialty drugs administered in your physician’s office or an outpatient setting. The Plan has an exclusive arrangement with Accredo (Home Delivery) for dispensing all specialty drugs used for long term therapy (chronic specialty drugs).

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

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

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

• Outpatient care in an urgent care facility

Note: See this Section, Telehealth Services for information on the Plan's Telehealth benefit you may use in non-medical emergencies.

Note: Services received for routine preventive care are paid under this Section, Preventive care, adult or Preventive care, children.

Note: For services related to an accidental injury or medical emergency, see Section 5(d).

In-network (includes Guam): $35 copayment per occurrence (No deductible)

Out-of-network (includes Guam): $35 copayment per occurrence and any difference between our allowance and the billed amount (No deductible)

• Professional non-emergency services provided in a CVS Minute Clinic, including telemedicine visits

In-network: Nothing (No deductible)

Out-of-network: No benefit

Providers outside the 50 United States (includes Guam): No benefit

• Professional non-emergency services provided in a walk-in clinic (other than in a CVS Minute Clinic), including telemedicine visits  (see Section 3, Covered facilities)

Note: See this Section, Telehealth Services for information on the Plan's Telehealth benefit you may use in non-medical emergencies.

Note: For services related to an accidental injury, see Section 5(d).

Note: Services received for routine preventive care are paid under this Section, Preventive care, adult or Preventive care, children.

In-network (includes Guam): $10 copayment per visit (No deductible)

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

Not covered:

• Procedures, services, drugs, and supplies related to the treatment of impotency, sexual dysfunction, or sexual inadequacy

Telehealth consultations are available to members in the 50 United States with primary care and specialty providers only through our telehealth vendor Teladoc^® such as:

• Doctors of Medicine (MD)
• Doctors of Osteopathic Medicine (DO)
• Nutritionists
• Licensed Clinical Social Workers (LCSW)
• Psychiatrists
• Psychologists
• Dermatologists

Access telehealth services 24/7/365 by web, phone, and the Teladoc^® mobile app to receive treatment within minutes for non-emergency, acute general medical needs such as: flu, cough, colds, seasonal allergies, sinus problems, arthritis, upper respiratory infection, backaches and food poisoning. You also can see a behavioral health provider for depression, anxiety and stress, as well as a nutritionist for dietary conditions or dermatologist for skin conditions

Note: Because of the complexity of medical licensure/prescribing laws among the 50 United States and foreign countries, Teladoc^® cannot offer this service to members outside the 50 United States.

Note: See also Section 5(e), Mental health and substance use disorder benefits for telehealth services for members in the 50 United States through Teladoc^®. See also Section 5(e), Mental health and substance use disorder benefits for behavioral health telehealth services for members outside the 50 United States.

Note: Telehealth is available in all 50 United States.

To sign up:
See www.teladoc.com/Aetna or call 855-Teladoc (1-855-835-2362) for information regarding telehealth consults.

In-network: Nothing (No deductible)

Out-of-Network: No benefit

Providers outside the 50 United States (includes Guam): No benefit

Telehealth consultations for general medicine are available to members outside the 50 United States only through our telehealth vendor, vHealth (Worldwide). Access general medicine telehealth services 24/7/365 by web or phone. Treatment may include preventive care as well as treatment for acute and chronic illnesses. A provider also may give referrals and prescribe medications, when appropriate. In addition, you can use the vHealth mobile app to receive treatment for general medicine.

Note: General medicine telehealth through vHealth is available to members with a foreign address (including APO, FPO, DPO and Pouch Mail addresses). In addition, members with a stateside address may access telehealth through vHealth (Worldwide) while traveling outside the 50 United States.

Preventive Care Coach Program offered through vHealth (Worldwide) is only available to members outside the 50 United States. This program will pair you with a health coach who will assess your overall health, or specific health and wellbeing focus areas, suggest potential and relevant checkups and test pathways for you. Your health coach will be available on an ongoing basis to help you manage your health and wellbeing.

You can request this service by accessing the vHealth App and/or Portal. Select the Preventive Care Coach option within your product menu and follow the next steps.

To sign up:
Download vHealth (Worldwide) in the App Store or Google Play Store or visit https://vhealth-teladochealth.com/en.

Call 857-256-3784 (US) or +44 (0) 20 3499 2851 (UK) for information regarding telehealth consultations.

Note: See also Section 5(e), Mental health and substance use disorder benefits for behavioral health telehealth services for members outside the 50 United States.

In-network: Nothing (No deductible)

Out-of-Network: No benefit

Providers outside the 50 United States (includes Guam): No benefit

Tests, such as:

• Blood tests
• Menopause and perimenopause testing
• Urinalysis

Note: Urinalysis for drug testing/screening purposes is covered only as described in "FEHBP Urine Drug Testing Coverage", available on our website www.AFSPA.org/FSBP  or by calling us at 202-833-4910.

• Non-routine pap tests
• Pathology
• X-rays
• Non-routine mammograms
• CT Scan/PET Scan/SPECT/MRI

Note: Prior approval is required for Radiology imaging procedures, such as, but not limited to, CT Scans, PET Scans, SPECT Scans, and MRIs except in the case of an accident or a medical emergency (see Section 3, How you get care, under Other services).

• Ultrasound
• Electrocardiogram and EEG
• Hearing exam for non-auditory illness or disease
• FDA recommended pharmacogenetic testing to optimize prescription drug therapies used to treat certain conditions, such as:
  • For prevention of major adverse cardiovascular events (Plavix)
  • For prevention of blood clots (Warfarin)

Note: The Plan may add tests as they are recommended by the FDA.

• Medically appropriate genetic counseling and testing

Note: We cover only certain genetic tests determined medically appropriate by the Plan. We encourage you to confirm coverage for the proposed tests prior to incurring services, please e-mail us at FSBPhealth@aetna.com or call us at 800-593-2354.

Note: The Plan offers confidential telephone and web-based genetic counseling services. These services are offered through Informed DNA, a national genetic counseling company staffed with independent board-certified genetic counselors. Informed DNA is not available to members outside of the 50 United States. For more information or to schedule an appointment for genetic counseling, call Informed DNA at 800-975-4819.

Note: For genetic counseling and testing for maternity, please refer to Section 5(a), Maternity care.

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

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

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

Lab Savings Program

You may use this voluntary program for covered outpatient lab tests performed at Quest Diagnostics or LabCorp. Show your FSBP identification card each time you obtain lab work and tell your physician you would like to use Quest Diagnostics or LabCorp. If the physician draws the specimen, they can call Quest Diagnostics at 800-646-7788 or LabCorp at 888-522-2677 for pick up or you can go to an approved collection site and show your FSBP ID card along with the test requisition from your physician and have the specimen drawn there.

Note: To find an approved collection site near you, call Quest Diagnostics at 800-646-7788 or LabCorp at 888-522-2677 or search for Quest Diagnostics or LabCorp using your Zip Code in the Plan's Online Provider Directory at www.fsbphealth.com.

Nothing (No deductible)

Note: This benefit applies to expenses for lab tests performed in the 50 United States only. Related expenses for services by a physician (or lab tests performed by an associated Laboratory not participating in the Lab Savings Program) are subject to the applicable deductibles and coinsurance.

• One routine physical examination per person, per calendar year

Note: This includes a separate gynecological exam once per calendar year.

Note: Obtaining a Biometric Screening through your physician completes one step of the Simple Steps to Living Well Together Incentive Program as described in Section 5(h).

The following preventive services are covered at the time interval recommended at each of the links below unless otherwise stated in this Section.

• Travel immunizations recommended by the CDC

Note: The Plan has no age limitations on Influenza, Pneumococcal, Human Papillomavirus (HPV) and Shingles vaccines.

Note: Immunizations obtained from a participating retail network pharmacy have a $0 copay and are covered under Section 5(f), Prescription drug benefits.

Note: These benefits do not apply to children under age 22 (see Preventive care, children).

Note: See Section 10, Definitions, Routine preventive services/immunizations.

• U.S. Preventive Services Task Force (USPSTF) A and B recommended screenings such as cancer, osteoporosis, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• Colorectal cancer tests starting at age 45, includes:
  • Fecal occult blood test - once per calendar year
  • Sigmoidoscopy - one every five years
  • Colonoscopy, including facility and anesthesia charges related to the colonoscopy exam - one every 10 years
• Prostate cancer screening (PSA) – once per calendar year for members age 40 through 69

Note: Age and frequency limitations do not apply to the cancer screenings listed above if there is a family history or high risk factor that indicates the need for screenings.

• Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:
  • Dietary and nutritional counseling (includes individual and group behavioral counseling) up to 26 visits combined per calendar year
  • Individual counseling on prevention and reducing health risks
  • Family centered programs when medically identified to support obesity prevention and management by an in-network provider
• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines. See Section 5(f) for cost share requirements for anti-obesity medications.
• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity. See Section 5(b) for surgery requirements and cost share.
• Screening and counseling for interpersonal and domestic violence
• Osteoporosis routine screening for members age 50 and older once per calendar year
• Preventive care benefits for women such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of preventive care benefits for women go to the Health and Human Services (HHS) website at https://www.hrsa.gov/womens-guidelines
• Routine mammogram
  
• Adult Immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule. For a complete list of endorsed immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/
  
• To build your personalized list of preventive services go to
  https://health.gov/myhealthfinder

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

In-network (includes Guam): Nothing (No deductible)

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

Providers outside the 50 United States (does not include Guam): Nothing (No deductible)

• One mental wellness screening or assessment per person, per calendar year

Note: For additional mental health support, please see Section 5(e) and 5(h) for benefits available to you.

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a mental wellness screening or assessment that is not included in the preventive recommended listing of services outlined elsewhere in this Section, will be subject to the applicable member copayments, coinsurance, and deductible

In-network (includes Guam): Nothing (No deductible)

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

Providers outside the 50 United States (does not include Guam): Nothing (No deductible)

Not covered:

• Physical exams required for obtaining or continuing employment or insurance

All charges

• Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
• Retinal screening exam performed by an ophthalmologist for infants with low birth weight, less than 1 year of age and with an unstable clinical course
• Screening, testing, diagnosis, and treatment (including hearing aids for hearing loss)
• Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:
  • Dietary and nutritional counseling (includes individual and group behavioral counseling) up to 26 visits combined per calendar year
  • Individual counseling on prevention and reducing health risks
  • Family centered programs when medically identified to support obesity prevention and management by an in-network provider
• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines. See Section 5(f) for cost share requirements for anti-obesity medications.
• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity. See Section 5(b) for surgery requirements and cost share.

Note: A gynecological exam and Pap smear once per calendar year for members under the age of 22, if medically recommended, are covered under this Section, Preventive care, adult.

Note: Dependent children between the ages of 18 and 22 who obtain a Biometric Screening through their physician complete one step of the Simple Steps to Living Well Together Incentive Program, which is described in Section 5(h).

Note: Dependent children 22 and older are covered under this Section, Preventive care, adult.

• You may also find a complete list of U.S. Preventive Services Task Force (USPSTF) A and B recommendations online at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations/
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder
  

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

In-network (includes Guam): Nothing (No deductible)

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

Providers outside the 50 United States (does not include Guam): Nothing (No deductible)

• One mental wellness screening or assessment per person, per calendar year

Note:  For additional mental health support, please see Section 5(e) and 5(h) for benefits available to you.

Note: Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a mental wellness screening or assessment that is not included in the preventive recommended listing of services outlined in this elsewhere in this Section, will be subject to the applicable member copayments, coinsurance, and deductible

In-network (includes Guam): Nothing (No deductible)

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

Providers outside the 50 United States (does not include Guam): Nothing (No deductible)

• Children’s immunizations endorsed by the Centers for Disease Control (CDC) including DTaP/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the website at https://www.cdc.gov/vaccines/schedules/index.html
• Travel immunizations recommended by the CDC

Note: Immunizations obtained from a participating retail network pharmacy have a $0 copay and are covered under Section 5(f), Prescription drug benefits.

In-network (includes Guam): Nothing (No deductible)

Out-of-network (includes Guam): Only the difference between our allowance and the billed amount (No deductible)

Providers outside the 50 United States (does not include Guam): Nothing (No deductible)

Not covered:

• Physical exams required for obtaining or continuing employment or insurance

All charges

Complete maternity (obstetrical) care, such as:

• Prenatal care (including laboratory tests)
• Specialty visits for complications of pregnancy
• Prenatal and Postpartum care
• Delivery
• Screening and counseling for prenatal and postpartum depression
• Anesthesia
• Sonograms
• Amniocentesis
• Gestational diabetes screening
• Medically appropriate genetic counseling and testing

Note: See Section 5(h), Special features for information on the Plan’s Healthy Pregnancy Program.

Note: We cover only certain genetic tests determined medically appropriate by the Plan. We encourage you to confirm coverage for the proposed tests prior to incurring services, please e-mail us at FSBPhealth@aetna.com or call us at 800-593-2354.

Note: The Plan offers confidential telephone and web-based genetic counseling services. These services are offered through Informed DNA, a national genetic counseling company staffed with independent board-certified genetic counselors. Informed DNA is not available to members outside of the 50 United States. For more information or to schedule an appointment for genetic counseling, call Informed DNA at 800-975-4819.

Note: For services related to an accidental injury or medical emergency, see Section 5(d).

In-network (includes Guam): Nothing (No deductible)

Out-of-network (includes Guam): 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

Providers outside the 50 United States (does not include Guam): Nothing (No deductible)

Physical and emotional support provided by a doula to our pregnant member (includes prenatal services, childbirth, and up to three (3) months postpartum care).

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

In-network, out-of-network, and providers outside the 50 United States: Nothing (No deductible) up to the Plan maximum of $1,200 per calendar year and all charges above $1,200 per calendar year

• Breastfeeding and lactation support, supplies and counseling for each birth

Note: Breast pump and supplies are limited to:

• Purchase or rental of breastfeeding equipment to an amount no greater than what we would have paid if the equipment had been purchased. We cover the cost of breastfeeding equipment including hospital grade equipment and the items included in the initial supply kit provided with a new pump order. Supplies do not include coverage for other breastfeeding supplies such as maternity bras, nursing pads or additional bottles. When breastfeeding equipment and supplies are purchased at a participating Express Scripts (ESI) Pharmacy or retail store which houses an ESI participating pharmacy (including its websites), you pay nothing (No deductible).  Purchase the items and submit a claim to us for reimbursement. 

Note: Here are some things to keep in mind:

• You do not need to precertify your vaginal delivery; see Section 3, How you get care for other circumstances when you must precertify, such as extended stays for you or your baby.
• As part of your coverage, you have access to in-network certified nurse midwives, home nurse visits and board-certified lactation specialists during the prenatal and post-partum period. 
• You may remain in the hospital up to 3 days after admission for a vaginal delivery and 5 days after admission for a cesarean delivery. We will cover an extended stay if medically necessary. See Section 3, How you get care for other circumstances.
• Hospital services are covered under Section 5(c) and Surgical benefits under Section 5(b).
• For facility care related to maternity, including care at birthing centers, see Section 5(c), Inpatient hospital or Outpatient hospital or ambulatory surgical center.

In-network (includes Guam): Nothing (No deductible)

Out-of-network (includes Guam): 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

Providers outside the 50 United States (does not include Guam): Nothing (No deductible)

• We consider bassinet or nursery charges during the covered portion of the mother’s maternity stay to be the expenses of the mother and not expenses of the newborn child. We consider expenses of the child after the mother’s discharge to be the expenses of the child. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits. We cover these expenses only if the child is covered by a Self Plus One or Self and Family enrollment. Surgical benefits, not Maternity benefits, apply to circumcision.

Note: Maternity care expenses incurred by a Plan member serving as a surrogate mother are covered by the Plan subject to reimbursement from the other party to the surrogacy contract or agreement.  The involved Plan member must execute our Reimbursement Agreement against any payment she may receive under a surrogacy contract or agreement.  Expenses of the new-born child are not covered under this or any other benefit in a surrogate mother situation.

Note: If your child stays after your discharge and is covered under a Self Plus One or Self and Family enrollment, you must pay a separate hospital copayment of $200 for out-of-network facilities. If your child is not covered under a Self Plus One or Self and Family enrollment, you pay all of your child’s charges after your discharge.

Not covered:

• Procedures, services, drugs, and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest

A range of voluntary family planning services, without cost sharing, that includes at least one form of contraception in each of the categories on the Health Resources and Services Administration (HRSA) list. This list includes: limited to:

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

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

Note: For genetic counseling and testing, please refer to Section 5(a) Lab, X-ray and other diagnostic tests.

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

Over-the-counter and prescription drugs approved by the FDA to prevent unintended pregnancy.

Process: 

• Reviews can be initiated by the member, pharmacist or provider
• Members should call Express Scripts at 800-841-2734
• Providers also can initiate through an electronic prior authorization

Reimbursement for covered over-the-counter contraceptives can be submitted in accordance with Section 7.

If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.

In-network (includes Guam): Nothing (No deductible)

Out-of-network (includes Guam): 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

Providers outside the 50 United States (does not include Guam): Nothing (No deductible)

Not covered:

• Reversal of voluntary surgical sterilization
• Costs of donor sperm and donor egg
• Elective fertility preservation, such as egg freezing due to natural aging
• Storage costs

Infertility services for Artificial Insemination (AI) will be considered medically necessary for any member unable to conceive, regardless of relationship status or sexual orientation. For Advanced Reproductive Technology (ART), the Plan will continue to require prior authorization and will utilize Aetna’s medical necessity criteria to determine coverage. The Plan will cover AI as a core medical benefit, members will no longer need to meet a definition or obtain prior authorization.

The Plan covers two different infertility treatment levels: Basic Infertility and Advanced Reproductive Technology (ART). 

Note: Prior approval is required for ART, even if rendered outside the 50 United States. Call us at 800-593-2354 prior to scheduling. See Section 3, Other services.

Note: For services listed under ART, you must use a provider who participates in our Institutes of Excellence™ (IOE) Infertility Providers or a provider outside the 50 United States to receive benefits. For additional information regarding the IOE Infertility Providers, please call 800-593-2354 or visit www.aetnainfertilitycare.com.

Note: The Plan offers a fertility advocate and digital resources through Maven to support you through your infertility journey.  To speak directly with a fertility advocate call 833-415-1709. See Section 5(h), under Healthy Pregnancy Program for information on family planning.

Note: Fertility drugs are covered under Section 5(f), Prescription drug coverage. Certain injectable infertility drugs require prior approval.

Basic Infertility

• Initial diagnostic tests and procedures done only to identify the cause of infertility;
• Medical or surgical procedures done to create or enhance fertility;
• Artificial insemination (AI) and monitoring of ovulation to include:
  - Intravaginal insemination (IVI)
  - Intracervical insemination (ICI)
  - Intrauterine insemination (IUI)

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

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

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

Advanced Reproductive Technology (ART)

• Ovulation induction cycle(s) while on an injectable medication to stimulate the ovaries
• Services provided in the setting of ovulation induction such as ultrasounds, laboratory studies, and physician services

Note: An ovulation cycle is an attempt at ovulation induction while on injectable medication to stimulate the ovaries with or without artificial insemination

• In vitro fertilization (IVF)
• Embryo transfer and gamete intrafallopian transfer (GIFT) and Zygote intrafallopian transfer (ZIFT)
• Intracytoplasmic sperm injection (ICSI)
• Iatrogenic fertility preservation procedures (retrieval of and freezing of eggs or sperm) caused by chemotherapy, pelvic radiotherapy, ovary or testicle removal and other gonadotoxic therapies for the treatment of disease.

You are eligible for ART if you meet our medical necessity criteria, which includes:

• You or your partner have not gone through voluntary sterilization with or without reversal.
• You have met the requirement for the number of months trying to conceive through egg and sperm contact.
• Your unmedicated day three (3) Follicle Stimulating Hormone (FSH) level and testing of ovarian responsiveness meet the criteria outlined in Aetna’s Clinical Policy Bulletin (CPB) for Infertility (visit https://fsbphealth.com/maternal-health-and-pregnancy/ to access the CPB – Infertility).
• You have failed to conceive after a trial of ovulation induction:

  • For women 37 years of age or younger, three cycles of ovulation induction (with or without intrauterine insemination); or

  • For women 38 years of age or older, no trial of ovulation induction is required 

• Natural or artificial insemination would not be expected to be effective, and ART would be expected to be the only effective treatment.

Institutes of Excellence™ (IOE) Infertility Providers: 10% of the Plan allowance

Out-of-network: No benefit

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

Not covered:

• Reversal of voluntary surgical sterilization
• Costs of donor sperm and donor eggs
• Elective fertility preservation, such as egg freezing due to natural aging
• Storage cost
• Costs for obtaining sperm from a person not covered under this Plan
• Infertility treatment when a successful pregnancy could have been obtained through less costly treatment
• Infertility treatment when infertility is due to a natural physiologic process such as age-related ovarian insufficiency (e.g., perimenopause, menopause) as measured by an unmedicated FSH level at or above 19 on cycle day two (2) or three (3) of your menstrual cycle or other abnormal testing results as outlined in Aetna's Infertility Clinical Policy. 
• Injectable infertility medication including but not limited to menotropins, hCG, and GnRH agonists, expect as described in Section 5(f). Prescription Drug Benefit
• Any ART services not prior approved by the Plan
• Coverage for services received by a spouse or person who is not a covered member under the Plan.

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

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

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

Not covered:

• Provocative food testing, end point titration techniques, sublingual allergy desensitization and hair analysis

• Chemotherapy and radiation therapy (includes radium and radioactive isotopes)

Note: Chemotherapy and radiation oncology require prior approval (see Section 3, Other services).

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed in Section 5(b), Organ/tissue transplants.

Note: See Section 5(h), Special features 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.

• Intravenous (IV)/infusion therapy (supplies) – Home IV and antibiotic therapy (supplies)

Note: See also this Section, Home health services.

• Growth hormone therapy
• Respiratory and inhalation therapies (includes oxygen and equipment for its administration)
• Cardiac rehabilitation therapy

Note: The Plan provides benefits only for Phase 1 and Phase 2 cardiac rehabilitation therapy.

• Renal dialysis (includes other covered charges associated with the dialysis treatment)
• Biofeedback only when treating incontinence, migraine headaches, temporomandibular joint (TMJ) dysfunction, irritable bowel syndrome (IBS) and to assist with pain management

Note: Applied behavior analysis (including the assessment) is covered under Section 5(e), Mental health and substance use disorder benefits, and requires prior approval.  See Section 3, How you get care.

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

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

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

Services and supplies related to Gene-Based Cellular and other Innovative Therapies (GCIT™) include:

• Cellular immunotherapies
• Genetically modified oncolytic viral therapy
• Other types of cells and tissues from and for use of the same person (autologous) and cells and tissues from one person for use by another person (allogenic) for certain therapeutic conditions other than transplants
• Human gene therapy that seeks to change the function of a gene or alter the biologic properties of living cells for therapeutic use. Examples include therapies using:
  
  
  - Luxturna® (Voretigene neparvovec), Zolgensma® (Onasemnogene abeparvovec-xioi), Spinraza® (Nusinersen)
• Products derived from gene editing technologies, including CRISPR-Cas9
• Oligonucleotide-based therapies, Examples include:- Antisense (Spinraza) siRNA
  

To receive the in-network level of benefits, you must use a provider who participates in our GCIT™ Designated Network.

Note: Prior approval is required. Call us at 800-593-2354 prior to scheduling. See Section 3, Other services.

Note: See Section 5(c), Outpatient hospital or ambulatory surgical center for services provided by a hospital.

Note: The Plan has special arrangements with facilities to provide services and supplies related to GCIT™ (see Section 5(h), Wellness and Other Special Features, GCIT™ Designated Network). The GCIT™ Designated Network was designed to provide access to high quality medical care for patients who have been diagnosed with certain genetic conditions. We also may assist you and one family member or caregiver with travel and lodging arrangements if you use a provider in our GCIT™ Designated Network. Your healthcare professional can coordinate arrangements by calling a case manager in the Plan’s Medical Management Department at 800-593-2354. For additional information regarding the GCIT™ Designated Network, please call this number.

GCIT™ Designated Network: 10% of the Plan allowance

Out-of-network: All charges

Providers outside the 50 United States (includes Guam): 10% of the Plan allowance

125 total combined outpatient physical, occupational, and speech therapy visits per calendar year for all three listed therapies

Note: See Section 5(e), Mental health and substance use disorder benefits for physical, occupational and speech therapy for the diagnoses of autism and developmental delays.

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

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

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

Not covered:

• Custodial care (see Section 10, Definitions)
• Exercise programs
  

• Routine hearing exam and testing for hearing loss

Note: For benefits for the devices, see this Section, Orthopedic and prosthetic devices.

Note: For child screening, testing, diagnosis, and treatment (including hearing aids for hearing loss), see this Section, Preventive care, children.

Note: For hearing treatment related to non-auditory illness or disease see this Section, Diagnostic and treatment services.

In-network (includes Guam): Nothing (No deductible)

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

Providers outside the 50 United States (does not include Guam): Nothing (No deductible)

Not covered:

• Hearing services that are not shown as covered

One pair of eyeglasses or contact lenses (including fitting) and refractions per incident if required to correct an impairment directly caused by:

• Accidental ocular injury or intraocular surgery
• Keratoconus
• Glaucoma

Note: For benefits for intraocular lenses, see this Section, Orthopedic and prosthetic devices.

Note: Routine eye examinations are not covered, except when needed for covered eyeglasses or contact lenses above.

Note: Diabetic retinal eye exams are covered in this Section, Lab, X-ray and other diagnostic tests.

Note: Expenses related to any of the conditions noted above must be incurred within one year of the date of accident, surgery or diagnosis.

Note: See Non-FEHB Section for information about the vision discount plan (for exams, glasses and contact lenses) and QualSight Lasik (for LASIK surgery) offered by the American Foreign Service Protective Association.

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

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

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

Not covered:

• Routine eye examinations, except when needed for covered eyeglasses or contact lenses as noted above
• Deluxe lens features for eyeglasses or contact lenses such as special coating, polarization, UV treatment, etc.
• Eyeglasses or contact lenses, except as noted above 
• Eye exercises and visual training (orthoptics)
• Refractions, except as noted above
• All refractive surgeries, except as noted above

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

Note: For foot orthotic devices, see this Section, Orthopedic and prosthetic devices

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

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

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

Not covered:

• Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above

• Artificial limbs and eyes
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Internal prosthetic devices, such as artificial joints, pacemakers, implanted hearing-related devices (such as bone anchored hearing aids (BAHA) and cochlear implants) and surgically implanted breast implants following mastectomy
• Intraocular lenses (IOL) including multifocal, accommodating, or toricpremium IOLs such as Crystalens, ReStor, and ReZoom
• Foot orthotic devices prescribed by a physician or other healthcare professional and custom fitted for the feet, including necessary repair and adjustment

Note: Foot orthotic devices for the feet include, but are not limited to: 

• Impression casting; and
• Corrective shoes for treatment of malformation and weakness of the foot

Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b), Surgical and anesthesia services. For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c), Services provided by a hospital or other facility, and ambulance services.

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

Note: See Section 5(b), Surgical and anesthesia services for coverage of the surgery to insert the device and Section 5(c), Services provided by a hospital or other facility, and ambulance services, if billed by the facility.

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

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

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

• Wigs needed as a result of chemotherapy or radiation treatment for cancer

• Adult hearing aid devices or replacement per person every 3 consecutive calendar years

Note: Hearing aid replacements may be purchased at any time during the third calendar year from the last date of purchase.

Note: Repairs for hearing aids are not covered.

Note: Child hearing aid exams and child hearing aids are covered under this Section, Preventive care, children.

Note: Implanted hearing related devices such as bone anchored hearing aids (BAHA) and cochlear implants are covered as stated above along with internal prosthetic devices.

In-network, out-of-network, and providers outside the 50 United States: Nothing (No deductible) up to the Plan maximum of $4,000 per person or replacement per person every 3 consecutive calendar years and all charges after the Plan maximum

Not covered:

• Orthopedic and corrective shoes, arch supports, heel pads, and heel cups, except as listed above
• Lumbosacral supports
• Corsets
  

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

• Are prescribed by your attending physician (i.e., the physician or other medical professional who is treating your illness or injury);
• Are medically necessary;
• Are primarily and customarily used only for a medical purpose;
• Are generally useful only to a person with an illness or injury;
• Are designed for prolonged use; and
• Serve a specific therapeutic purpose in the treatment of an illness or injury.

We cover rental, up to the purchase price, or purchase (at our option), including necessary repair and adjustment, of durable medical equipment such as:

• Wheelchairs
• Hospital beds
• Oxygen and equipment for its administration
• Dialysis equipment
• Crutches
• Braces
• Casts, splints, and trusses
• Walkers
• CPAP machines and supplies
• Elastic stockings and support hose that require a physician’s or other healthcare professional’s written prescription

Note: We will cover only the cost of medically necessary standard equipment.  Coverage for specialty items (such as all-terrain wheelchairs, sports prosthetics, etc.) is limited to the cost of the standard equipment.

Note: We will cover charges for service contracts for medically necessary durable medical equipment that you purchase or rent.

Seat lift mechanisms for lift chairs based on the following criteria:

• The patient must have severe arthritis of the hip or knee or a severe neuromuscular disease;
• The seat lift mechanism must be a part of the physician’s or other healthcare professional's course of treatment and be prescribed to affect movement, or arrest or retard deterioration in the patient’s condition;
• The patient must be completely incapable of standing up from a regular armchair or any chair in their home;
• Once standing, the patient must have the ability to walk; and 
• Coverage is limited to seat lift mechanism even if incorporated into a chair.

 Medical supplies:

• Medical foods and nutritional supplements only when administered by catheter or nasogastric tubes
• Nutritional formulas for the treatment of Inborn Errors of Metabolism, when administered under the direction of a physician

Note: For colostomy, ostomy, insulin, and diabetic supplies, see Section
5(f), Covered medications and supplies.

Note: See Section 5(h), Special features, for information about Livongo, the Plan’s remote diabetes monitoring program.

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

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

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

Augmentative and alternative communications (AAC) devices such as:

• Computer story boards
• Light talkers
• Enhanced vision systems
• Speech aid prostheses for pediatrics
• Speech aid prostheses for adults
• Magnifier Viewing System
• Script Talk reader devices

Note: For surgical insertion of speech aid prostheses, see Section 5(b), Surgical procedures.

Not covered:

• Other items that do not meet the definition of durable medical equipment such as sun or heat lamps, whirlpool baths, heating pads, cold therapy units, air purifiers, humidifiers, air conditioners, and exercise devices
• Desktop and laptop computers, pagers, personal digital assistants (PDAs), smart phones, and tablet devices (e.g., iPads), or other devices that are not dedicated speech generating devices
• Oral nutritional supplements that do not require a prescription under Federal law even if your physician or other healthcare professional prescribes them or if a prescription is required under your state law, or are not administered by catheter or nasogastric tubes except for nutritional formulas for the treatment of Inborn Errors of Metabolism when administered under the direction of a physician
• Grocery items routinely available at food stores
• Van lifts, stair lifts, wheelchair lifts or ramps
• Vehicle modifications, replacements, or upgrades
• Home modifications, upgrades, or additions

Limited to 90 visits per calendar year when the attending physician or other healthcare professional:

• Orders the care;
• Identifies the specific professional skills required by the patient and the medical necessity for skilled services; and
• Indicates the length of time the services are needed. 

Note: Services of a licensed social worker (LCSW) are included in the 90 visit calendar year maximum.

Note: A home health aide must provide medically necessary skilled services under the supervision of a Registered Nurse (R.N.) consisting of mainly medical care and therapy provided solely for the care of the insured person.

A home health agency (or visiting nurses where services of a home health agency are not available) must furnish the care in accord with a home health care plan. The home health care plan must be certified by your physician or other healthcare professional and furnished in your home.

Note: We define home health agency as a public or private agency or organization appropriately licensed, qualified and operated under the law of the state in which it is located.

Note: We define home health care plan as a written plan, approved in writing by a physician or other healthcare professional, for continued care and treatment of a Plan member:

• Who is under the care of a physician or other healthcare professional; and
• Who would need a continued stay in a Hospital or Skilled Nursing Facility without the home health care.

We cover private duty nursing when:

• Care is ordered by the attending physician or other healthcare professional; and
• Your physician or other healthcare professional identifies the specific professional nursing skills that you require, as well as the length of time needed.

Note: Private duty nursing requires prior approval. See Section 3, Other Services, for additional details on prior approval.

Note: Private duty nursing visits are included in the 90 home health services visit maximum.

Note: Physical, occupational and/or speech therapy services performed in an outpatient setting and/or at home will count toward the 125-therapy visit limitation per calendar year, as listed in Physical, occupational and speech therapy, except for the diagnoses of autism and developmental delays. See Section 5(e), Mental health and substance use disorder benefits for physical, occupational and speech therapy for the diagnosis of autism and developmental delays.

In-network (includes Guam): 10% of Plan allowance and any visits above 90 visits per calendar year (No deductible); and all charges above one visit per day

Out-of-network (includes Guam): 30% of Plan allowance and any difference between our allowance and the billed amount and any visits above 90 visits per calendar year (No deductible); and all charges above one visit per day

Providers outside the 50 United States: 10% of Plan allowance and any visits above 90 visits per calendar year (No deductible); and all charges above one visit per day.

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient’s family
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative
• Services rendered by a Home Health Aide are covered only as stated on the previous page
• Custodial care (see Section 10, Definitions)

Covered services are limited to 50 visits per person, per calendar year:

• Manipulation of the spine and extremities

Note: Chiropractic is a system of therapy that attributes disease to abnormal function of the nervous system and attempts to restore normal function by manipulation of the spinal column and other body structures.

Note: Consultations and diagnostic services are covered under Section
5(a), Diagnostic and treatment services and also Lab, X-ray and other diagnostic tests; and do not count toward the visit limit.

In-network (includes Guam): Nothing (No deductible) up to the Plan maximum of $75 per visit and then all charges up to the Plan allowance; and all charges above 50 visits per person, per calendar year

Out-of-network (includes Guam) and providers outside the 50 United States: Nothing (No deductible) up to the Plan maximum of $75 per visit; and all charges above $75 per visit and/or 50 visits per person, per calendar year

Acupuncture limited to 50 visits per person, per calendar year

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

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

In-network (includes Guam): Nothing (No deductible) up to the Plan maximum of $75 per visit and then all charges up to the Plan allowance; and all charges above 50 visits per person, per calendar year

Out-of-network (includes Guam) and providers outside the 50 United States: Nothing (No deductible) up to the Plan maximum of $75 per visit; and all charges above $75 per visit and/or 50 visits per person, per calendar year

Massage therapy only when performed by a covered provider (see Section 3) limited to 50 visits per person, per calendar year

Note: You are required to submit a claim as outlined in Section 7, Filing a claim for covered services. Your claim must include the provider’s first and last name and address, the provider’s Massage Therapy License Number (if a United States provider and applicable per state law), an itemized bill that includes the description of services provided, cost of each service and proof of payment for services.

Note: See also Section 7, Filing a claim for covered services under Overseas Claims when filing a claim for a provider outside the 50 United States.

In-network (includes Guam): Nothing (No deductible) up to the Plan maximum of $75 per visit and then all charges up to the Plan allowance; and all charges above 50 visits per person, per calendar year

Out-of-network (includes Guam) and providers outside the 50 United States: Nothing (No deductible) up to the Plan maximum of $75 per visit; and all charges above $75 per visit and/or 50 visits per person, per calendar year

Not covered:

• Chelation therapy except for acute arsenic, gold, mercury or lead poisoning; or use of Desferoxamine in iron poisoning
• Therapies such as, Flotation Therapy, Craniosacral Therapy, Salt Therapy, and Stretch
• Therapy Naturopathic services and medications
• Homeopathic services and medications
• Rolfing
• Kinesiology
• Moxibustion
• Reiki
• Rapid Tension Relief
• Taping
• Body Scrub
• Other services except as listed on previous page

All charges

Simple Steps to Living Well Together Program

(See Section 5(h), Special features, for information on this Program.)

• Tobacco Cessation Program
  • Two quit attempts per calendar year as part of the Plan’s Tobacco Cessation Program. The quit attempts include proactive phone counseling and up to four tobacco and nicotine counseling sessions of at least 30 minutes each in each quit attempt.
    • Over-the-counter (OTC) medications approved by the FDA to treat nicotine dependence can be obtained through the Tobacco Cessation Program at no charge (see Section 5(f), Prescription drug benefits for more details). 

Note: To enroll in the program, contact a Lifestyle and Condition Health Coach at 866-533-1410. Coaches are available Monday–Friday: 8:00 a.m. – 8:00 p.m. ET. You may also enroll online at www.myactivehealth.com/FSBP.

• Lifestyle and Condition Coaching (LCC)

• The LCC Program uses a holistic approach to help you and your covered dependents achieve your best health. Our LCC Health Coaches provide guidance, support, and resources for over 40 lifestyle and medical conditions 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.
• Lifestyle Coaching such as:
• General health education
• Prehypertension
• Metabolic syndrome
• Prediabetes
• Weight management
• Physical activity
• Nutrition management
• Stress management
• Sleep management
• Pain management
• Menopause and perimenopause
• Tobacco cessation
• Condition Coaching such as:
  • Vascular (coronary artery disease, heart failure, high cholesterol, adult and pediatric diabetes and high blood pressure)
  • Gastrointestinal (ulcerative colitis/Inflammatory Bowel Disease (IBS)/Crohn’s, chronic hepatitis B and C
  • Pulmonary (adult and pediatric asthma, chronic obstructive pulmonary disease (COPD))
  • Orthopedic/Rheumatologic (chronic neck and back pain, rheumatoid arthritis, osteoarthritis, systemic lupus erythematosus)
  • Neurological (migraines, seizures)
  • Other (adult and pediatric weight management, chronic kidney disease stages 1-4, end state renal disease, depression

See the Plan’s benefit, Lifestyle and Condition Coaching (LCC) Program, in Section 5(h), Special features.

In-network, out-of-network, and providers outside the 50 United States: Nothing (No deductible)

Simple Steps to Living Well Together Program

(See Section 5(h), Special features, for information on this Program.)

• Diabetic education or training

In-network (includes Guam) and providers outside the 50 United States (does not include Guam): 10% of the Plan allowance (No deductible)

Out-of-network (includes Guam): 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

myStrength™ – 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.

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Gender affirming surgery as follows:
• breast removal
• breast augmentation (implants/lipofilling)
• gonadectomy (hysterectomy and oophorectomy or orchiectomy)
• genital reconstructive surgery (i.e., vaginectomy, urethroplasty, metoidioplasty, phalloplasty, scrotoplasty, placement of a testicular prosthesis and erectile prosthesis, penectomy, vaginoplasty, labiaplasty, and clitoroplasty)
• pectoral muscle implants
• hair removal including genital electrolysis, non-genital area electrolysis or laser hair removal (e.g., face, chest)
• liposuction/lipofilling specific to gender affirmation
• facial contouring such as genioplasty, jaw and/or chin reshaping, lip shortening, scalp (hairline) advancements, hair grafts
• voice modification, including voice feminization and masculinization surgery

Note: Prior approval is required for gender affirming surgery, call us at 800-593-2354 or see Section 3,  How you get care, under Other services for additional information.

Note: Hormone therapy is covered under Section 5(f), Prescription drug benefits. Prior authorization may be required.

• Surgical treatment of severe obesity (bariatric surgery, such as gastric bypass, gastric sleeve, stomach stapling, or lap band procedure) – a condition in which an individual has: 1)  heart disease,  nonalcoholic steatohepatitis (NASH) or hyperlipidemia; and 2) been under at least one medically supervised weight loss program for 12 or more sessions and occurred within 2 years prior to surgery.  The program should be multi-disciplinary by combining diet and nutritional counseling with an exercise program and a behavior modification program.

Note: Prior approval is required. Call us at 800-593-2354 for more information. See Section 3, Other services.

• Insertion of internal prosthetic devices. See Section 5(a), Orthopedic and prosthetic devices for device coverage information
• Treatment of burns

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

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

Note: Second opinion is covered under Section 5(a), Diagnostic and treatment services and in Section 5(h), Special features, Overseas Second Opinion.

In-network (includes Guam): 10% of the Plan allowance (No deductible)

Out-of-network (includes Guam): 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

Providers outside the 50 United States (does not include Guam): 10% of the Plan allowance (No deductible)

• Routine circumcision of a newborn child (only when the child is covered under a Self Plus One or Self and Family enrollment)

Note: Includes related services including anesthesia.

In-network (includes Guam): Nothing (No deductible)

Out-of-network (includes Guam): 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

Providers outside the 50 United States (does not include Guam): Nothing (No deductible)

When multiple or bilateral surgical procedures are performed during the same operative session by the same surgeon, the Plan's benefit is determined as follows:

• For the primary procedure, the Plan's allowance
• For the secondary procedures
  • 50% of the Plan's allowance (unless the provider is an in-network or other participating provider in the United States and their contract provides for a different amount)
• For tertiary and subsequent procedures:
  • 25% of the Plan’s allowance (unless the provider is an in-network or other participating provider in the United States and their contract provides for a different amount)

Note: This does not apply to providers outside the 50 United States.

Note: For certain surgical procedures, we may apply a value of less than 50% for subsequent procedures.

Note: Multiple or bilateral surgical procedures performed through the same incision are “incidental” to the primary surgery. That is, the procedure would not add time or complexity to patient care. We do not pay extra for incidental procedures.

In-network (includes Guam): 10% of the Plan allowance for the individual procedure (No deductible)

Out-of-network (includes Guam): 30% of the Plan allowance for the individual procedure and any difference between our allowance and the billed amount (No deductible)

Providers outside the 50 United States (does not include Guam): 10% of the Plan allowance for the individual procedure (No deductible)

• Assistant Surgeon

Assistant surgical services provided by a surgeon when medically necessary to assist the primary surgeon. When a surgery requires an assistant surgeon, the Plan’s allowance for the assistant surgeon is 16% of the allowance for the surgery and 12% of our allowance for the surgery when provided by a registered nurse first assistant or certified surgical assistant (unless the provider is an in-network or other participating provider in the United States and their contract provides for a different amount).

Note: This does not apply to providers outside the 50 United States.

In-network (includes Guam): 20% of the Plan allowance (No deductible)

Out-of-network (includes Guam): 20% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

Providers outside the 50 United States (does not include Guam): 20% of the Plan allowance (No deductible)

• Co-surgeons (inpatient/outpatient)

Note: When the surgery requires two surgeons with different skills to perform the surgery, the Plan’s allowance for each surgeon is 62.5% of what it would allow for a single surgeon for the same procedure(s) (unless the provider is an in-network or other participating provider in the United States and their contract provides for a different amount).

Note: This does not apply to providers outside the 50 United States.

In-network (includes Guam): 10% of the Plan allowance (No deductible)

Out-of-network (includes Guam): 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

Providers outside the 50 United States (does not include Guam): 10% of the Plan allowance (No deductible)

Not covered:

• Cosmetic surgery except for the repair of accidental injuries; to correct a congenital anomaly; or for the reconstruction of a breast following a mastectomy

Note: We define cosmetic surgery as any operative procedure or any portion of a procedure performed primarily to improve physical appearance and/or treat a mental condition through change in bodily form except for coverage for gender affirming surgery as noted elsewhere in this Section.

• All refractive surgeries, except as noted in Section 5(a) Vision services
• Routine surgical treatment of conditions of the foot (see Section 5(a), Foot care)
• Services of a standby surgeon
• Reversal of voluntary sterilization
• Surgeries related to impotency, sexual dysfunction or sexual inadequacy
• Gender affirming surgery, other than the surgeries listed as covered
• Reversal of gender affirming surgery

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • The condition produced a major effect on the member’s appearance; and
  • The condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm (congenital anomaly). Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers and toes; and other conditions that we may determine to be congenital anomalies.  We will not consider the term congenital anomaly to include conditions relating to teeth or intra-oral structures supporting the teeth.
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • Surgery to produce a symmetrical appearance of breasts;
  • Treatment of any physical complications, such as lymphedemas;
  • Breast prostheses; and surgical bras and replacements (see Section 5(a), Orthopedic and prosthetic devices for coverage)

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

In-network (includes Guam): 10% of the Plan allowance (No deductible)

Out-of-network (includes Guam): 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

Providers outside the 50 United States (does not include Guam): 10% of the Plan allowance (No deductible)

• Gender affirming surgery as follows:
  • breast removal
  • breast augmentation (implants/lipofilling)
  • gonadectomy (hysterectomy and oophorectomy or orchiectomy)
  • genital reconstructive surgery (i.e., vaginectomy, urethroplasty, metoidioplasty, phalloplasty, scrotoplasty, placement of a testicular prosthesis and erectile prosthesis, penectomy, vaginoplasty, labiaplasty, and clitoroplasty)
  • pectoral muscle implants
  • hair removal including genital electrolysis, non-genital area electrolysis or laser hair removal (e.g., face, chest)
  • liposuction/lipofilling specific to gender affirmation

  • facial contouring such as genioplasty, jaw and/or chin reshaping, lip shortening, scalp (hairline) advancement, hair grafts

  • voice modification, including voice feminization and masculinization surgery

Note: Prior approval is required for gender affirming surgery, call us at 800-593-2354 or see Section 3,  How you get care, under Other services for additional information.

Note: Hormone therapy is covered under Section 5(f), Prescription drug benefits. Prior authorization may be required.

In-network (includes Guam): 10% of the Plan allowance (No deductible)

Out-of-network (includes Guam): 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

Providers outside the 50 United States (does not include Guam): 10% of the Plan allowance (No deductible)

Not covered:

• Cosmetic surgery except for repair of accidental injuries; to correct a congenital anomaly; or for reconstruction of a breast following mastectomy

Note: We define cosmetic surgery as any operative procedure or any portion of a procedure performed primarily to improve physical appearance and/or treat a mental condition through change in bodily form except for coverage for gender affirming surgery as noted in Surgical procedures.

• Surgeries related to impotency, sexual dysfunction or sexual inadequacy

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones
• Surgical correction of severe functional malocclusion only when we determine the correction of the malocclusion to be medically necessary
• Removal of stones from salivary ducts
• Excision of leukoplakia or malignancies
• Excision of non-dentigerous cysts and incision of non-dentigerous abscesses
• Surgical correction of temporomandibular joint (TMJ) dysfunction to include initial consultation and post operative medical exam
• Surgical removal of impacted teeth, including anesthesia charges
• Other surgical procedures not involving the teeth or their supporting structures

In-network (includes Guam): 10% of the Plan allowance (No deductible)

Out-of-network (includes Guam): 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

Providers outside the 50 United States (does not include Guam): 10% of the Plan allowance (No deductible)

Not covered:

• Oral implants, transplants and related services except those required to treat accidental injuries as described under Section 5(g), Dental benefits
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingival and alveolar bone) except as provided under Section 5(g), Dental benefits
• Excision of non-impacted teeth

Solid organ transplants are subject to medical necessity and experimental/investigational review. Refer to Section 3, Other services for prior approval procedures. The medical necessity limitation is considered satisfied for other tissue transplants if the patient meets the staging description. Solid organ transplants are limited to:

• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
• Cornea
• Heart
• Heart/lung
• Intestinal transplants
  • Isolated small intestine
  • Small intestine with the liver
  • Small intestine with multiple organs, such as the liver, stomach, and pancreas
• Kidney
• Kidney-Pancreas
• Liver
• Lung single/bilateral/lobar
• Pancreas

Plan-designated transplant network facility for tissue and organ transplant (see Section 5(h) Special features, Institutes of Excellence): 10% of the Plan allowance (No deductible)

In-network (includes Guam): 20% of the Plan allowance (No deductible) 

Out-of-network (includes Guam): 100% of all charges (No catastrophic coverage)

Providers outside the 50 United States (does not include Guam): 10% of the Plan allowance (No deductible)

The tandem blood or marrow stem cell transplants for covered transplants below are subject to medical necessity review by the Plan. Refer to Section 3, Other services for prior approval procedures.

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

Plan-designated transplant network facility for tissue and organ transplant (see Section 5(h) Special features, Institutes of Excellence): 10% of the Plan allowance (No deductible)

In-network (includes Guam): 20% of the Plan allowance (No deductible) 

Providers outside the 50 United States (does not include Guam): 10% of the Plan allowance (No deductible)

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below.

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced myeloproliferative disorders (MPDs)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Infantile malignant osteopetrosis
  • Kostmann’s syndrome
  • Leukocyte adhesion deficiencies
  • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria (PNH), Pure Red Cell Aplasia)
  • Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy
  • Mucopolysaccaridosis (e.g., Hunter’s syndrome, Hurler’s syndrome, Sanfillippo’s syndrome, Maroteaux-Lamy syndrome variants)
  • Myelodysplasia/myelodysplastic syndromes
  • Myeloproliferative disorders
  • Paroxysmal nocturnal hemoglobinuria
  • Phagocytic/hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell anemia
  • X-linked lymphoproliferative syndrome
• Autologous transplants for: 
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis 
  • Ependymoblastoma
  • Ewing’s sarcoma
  • Medulloblastoma
  • Multiple myeloma
  • Neuroblastoma
  • Pineoblastoma
  • Testicular, mediastinal, retroperitoneal, and ovarian germ cell tumors
  • Waldenstrom’s macroglobulinemia

Plan-designated transplant network facility for tissue and organ transplant (see Section 5(h) Special features, Institutes of Excellence): 10% of the Plan allowance (No deductible)

In-network (includes Guam): 20% of the Plan allowance (No deductible) 

Out-of-network (includes Guam): 100% of all charges (No catastrophic coverage)

Providers outside the 50 United States (does not include Guam): 10% of the Plan allowance (No deductible)

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of Health approved clinical trial or a Plan-designated center of excellence if approved by the Plan’s medical director in accordance with the Plan’s protocols.

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient’s condition) if it is not provided by the clinical trial. Section 9 has additional information on costs related to clinical trials. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

• Allogenic transplants for:
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Beta thalassemia major
  • Chronic inflammatory demyelination polyneuropathy (CIDP)
  • Early state (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Sickle cell anemia
• Non-myeloablative allogeneic, reduced intensity conditioning (or RIC) for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Breast cancer
  • Chronic lymphocytic leukemia
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) relapsed/refractory disease
  • Chronic myelogenous leukemia
  • Colon cancer
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Myelodysplasia/Myelodysplastic Syndromes
  • Myeloproliferative disorders (MPDs)
  • Non-small cell lung cancer
  • Ovarian cancer
  • Prostate cancer
  • Renal cell carcinoma
  • Sarcomas
  • Sickle cell disease
• Autologous transplants for:
  • Advanced childhood kidney cancers
  • Advanced Ewing sarcoma
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Aggressive non-Hodgkin lymphomas
  • Breast cancer
  • Childhood rhabdomyosarcoma
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Early state (indolent or non-advanced) small cell lymphocytic lymphoma
  • Epithelial ovarian cancer
  • Mantle cell (Non-Hodgkin lymphoma)
  • Small cell lung cancer
• Autologous transplants for the following autoimmune diseases:
  • Multiple sclerosis
  • Systemic lupus erythematosus
  • Systemic sclerosis
  • Scleroderma
  • Scleroderma-SSC (severe, progressive)

Note: We cover related medical and hospital expenses of the donor when we cover the recipient. You are a recipient when you surgically receive a body organ(s) transplant. You are a donor when you surgically donate a body organ(s) for transplant surgery. Transplant surgery means transfer of a body organ(s) from the donor to the recipient.

Note: We cover donor screening tests for up to four potential transplant donors per year from individuals unrelated to the patient, in addition to testing of family members.

Note: The Plan has special arrangements with facilities to provide services for tissue and organ transplants only (see Section 5(h), Special features, Institutes of Excellence). The transplant network was designed to give you an opportunity to access providers that demonstrate high quality medical care for transplant patients. We also may assist you and one family member or caregiver with travel and lodging arrangements if you use one of our Institutes of Excellence. Your healthcare professional can coordinate arrangements by calling a case manager in the Plan’s Medical Management Department at 800-593-2354. For additional information regarding the transplant network, please call this number.

Plan-designated transplant network facility for tissue and organ transplant (see Section 5(h) Special features, Institutes of Excellence): 10% of the Plan allowance (No deductible)

In-network (includes Guam): 20% of the Plan allowance (No deductible) 

Out-of-network (includes Guam): 100% of all charges (No catastrophic coverage)

Providers outside the 50 United States (does not include Guam): 10% of the Plan allowance (No deductible)

Not covered:

• Donor screening tests and donor search expenses, except those performed for the actual donor or as specified above
• Services or supplies for, or related to, surgical transplant procedures for artificial or human organ transplants not listed as covered
• Transplants not listed as covered
• Services or supplies for, or related to, surgical transplant procedures performed at out-of-network facilities

Professional services (except when billed by the hospital or skilled nursing facility) provided in:

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

Note: Anesthesia rendered by a dentist only in relation to covered oral and maxillofacial surgery is also covered (see this Section, Oral and maxillofacial surgery).

Note: Anesthesia services and supplies related to dental procedures are covered when necessitated by a non-dental physical impairment to safeguard the health of the patient, even though the Plan may not cover the services of dentists, physicians or other healthcare professionals in connection with the dental treatment.

Note: When multiple anesthesia providers are involved during the same surgical session, the Plan's allowance for each provider will be determined using CMS guidelines.

In-network (includes Guam): 10% of the Plan allowance (No deductible)

Out-of-network (includes Guam): 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

Providers outside the 50 United States (does not include Guam): 10% of the Plan allowance (No deductible)

Room and board, such as:

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

Note: We only cover a private room when you must be isolated to prevent contagion. Otherwise, we will pay the hospital’s average charge for semiprivate accommodations. If the hospital only has private rooms, then we will consider the private room rate.

Note: Staying overnight in a hospital does not always mean you are an inpatient. You are considered an inpatient the day a physician formally admits you to a hospital with a physician's order. Confinement as an inpatient or an outpatient affects your out-of-pocket expenses. Always ask your physician or the hospital staff if you are an inpatient, outpatient, or observation care.  Although you may stay overnight in a hospital room and receive meals and other hospital services, some hospital services including “observation care” are actually outpatient care (see this Section, Outpatient hospital or ambulatory surgical center). If you are admitted to the hospital as an inpatient after your observation care ends, you must precertify the inpatient admission per Section 3.

Other services and supplies you receive while in a hospital, such as:

• Use of operating, recovery, maternity, and other treatment rooms
• Rehabilitative services
• Prescribed drugs and medications for use in the hospital
• X-ray, laboratory, and pathology services and machine diagnostic tests
• Blood or blood plasma, if not donated or replaced, and its administration
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Drugs, medical supplies, medical equipment, prosthetic, and orthopedic devices and any covered items billed by a hospital
• Professional services of a physician or healthcare professional
• Special overseas benefit  –  Inpatient private duty nursing services by an
  R.N. or L.P.N. when the services are rendered outside the 50 United States

Note: We pay emergency room fees billed by the hospital as Inpatient hospital benefits if you are admitted as an inpatient through the emergency room.

Note: We base our benefits on whether the facility or a healthcare professional bills for the services or supplies. For example, charges for professional services such as surgery, anesthesiology, medical or therapy services, etc., we pay the specific surgery, anesthesia, medical or therapy benefit under Section 5(a) and the calendar year deductible applies, except when billed by the hospital.

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment to safeguard the health of the patient,even though we may not cover the services of dentists, physicians, or other healthcare professionals in connection with the dental treatment.

Precertification is not required for admissions outside the 50 United States (including Guam).

In-network (includes Guam): Nothing

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

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

Not covered:

• Admission to nursing homes, rest homes, places for the aged, convalescent homes, or any place that is not a hospital, skilled nursing care facility, or hospice (see Section 3, Covered providers and Covered facilities)
• Custodial care (see Section 10, Definitions)
• Any part of a hospital admission that is not medically necessary (see Section 10, Definitions), such as when you do not need acute hospital inpatient (overnight) care, but could receive care in some other setting without adversely affecting your condition or the quality of your medical care. Note: In this event, we pay benefits for services and supplies other than room and board and in-hospital physician or other healthcare professional care at the inpatient level for other medically necessary services and supplies you receive while in the hospital.
• Inpatient private duty nursing except as provided on the previous page
• Personal comfort items, such as radio, television, beauty and barber services, identification tags, baby beads, footprints, guest cots and meals, newspapers, and similar items
• Inpatient hospital services/supplies for surgery we do not cover except as noted above for non-covered dental procedures

• Operating, recovery, and other treatment rooms
• Observation stays of 24 hours or less
• Prescribed drugs and medications for use in the facility
• X-ray, laboratory, and pathology services and machine diagnostic tests
• Blood and blood plasma, if not donated or replaced, and its administration
• Dressings, casts, and sterile tray services
• Anesthetics and anesthesia service
• Drugs, medical supplies, medical equipment including oxygen, prosthetic and orthopedic devices, and any covered items billed by a hospital

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment to safeguard the health of the patient, even though we may not cover the services of dentists, physicians or other healthcare professionals in connection with the dental treatment.

In-network (includes Guam): 10% of the Plan allowance (calendar year deductible applies) (cost share waived for maternity related services)

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

Providers outside the 50 United States (does not include Guam): 10% of the Plan allowance (calendar year deductible applies) (cost share waived for maternity related services)

Observation stays for more than 24 hours performed and billed by a hospital or freestanding ambulatory facility

Note: Observation stays for more than 24 hours require prior approval. See Section 3, Other Services for additional details on prior approval.

Note: All outpatient services billed by the facility during the time you are receiving observation services are included in the cost-share amounts shown here. See Section 5(a), for any costs associated with the professional charges.

In-network (includes Guam): Nothing

Out-of-network (includes Guam): $200 copayment per observation stay and 20% of the Plan allowance and any difference between our allowance and the billed amount

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

Services and supplies related to Gene-Based Cellular and other Innovative Therapies (GCIT™) include:

• Cellular immunotherapies
• Genetically modified oncolytic viral therapy
• Other types of cells and tissues from and for use of the same person (autologous) and cells and tissues from one person for use by another person (allogenic) for certain therapeutic conditions other than transplants
• Human gene therapy that seeks to change the function of a gene or alter the biologic properties of living cells for therapeutic use. Examples include therapies using:
  - Luxturna® (Voretigene neparvovec), Zolgensma® (Onasemnogene abeparvovec-xioi), Spinraza® (Nusinersen)
• Products derived from gene editing technologies, including CRISPR-Cas9
• Oligonucleotide-based therapies, Examples include:
  - Antisense (Spinraza) siRNA

To receive the in-network level of benefits, you must use a provider who participates in our GCIT™ Designated Network.

Note: Prior approval is required. Call us at 800-593-2354 prior to scheduling. See Section 3, Other services.

Note: See Section 5(a) Treatment therapies for services provided by a physician.

Note: The Plan has special arrangements with facilities to provide services and supplies related to GCIT™ (see Section 5(h), Wellness and Other Special Features, GCIT™ Designated Network). The GCIT™ Designated Network was designed to provide access to high quality medical care for patients who have been diagnosed with certain genetic conditions. We also may assist you and one family member or caregiver with travel and lodging arrangements if you use a provide in our GCIT™ Designated Network. Your healthcare professional can coordinate arrangements by calling a case manager in the Plan’s Medical Management Department at 800-593-2354. For additional information regarding the GCIT™ Designated Network, please call this number.

GCIT™ Designated Network: 10% of the Plan allowance

Out-of-network: All charges

Providers outside the 50 United States (includes Guam): 10% of the Plan allowance

Not covered:

• Outpatient hospital services/supplies for surgery we do not cover except as noted on the previous page for non-covered dental procedures

We cover semiprivate room, board, services, and supplies in a Skilled Nursing Facility (SNF) for up to 90 days per calendar year when the admission is:

• medically necessary; and
• under the supervision of a physician.

Note: When Medicare A is primary, the initial days paid in full by Medicare are considered part of the 90 day per calendar year benefit.

Precertification is not required for admissions outside the 50 United States (including Guam).

In-network (includes Guam): Nothing up to the Plan allowance for up to 90 days per calendar year and all charges after 90 days.

Out-of-network (includes Guam): $200 copayment per admission and 20% of the Plan allowance and any difference between our allowance and the billed amount up to a maximum of 90 days per calendar year and all charges after 90 days.

Providers outside the 50 United States (does not include Guam): Nothing up to the Plan allowance for up to 90 days per calendar year and all charges after 90 days.

Not covered:

• Custodial care (see Section 10, Definitions)

Hospice Care Program is a coordinated program of home or inpatient pain control and supportive care for a terminally ill patient and the patient’s family. Care must be provided by a medically supervised team under the direction of an independent hospice administration that we approve.

Note: This benefit does not apply to services covered under any other provisions of the Plan.

Note: See Section 5(h), Compassionate Care under Care Management Programs, for information on advance care planning.

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

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

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

• Professional ambulance service to the nearest facility equipped to handle your medical condition, including air ambulance, when medically necessary.

Note: If you are outside the 50 United States and need assistance arranging for air ambulance transportation to the nearest facility equipped to handle your medical condition, please call us at 800-593-2354, Monday-Friday from            6:00 a.m. - 5:00 p.m. Mountain Standard Time (MST) or, after hours only, you can call 866-895-7795 or +44 (0)1252 351 200.

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

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

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

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

Not covered:

• Ambulance transport for you or your family’s convenience

We pay 100% of the Plan allowance for the following care you receive as a result of an accidental injury:

• Emergency Room (ER) or urgent care facility charges, ER, urgent  care physician’s, or other healthcare professional's 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 for accidental injury; or
• Series of rabies vaccinations.

Note: See Section 5(a), Telehealth Services for information on the Plan's Telehealth benefit you may use in non-medical emergencies.

Note: Regular Plan benefits apply after the initial ER, urgent care, physician, or other healthcare professional office visit.

Note: We pay for services performed outside the ER or urgent care facility under the appropriate Plan benefit.

Note: We pay hospital benefits as specified in Section 5(c), Services provided by a hospital or other facility if you are admitted to the hospital.

Note: We pay prescription medications under Sections 5(a), 5(c) or 5(f) as appropriate.

In-network (includes Guam): Nothing (No deductible)

Out-of-network (includes Guam): Only the difference between the Plan allowance and the billed amount (No deductible)

Providers outside the 50 United States (does not include Guam): Nothing (No deductible)

Initial services and items you receive in the outpatient Emergency Room (ER), physician's, or other healthcare professional's office because of a medical emergency (non-accident). Services and items covered include:

• Medical services and supplies
• Physician and professional services
• X-ray, laboratory, pathology services, and machine diagnostic tests
• Professional services for anesthesia

Note: See Section 5(a), Telehealth Services for information on the Plan's Telehealth benefit you may use in non-medical emergencies.

Note: Regular Plan benefits apply after initial ER, physician’s, or other healthcare professional's office visit.

Note: Non-medical emergency services received at a Convenience Care Clinic are paid under Section 5(a), Diagnostic and treatment services.

Note: We pay emergency room fees billed by the hospital as Inpatient hospital benefits as specified in Section 5(c), Inpatient hospital if you are admitted as an inpatient through the emergency room.

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

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

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

• Outpatient care in an urgent care facility because of a medical emergency

Note: See Section 5(a), Telehealth Services for information on the Plan's Telehealth benefit you may use in non-medical emergencies.

Note: Services received from an in-network provider for routine preventive care are paid under Section 5(a), Preventive care, adult or Preventive care, children.

In-network (includes Guam): $35 copayment per occurrence (No deductible)

Out-of-network (includes Guam): $35 copayment per occurrence and any difference between our allowance and the billed amount (No deductible)

Providers outside the 50 United States (does not include Guam): $35 copayment per occurrence (No deductible)

• Professional ambulance service to the nearest facility equipped to handle your medical condition, including air ambulance, when medically necessary.

Note: If you are outside the 50 United States and need assistance arranging for air ambulance transportation to the nearest facility equipped to handle your medical condition, please call us at 800-593-2354, Monday-Friday from 6:00 a.m. - 5:00 p.m. Mountain Standard Time (MST) or, after hours only, you can call 866-895-7795 or +44 (0)1252 351 200.

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

In-network (includes Guam): 10% of the Plan allowance (No deductible)

Out-of-network (includes Guam): 10% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

Providers outside the 50 United States (does not include Guam): 10% of the Plan allowance (No deductible)

Not covered:

• Ambulance transport for you or your family’s convenience

We cover professional services by licensed professional mental health and substance use disorder practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or family therapists.

Professional services including:

• Psychiatric office visits to a behavioral health practitioner
• Substance use disorder office visits
• Behavioral therapy
• Telemedicine consultations

Note: Telemedicine consultations are covered when your provider uses a Health Insurance Portability and Accountability Act (HIPAA) compliant tool such as Vidyo or Bluejeans for facilitating telehealth consultations.

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

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

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

Applied behavior analysis (ABA)

Note: The Plan covers medically necessary assessment and treatment with Applied Behavior Analysis therapy only when provided by behavioral health providers.  These providers include:

• Providers who are licensed or who possess a state-issued or state-sanctioned certification in ABA therapy.
• Behavior analysts certified by the Behavior Analyst Certification Board (BACB).
• Registered Behavior Technicians (RBTs) certified by the BACB or equivalent paraprofessionals who work under the supervision of a licensed provider or a certified behavior analyst.

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

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

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

Skilled behavioral health services provided in the home, but only when all of the following criteria are met:

• You are homebound
• Your physician orders the services
• The services take the place of an admission to a hospital or a residential treatment facility, or you are unable to receive the same services outside your home
• The skilled behavioral healthcare is appropriate for the active treatment of a condition, illness or disease to avoid placing you at risk for serious complications

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

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

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

Not covered:

• Assessment or treatment with ABA for which you have not obtained prior approval or received concurrent care review approval
• See Section 6, General exclusions, for other non-covered services

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

Telehealth consultations are available to members in the 50 United States with primary care and specialty providers only through our telehealth vendor Teladoc^® such as: 

• Doctors of Medicine (MD)
• Doctors of Osteopathic Medicine (DO)
• Nutritionists
• Licensed Clinical Social Workers (LCSW)
• Psychiatrists
• Psychologists
• Dermatologists

Access telehealth services 24/7/365 by web, phone, and the Teladoc^® mobile app to receive treatment within minutes for non-emergency, acute general medical needs such as: flu, cough, colds, seasonal allergies, sinus problems, arthritis, upper respiratory infection, backaches and food poisoning. You also can see a behavioral health provider for depression, anxiety and stress, as well as a nutritionist for dietary conditions or dermatologist for skin conditions.

Note: Because of the complexity of medical licensure/prescribing laws among the 50 United States and foreign countries, Teladoc^® cannot offer this service to members outside the United States.

Note: See also Section 5(a), Telehealth Services for medical telehealth services for members in the 50 United States.

Note: Telehealth is available in all 50 United States.

To sign up:
See www.teladoc.com/Aetna or call 855-Teladoc (1-855-835-2362) for information regarding telehealth consults.

In-network: Nothing (No deductible)

Out-of-network: No benefit

Providers outside of the 50 United States (includes Guam): No benefit

Telehealth consultations are available to members outside the 50 United States through our telehealth vendor, Lyra Health. Access telehealth behavioral health services 24/7/365 by web or phone (1-877-505-7147) for conditions such as anxiety, depression and stress. A provider also may give referrals when appropriate.

Note: Telehealth through Lyra Health is available to members with a foreign address (including APO, FPO, DPO and Pouch Mail addresses). In addition, members with a stateside address may access telehealth through Lyra Health while traveling outside the 50 United States.

To sign up:
Download Lyra Health mobile app in the App Store or Google Play Store or visit https://lyrahealth.com/

In-network: Nothing (No deductible)

Out-of-network: No benefit

Providers outside of the 50 United States (includes Guam): No benefit

Not covered:

• Consultations through Skype, FaceTime and other non-HIPAA compliant tools

All charges

• Psychological testing provided and billed by a licensed mental health and substance use practitioner
• Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility

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

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

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

• Inpatient services provided and billed by a hospital or other covered facility, including an overnight Residential Treatment Center (RTC)

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

Note: We only cover a private room when you must be isolated to prevent contagion. Otherwise, we will pay the hospital’s average charge for semiprivate accommodations. If the hospital only has private rooms, then we will consider the private room rate.

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

In-network inpatient facility (includes Guam): Nothing for room and board and other services (No deductible)

Out-of-network inpatient facility (includes Guam): 20% of the Plan allowance and any difference between our allowance and the billed amount for room and board and other services (No deductible)

Providers outside the 50 United States (does not include Guam): Nothing for room and board and other services (No deductible)

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

All other outpatient mental health treatment, including:

• Ambulatory detoxification, which is outpatient services that monitor withdrawal from alcohol or other substance use, including administration of medications
• Electro-convulsive therapy (ECT)
• Intensive outpatient program provided in a facility or program for mental health treatment provided under the direction of a physician
• Mental health injectables
• Observation stays of 24 hours or less
• Outpatient detoxification
• Partial hospitalization treatment provided in a facility or program for mental health treatment provided under the direction of a physician
• Substance use injectables
• Transcranial magnetic stimulation
• Treatment of withdrawal symptoms

Note: Intensive outpatient programs must be licensed to provide mental health and/or substance use disorder treatment. Services must be provided for at least two hours per day and may include group, individual, and family therapy along with psychoeducational services and adjunctive psychiatric medication management.

Note: Partial hospitalization programs must be licensed to provide mental health and/or substance use disorder treatment. Services must be at least four hours per day and may include group, individual, and family therapy along with psychoeducational services and adjunctive medication management. 

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

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

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

Observation stays for more than 24 hours performed and billed by a hospital or freestanding ambulatory facility

Note: Observation stays for more than 24 hours require prior approval. See Section 3, Other Services for additional details on prior approval.

Note: All outpatient services billed by the facility during the time you are receiving observation services are included in the cost-share amounts shown here. See Section 5(a), for any costs associated with the professional charges.

In-network (includes Guam): Nothing (No deductible)

Out-of-network (includes Guam): 20% of the Plan allowance and any difference between our allowance and the billed amount for room and board and other services (No deductible)

Providers outside the 50 United States (does not include Guam): Nothing (No deductible)

Outpatient physical, occupational, and speech therapy visits for the diagnoses of autism and developmental delays

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

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

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

You must present your Foreign Service Benefit Plan ID Card when filling your prescription at a Plan network pharmacy.

You may purchase the following medications and supplies prescribed for you by a United States licensed physician or other healthcare professional from either a Plan network pharmacy or by mail through the Express Scripts Pharmacy:

• Drugs and medications that by Federal law of the U.S. require a physician’s or other healthcare professional's written prescription for their purchase except those listed as not covered
• Insulin and diabetic supplies
• Medications prescribed to treat obesity

Note: See Section 5(h), Special features, for information about Livongo, the Plan's remote diabetes monitoring program.

• Prescription drugs for weight management
• Vitamins (including injectable B-12) and minerals that by Federal law of the U.S. require a physician's or other healthcare professional's prescription for their purchase
• FDA approved women's oral contraceptives, including the "morning after pill" (non-preferred brand name drugs) that require a prescription  (see elsewhere in this Section for generic, single source brand name drugs and prescribed "dispense as written (DAW1)" medication coverage)
• Tobacco cessation drugs and medications (see elsewhere in this Section). See also Educational classes and programs in Section 5(a), Medical services and supplies for information about the Plan’s Tobacco Cessation Program.
• Needles and syringes for the administration of covered medications
• Drugs to treat gender dysphoria
• Medications prescribed to treat obesity
• Three (3) cycles of drugs to treat infertility per person, per calendar year

Note: The Plan requires a coverage review (prior authorization, step therapy, quantity management) of certain prescription drugs based on FDA-approved prescribing and safety information, clinical guidelines and uses that are considered reasonable, safe and effective. See this Section, Prescription Drug Utilization Management, for more information. To find out if your prescription is affected by our Prescription Drug Utilization Management programs or more about your prescription drug benefits, visit the Express Scripts Pharmacy online at www.express-scripts.com. If you are a first-time visitor to the site, register with your member ID or call their Member Services at 800-818-6717.  Members outside the United States may call the Pharmacy at 800-497-4641. In addition, if you are outside the United States, you may contact Express Scripts' Expatriate Team at ExpressprocessingGen@express-scripts.com. 

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

• Network retail - up to a 30-day supply (non-specialty medications) (No deductible applies for all Levels):
• Tier I (Generic Drug):  $10 copay
• Tier II (Preferred Brand Name Drug): 25% ($30 minimum; $100 maximum)
• Tier III (Non-Preferred Brand Name Drug): 35% ($60 minimum; $200 maximum)

Note: For non-specialty maintenance medications purchased at a participating Smart90^® Retail Network pharmacy, see next page, under You pay, for copay/coinsurance information.

• Network retail - up to a 30-day supply (specialty medications) (No deductible applies for all Levels):
• Tier IV (Generic Specialty Drugs): 25% up to a maximum of $150
• Tier V (Preferred Brand Name Specialty Drugs): 25% up to a maximum of $200
• Tier VI (Non-Preferred Brand Name Specialty Drugs): 35% up to a maximum of $300

Note: Chronic specialty drugs must be obtained from Accredo. If you continue to use retail and the Plan has instructed you to use Accredo, you pay 100% of the cost.

• Network retail (Medicare):
  • The Plan coordinates benefits with Medicare Part B and Part D coverage. 
  • See this Section, Information about prescription drug coordination of benefits (COB) with Medicare Part B and/or Part D.
• Out-of-network retail (in the 50 United States, including Medicare): 100% of cost
• Out-of-network retail (outside the 50 United States, including Medicare): 10% of cost (No deductible)

Note: If there is no generic equivalent available, you will still have to pay the Preferred Brand Name Drug or Non-Preferred Brand Name Drug coinsurance or copay.

Note: Information in the left hand column of the previous page applies here.

Note: Certain preventive migraine medications are required to be obtained through home delivery. Contact Express Scripts at 800-818-6717 to determine if your medication is required to be obtained through home delivery. If you continue to use retail, you pay 100% of the cost.

Note:  If you are enrolled in our Medicare Advantage Plan or our Medicare PDP, see Section 9 for your prescription coinsurance and copays or visit www.express-scripts.com for additional details.

• Network home delivery – the Express Scripts Pharmacy^SM or participating Smart90^® Retail Network pharmacies - up to a 90-day supply (No deductible applies for all Levels):
  • Tier I (Generic Drug): $15
  • Tier II (Preferred Brand Name Drug): $60
  • Tier III (Non-Preferred Brand Name Drug): 35% ($80 minimum; $500 maximum)
  • Tier IV (Generic Specialty Drugs): 25% up to a maximum of $150
  • Tier V (Preferred Brand Name Specialty Drugs): 25% up to a maximum of $200
  • Tier VI (Non-Preferred Brand Name Specialty Drugs): 35% up to a maximum of $300
• Network home delivery – the Express Scripts Pharmacy (Medicare):
  • The Plan coordinates benefits with Medicare Part B and Part D coverage.
  • See this Section, Information about prescription drug coordination of benefits (COB) with Medicare Part B and/or Part D.

Note: If there is no generic equivalent available, you will still have to pay the Preferred Brand Name Drug or Non-Preferred Brand Name Drug coinsurance or copay.

Note: A separate copay applies per prescription fill.

The following are covered:

• If you are outside the 50 United States and purchase prescriptions only from a retail pharmacy outside the 50 United States or a Military Treatment Facility (MTF) outside the 50 United States

Note:  The Plan covers three (3) cycles of drugs to treat infertility per person, per calendar year.

Note: Medications that are considered prescription drugs outside the 50 United States, but are non-prescription (OTC) medications in the 50 United States, are covered.

• If you do not use your prescription card to purchase colostomy, ostomy or diabetic supplies

Note: See Section 5(h), Special features, for information about Livongo, the Plan's remote diabetes monitoring program.

• 10% of the cost (including Medicare) (No deductible)

• FDA-approved women's oral contraceptives, including the "morning after pill" (generic, single-source brand name drugs, and prescribed "dispense as written (DAW1)" medication only) that require a prescription
• Diaphragms
• Cervical caps
• Vaginal rings
• Contraceptive hormonal patches
• Injectable contraceptives

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

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

Over-the-counter and prescription drugs approved by the FDA to prevent unintended pregnancy.

Process: 

• Reviews can be initiated by the member, pharmacist or provider
• Members should call Express Scripts at 800-841-2734
• Providers also can initiate through an electronic prior authorization

If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.

Reimbursement for covered over-the-counter contraceptives can be submitted in accordance with Section 7.

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

• Refer to Section 7, Filing a Claim for Covered Services.

• Network retail, network home delivery, and out-of-network retail (outside the 50 United States): Nothing (No deductible)
• Out-of-network retail (in the 50 United States): 100% of the cost

Note: If you are outside the 50 United States and purchase these prescriptions from a retail pharmacy on the economy or from a Military Treatment Facility you must include on your claim submission that the claim is for contraceptives and specify what contraceptive you purchased in order to receive benefits.

Opioid rescue agents such as naloxone are covered under this Plan with no cost sharing when obtained from a network pharmacy in any over-the-counter or prescription form available such as nasal sprays and intramuscular injections.

For more information consult the FDA guidance at: https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-duringopioid-overdose or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go to https://www.findtreatment.samhsa.gov/

• Network retail, network home delivery, and out-of-network retail (outside the 50 United States): Nothing (No deductible)
• Out-of-network retail (in the 50 United States): 100% of the cost

Note: If you are outside the 50 United States and purchase these medications from a retail pharmacy on the economy or from a Military Treatment Facility you must include on your claim submission what the claim is for and identify the specific medications in order to receive benefits.

Tobacco cessation drugs and medications approved by the FDA to treat tobacco and nicotine dependence for tobacco cessation purchased in the 50 United States

Physician or other healthcare professional prescribed over-the-counter (OTC) medications and prescription drugs approved by the FDA to treat tobacco and nicotine dependence for tobacco cessation are covered when you purchase them through:

• A Plan network pharmacy (you must present your Foreign Service Benefit Plan ID card)
• The Plan’s home delivery pharmacy (the Express Scripts Pharmacy)

Note: A U.S. licensed prescriber's written prescription is required at a Plan network pharmacy and the Express Scripts Pharmacy for OTC medications.

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

Nothing (No deductible)

Tobacco cessation drugs and medications approved by the FDA to treat tobacco and nicotine dependence for tobacco cessation purchased outside the 50 United States are covered when you purchase them through:

• A retail pharmacy outside the 50 United States
• A Military Treatment Facility (MTF) outside the 50 United States (Note: A U.S. licensed prescriber's written prescription is required for prescription drugs purchased from an MTF.)

Note: You must file a claim for drugs and medications purchased at a retail pharmacy or MTF outside the 50 United States.

• The Plan’s home delivery pharmacy (the Express Scripts Pharmacy)

Note: A U.S. licensed prescriber's written prescription is required for OTC medications and prescription drugs purchased from the Plan’s home delivery pharmacy.

Medications to promote better health recommended under the ACA and by the USPSTF (see Section 10, Definitions, Routine preventive services and immunizations.)

Note: To receive this benefit in the United States, you must use a network retail pharmacy and present a U.S. licensed prescriber's written prescription to the pharmacist.

Note: Benefits are not available for Tylenol, Ibuprofen, Aleve, etc.

• Network retail, network home delivery, and out-of-network retail (outside the 50 United States): Nothing (No deductible)
• Out-of-network retail (in the 50 United States): 100% of the cost

Note: If you are outside the 50 United States and purchase these medications from a retail pharmacy on the economy or from a Military Treatment Facility you must include on your claim submission what the claim is for and identify the specific medications in order to receive benefits.

Not covered:

• Drugs purchased at a Network pharmacy in the United States that are not in the Plan Formulary
• Drugs and supplies you purchase at an out-of-network pharmacy in the 50 United States except as covered under Sections 5(a) and 5(c) and except when Medicare Part B and Part D are primary
• Chronic specialty drugs you purchase at a network pharmacy
• All specialty drugs you purchase at an out-of-network pharmacy except when Medicare Part B and Part D are primary
• Drugs and supplies you purchase without using your Foreign Service Benefit Plan ID Card at a network pharmacy except as covered under Sections 5(a) and 5(c) and except when Medicare Part B and Part D are primary
• Non-specialty maintenance prescription medications (drugs you take regularly for ongoing conditions) that you do not purchase through a participating Smart90^® Retail Network pharmacy or through home delivery after you have purchased two courtesy fills at regular network retail
• Drugs and supplies (except colostomy, ostomy, or diabetic supplies) you purchase through home delivery from a source other than the Express Scripts Pharmacy^SM, Accredo Health Group, the Plan's specialty pharmacy, or Medicare Part B licensed provider, and except when Medicare Part B and Part D are primary
• Medications for which you did not obtain prior authorization and which require prior authorization
• Prescription drugs and over-the-counter (OTC) medications for tobacco cessation except those obtained with the use of your Foreign Service Benefit Plan ID Card at a Plan Retail Network Pharmacy, through the Express Scripts Pharmacy (home delivery), or when outside the 50 United States at a retail pharmacy or Military Treatment Facility
• Non-prescription (OTC) medications, except as noted under Preventive Medications
• Prescription drug coinsurance
• The Express Scripts Pharmacy (home delivery) copays
• Drugs and supplies for cosmetic purposes
• Medical foods and oral nutritional supplements except as described in Section 5(a), Durable medical equipment
• Vitamins and minerals except as described in Section 5(a) and this Section
• Medication that under Federal law does not require a prescription, even if your physician or other healthcare professional prescribes it or State law requires it or for which there is a non-prescription equivalent available
• Drugs and supplies related to the treatment of impotency, sexual dysfunction, or sexual inadequacy

All charges

Preventive Medications

Opioid rescue agents such as naloxone are covered under this Plan with no cost sharing when obtained from a network pharmacy participating with Express Scripts (ESI) in any over-the-counter or prescription form available such as nasal sprays and intramuscular injections.

For more information consult the FDA guidance at: https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-duringopioid-overdose.
Or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go to https://www.findtreatment.samhsa.gov/

Preventive Medications with a USPSTF A and B recommendations. of A or B. are covered without cost-share when prescribed by a healthcare professional and filled by a network pharmacy. These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients.

For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browserecommendations

Not covered:

• Drugs and supplies for cosmetic purposes

• Nonprescription medications

• Network retail, network home delivery, and out-of-network retail (outside the 50 United States): Nothing (No deductible)
• Out-of-network retail (in the 50 United States): 100% of the cost

Note: If you are outside the 50 United States and purchase these medications from a retail pharmacy on the economy or from a Military Treatment Facility you must include on your claim submission what the claim is for and identify the specific medications in order to receive benefits.

We cover dental work (including dental X-rays) to repair or initially replace sound natural teeth under the following condition:

• You must receive these services as a result of an accidental injury to the jaw or sound natural teeth.

Note: We cover dental care required as a result of accidental injury from an external force such as a blow or fall to sound natural teeth (not from biting or chewing) that requires immediate attention.

Note: We define a sound natural tooth as a tooth which:

• Is whole or properly restored;
• Is without impairment, periodontal, or other conditions; and
• Does not need treatment for any reason other than an accidental injury.

Note: The Plan will ask for information from your dentist that documents the teeth involved in the accident were sound natural teeth prior to the accident if such information is not submitted with the claim.

In-network (includes Guam): 20% of the Plan allowance (calendar year deductible applies)

Out-of-network (includes Guam): 20% of the Plan allowance and any difference between our allowance and the billed amount (calendar year deductible applies)

Providers outside the 50 United States (does not include Guam): 20% of the Plan allowance (calendar year deductible applies)

Preventive care, limited to two services per person, per calendar year

• Oral exam
• Prophylaxis (cleaning), adult and child
• Prophylaxis with fluoride, child (thru age 22)

Only the following amounts are payable (scheduled allowance):

• $13 per exam
• $23 per cleaning
• $26 per cleaning

Surgery

• Apicoectomy (tooth root amputation)
• Alveolectomy (excision of alveolar bone)
• Alveolar abscess, incision and drainage
• Gingivectomy (excision of gum tissue)

Note: Excision of impacted teeth and non-dental oral surgical procedures are covered under Section 5(b), Oral and maxillofacial surgery.

Only the following amounts are payable (scheduled allowance):

• $50 per root
• $40 per quadrant
• $10 per abscess
• $50 per quadrant

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).

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
  • At the top menu bar, select the “Member Resources” tab, and then under “Online Portals” select “Aetna 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.

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.

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
• At the top menu bar, select the “Member Resources” tab, and then under “Online Portals” select “Aetna 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).

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 "Health & Wellness" 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), at the top menu bar, select the “Member Resources” tab, and then under “Online Portals” select “Aetna 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 "Health & Wellness" 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.

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 healthcare professional. You may call 855-482-5750 or 704-834-6782.

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 or LabCorp 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:

• Complete 4 personal or group Lifestyle and Condition (LCC) Health Coaching Sessions (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.

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 LCC Health Coaching sessions (see elsewhere in this Section)
  • Complete 6 personal or group LCC Health Coaching sessions and earn $75
  • Complete an additional 2 (total of 8) personal or group LCC Health Coaching sessions and earn an additional $75

• Track your physical activity
  • Complete 5,000 steps per day for any 50 days and earn up to $25 each quarter; or
  • Complete 30 minutes of physical activity per day for any 50 days and earn up to $25 each quarter

Note: You can track this activity by connecting your activity device or by manually entering steps in the tracker activity through the  Aetna secure member website. Access the Plan’s website tool on Aetna's secure member website through our link at www.AFSPA.org/FSBP. At the top menu bar, select the “Member Resources” tab, and then under “Online Portals” select “Aetna secure member website” or go directly to  Myactivehealth.com/FSBP. Once you log on to Aetna's secure member website, go to “Discover a Healthier You” under Health and  Wellness. Select “Rewards” at the top of the page, then select “Track Your Physical Activity”.

• Get your breast cancer screening and earn $25
• Get your cervical cancer screening (pap smear) and earn $25
• Get your colorectal cancer screening and earn $25
• Get a flu shot and earn $25
• Get your COVID-19 vaccination and earn $25 upon receipt of documentation

Note: For benefit information for the breast cancer screening, cervical cancer screening, colon 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 wellness incentive reward for each one completed.

1. Controlling Blood Pressure for members with high blood pressure – Complete and earn $75

• If you are identified as having high blood pressure, we 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:
  
  • Complete 4 personal or group LCC Health Coaching sessions (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 – Complete and earn $75

• If you are identified as having metabolic syndrome/pre-diabetes ask your provider to 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)
  • Complete 4 personal or group LCC Health Coaching sessions (see elsewhere in this Section)

3. Controlling A1c Hemoglobin (HbA1c) levels for members with diabetes – Complete and earn $75

• If you are identified as having diabetes ask your provider to 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)
  • 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 healthcare provider with respect to the frequency of use and glucose testing.

4. Eliminating tobacco use for tobacco users – Complete and earn $75

• If you self-identify as a tobacco user on your HRA, you can participate in the Plan’s Tobacco Cessation Program by calling a Lifestyle and Condition Health Coach at 866-533-1410 Monday – Friday 8 a.m.-8 p.m. EST or enroll online at myactivehealth.com/FSBP. 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 – Complete and earn up to $200 

• Enroll in our Healthy Pregnancy Program and earn $50

• Submit documentation of a prenatal care visit during the first trimester and earn $50. To earn the incentive, the documentation must be submitted by your provider and include a copy of the prenatal care medical record including Obstetric Panel testing, ultrasound, or prenatal exam. 
• Complete a pre-delivery call with a nurse at 28 weeks and earn $50
• Complete a post-delivery call with a nurse four (4) weeks after delivery and earn $50

Note: To earn an incentive for the completed Healthy Actions above, mail your documentation to: Foreign Service Benefit Plan, C/O Wellness Incentives, 1620 L Street NW, Suite 800, Washington, DC 20036-5629.

To submit through the Member Portal:

• Visit www.myafspa.org on your desktop or afspamembers.afspa.org on your mobile device.
• Enter member portal credentials and click “sign-in.”
• Click “submit incentive” on the right-hand side of your portal (or in the form section of the mobile version of the portal)
• Select the option “Incentives” and click on "New Incentive" button (in the mobile version)
• Select the name of the person for whom the incentive is being submitted
• Select “Wellness Incentive/Healthy Actions” from the incentive type drop-down
• Provide reason for visit (i.e. Describe the type of Healthy Action - Flu Shot, Health Screening, etc.)
• Browse for the document(s) you wish to upload or take a picture to upload from your mobile device (in the mobile version only)
• Click “Submit Incentive"

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
• At the top menu bar, select the “Member Resources” tab, and then under “Online Portals” select “Aetna 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)); At the top menu bar, select the “Member Resources” tab, and then under “Online Portals” select “Aetna secure member website.” Once you log on to Aetna's secure member website, look for the "Health 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)

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

• At the top menu bar, select the “Member Resources” tab, and then under “Online Portals” select “Aetna secure member website”
• Log on to Aetna's secure member website
• Click on "Health & Wellness" icon, then select "Explore Resources" under "Discover a Healthier You" and proceed

To schedule an appointment to complete the HRA over the telephone, contact a LCC Health Coach at 866-533-1410. Coaches are available Monday through Friday from 8:00 a.m. - 8:00 p.m. ET. You may also schedule an appointment online at
www.myactivehealth.com/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.

You can obtain a Biometric Screening at a Quest Diagnostics or LabCorp Patient Service Center (PSC), through your physician by having your physician complete a Biometric Screening Physician Results Form and submit it to Quest Diagnostics or LabCorp. You also can order home collection materials (stateside only) through Quest Diagnostics or LabCorp. A Biometric Screening obtained through your physician is generally done during a routine physical examination.

To obtain your biometric screening through Quest Diagnostics, 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 or request home collection materials (stateside only). 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.

To obtain your biometric screening through LabCorp, visit https://www.wellconnectplus.com/?company=YB8U0O 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 or request home collection materials (stateside only). You also can register by calling 888-522-2677. You can review your results on LabCorp’s portal, WellConnect Plus, after your screening. 

*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.

Our Lifestyle and Condition Coaching (LCC) Program uses a holistic approach to help you and your covered dependents achieve your best health. Our LCC Health Coach will provide guidance, support, and resources for over 40 lifestyle and medical conditions 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:

• Lifestyle Coaching such as:
  • General health education
  • Prehypertension
  • Metabolic syndrome
  • Prediabetes
  • Weight management
  • Physical activity
  • Nutrition management
  • Stress management
  • Sleep management
  • Pain management
  • Tobacco cessation
• Condition Coaching such as:
  • Vascular (coronary artery disease, heart failure, high cholesterol, adult and pediatric diabetes and high blood pressure)
  • Gastrointestinal (ulcerative colitis/Inflammatory Bowel Disease (IBS)/Crohn’s, chronic hepatitis B and C)
  • Pulmonary (adult and pediatric asthma, chronic obstructive pulmonary disease (COPD))
  • Orthopedic/Rheumatologic (chronic neck and back pain, rheumatoid arthritis, osteoarthritis, systemic lupus erythematosus)
  • Neurological (migraines, seizures)
  • Other (adult and pediatric weight management, chronic kidney disease stages 1-4, end state renal disease, depression

How does the LCC Program work?

• You will receive support from your LCC Health Coach through various resources such as digital coaching, group coaching, and/or 1:1 telephonic coaching.  During 1:1 telephonic coaching, your LCC Health Coach will help you establish and achieve your health goals. 
• Your LCC Health Coach will help you explore ways to make changes in your behavior that will last.
• You will receive educational materials and information from your LCC Health Coach that can help you decide where you want to go with your health and how to get there.
• Appointments with your LCC Health Coach can last up to 30 minutes. How long and how often you meet with your LCC Health Coach depends on your individual needs and goals.

To enroll in a program, contact a LCC Health Coach at 866-533-1410. LCC Coaches are available Monday through Friday from 8:00 a.m. – 8:00 p.m. ET. You may also enroll online at www.myactivehealth.com/FSBP. Participation in this program is voluntary and is available at no cost to members.

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.

You have access to the Plan's Healthy Pregnancy Program to support you on your maternity journey. Our Healthy Pregnancy program, provides trusted information and guidance about family planning, support and postpartum care. 

With this program, you will also have access to the following resources:

• Nurses who are trained in obstetrics and high-risk pregnancy conditions
• Behavioral health support, including referrals to resources to deal with stress, depression, and anxiety
• Postpartum depression screening and support
• Resources and educational materials through our Maternity Support Program
• Guided medically appropriate genetic counseling and testing
• Preeclampsia prevention – If you are identified as high-risk, you will receive educational materials about preeclampsia risk factors, and the benefits of aspirin therapy.
• Fertility advocate to help you throughout your infertility journey, fertility preservation, same-sex conception needs, and more. The advocate will also provide support and guidance during fertility treatment and provide support if you become pregnant. For direct access to a fertility advocate, call 833-415-1709. No matter where you are on your journey, our nurses and experts are here to support you along the way.  Participation in this program is voluntary and available at no cost to you. The participant and their physician or healthcare provider remain in charge of the participant’s treatment plan. If you would like more information or would like to enroll in the Healthy Pregnancy Program, contact the Plan at 855-282-6344.

As part of our Healthy Pregnancy Program, you and your partner also get 24/7 access to Maven’s digital health platform and quality providers via unlimited video appointments, messaging, and classes.

Your Maven membership includes support on adoption, surrogacy, fertility, maternity, and postpartum care:

• A personal Care Advocate who serves as a trusted guide to help you navigate the Maven platform and connect you with providers throughout your journey
• Unlimited video chat and messaging with doctors, nurses, and coaches across 35+ specialties, including fertility, mental health, Doulas, Sleep coaches, pediatrics, and more
• Provider-led virtual classes and vetted articles tailored to your journey
• Counseling and expert guidance via Maven Adoption and Surrogacy Coaches through different adoption and surrogacy pathways and key considerations in the process

There is no additional cost for Maven. If you would like more information or to enroll in the Program visit https://mavenclinic.com/join/aetnafamily-OP or download the Maven Clinic app. If you have additional questions during enrollment, you can email the Maven Care Team at support@mavenclinic.com.

For other resources provided through Maven, please see below in Maven Digital Health Platform.

You and your partner also get 24/7 access to Maven’s digital health platform and quality providers via unlimited video appointments, messaging, and classes at no additional cost.   Maven provides more holistic support for you and your partner through different stages in life, including family planning, fertility, pregnancy, postpartum support, parenting and pediatrics, and menopause.

Comprehensive Support:  Maven will provide support to members who are going through the journey of preconception, adoption, surrogacy, fertility preservation, intrauterine insemination (IUI), or in-vitro fertilization (IVF). The program includes Maven’s digital family health platform, which supports members through key milestones and provides guidance for their journey. Through Maven’s digital platform, members can access unlimited telehealth support from family planning specialists. Members and their partners can also view their benefit information, read articles pertaining to their journey and track important milestones. In addition to the digital support of the program, Aetna’s fertility advocates proactively provide outreach to support and answer questions one-on-one with members throughout their fertility journey.  

For pregnancy and postpartum support, the program provides personalized engagement to members while they are pregnant.

If you would like more information or to enroll in the Program visit https://mavenclinic.com/join/aetnafamily-OP or download the Maven Clinic app. If you have additional questions during enrollment, you can email the Maven Care Team at support@mavenclinic.com

See above in Healthy Pregnancy Program for additional support available through Maven during your pregnancy.

Fertility preservation:  The program guides members through the risks and tradeoffs of egg freezing, helps them choose a clinic, and provides emotional support along the way. Members receive access to the following:

• One-on-one guidance and support through egg or embryo freezing consideration, consultations, and retrieval
• Care advocates who steer them to Aetna’s high-quality clinics based on their unique needs, helping achieve successful retrievals at lower costs
• On-demand access to specialists that are critical in the egg freezing process, including nutritionists, fertility awareness educators, career coaches, and mental health providers
• Help navigating the costs of egg freezing and answers to questions around the value of the investment for every individual
• Educational content, quizzes, and coaching from reproductive health and fertility experts to helping members achieve their health goals and explore paths to parenthood

• Support from the Maven application, which helps track milestones, navigate benefits, and provides members with virtual access to specialists at no additional charge to them

Intrauterine insemination and in-vitro fertilization:  The program also guides members through the difficult decision of selecting a treatment option and choosing a fertility clinic. Members receive access to the following:

• Fertility awareness educators and reproductive endocrinologists who provide personalized guidance on fertility treatment options
• Referrals to Aetna IOE fertility providers and fertility advocates with high success rates and high patient satisfaction
• Mental health services and a community of members who are on a similar journey
• Support for their partner, including programming and activities that are specific to their needs

Parenting and Pediatrics support: The Maven Parenting and Pediatrics program provides support for parents and children from early childhood through adolescence. For children who have special needs, the program includes access to on-demand specialists that support the parenting journey. Specialists include occupational therapists, speech-language pathologists, and special education advocates. Members also have preferred access to Maven’s ecosystem of childcare and tutoring partners.

Menopause support:  The Maven Menopause program offers clinical care management to identify menopausal symptoms early and help manage care throughout a member’s menopausal journey. This program is available 24/7 and includes a specialized virtual care team of providers focused on all stages of the menopause journey. It provides support for individuals across all related issues including, general menopause education, mood fluctuations, hot flashes, sleep issues, and balancing work through menopause.

If you would like more information or to enroll in the Program visit https://mavenclinic.com/join/aetnafamily-OP or download the Maven Clinic app. If you have additional questions during enrollment, you can email the Maven Care Team at support@mavenclinic.com.

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. At the top menu bar, select the “Member Resources” tab, and then under “Online Portals” select “Aetna secure member website.” Once you log on to Aetna's secure member website, look for the "Health & Wellness" 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.

The Plan offers additional services under our Care Management (CM) Programs that assist you with your care coordination for your acute or chronic conditions at no additional cost. These programs provide education, clinical support and access to digital support and well-being tools to help you better manage your health.

CM Programs offer you:

• One-on-one support with a nurse or social worker who serves as a trusted resource for you and your family. To begin call 800-593-2354;
• Group coaching on personalized health topics that is designed to provide health guidance in one thirty to sixty-minute class;
• Digital support that provides a variety of resources to help you manage your health better. To begin using the digital support of CM Programs, 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 offer digital support, nurse support, and group coaching so you can move easily between the services.

We offer several 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 healthcare 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.

Our CM Programs include:

Social Work Program

The Social Work Program is designed to assist you in improving your quality of life by taking steps to help you 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
• Federal and state programs  

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 offers support 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: targeted digital exercise therapy, injection therapies, cognitive therapies, psychosocial supports, medical devices (e.g. nerve stimulators) and additional chiropractic, acupuncture, massage therapy, or physical therapy visits. 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

The Compassionate Care Program offers you service and support when you or a family member have a serious illness or face imminent end-of life decisions. The program provides you 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 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 voluntary and provided to you and your dependents at no additional cost.

Cancer Support Program

The Cancer Support Program provides dedicated proactive support to individuals with a diagnosis of cancer, which can be life changing and overwhelming. Through our program, individuals will better understand their benefits, have the ability to locate the right provider for their specific need and get certain services approved. Individuals also will receive care management support for holistic care, treatment side effects, and medication management.

Through our Cancer Support Program, you have access to:

• Personal navigator – This person is your dedicated advocate with experience in cancer diagnosis and treatment who will provide you and your caregiver personalized support whenever you need it.
• Guided genetic health® - Genetic counseling and testing to help guide your treatment and assess your risk of developing cancer.
• Aetna Cancer Support Center – Provides resources, information from trusted sources for information and guidance on what to expect while managing cancer treatment and care.

Additionally, we offer TherapEase Cuisine, a nutritional program through Express Scripts PharmacySM, the Plan’s home delivery pharmacy.  TherapEase Cuisine offers an easy-to-use-online program providing cancer patients access to nutritional information that follows the Academy of Nutritional and Dietetics guidelines for cancer nutrition.  This nutritional program helps answer the question, “What should I be eating?” for those diagnoses 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. Then you create your free account and access online nutrition information.

See Section 5(a), Treatment therapies for our benefits for chemotherapy and radiation therapy.

.

Behavioral Health Program

The Behavioral Health Program provides resources and support to help you address behavioral health conditions such as anxiety, depression, substance use disorders, domestic violence and more. Our team can work with you to connect you with resources such as a clinical social worker, psychologist or other behavior health professional to obtain the right treatment.

Healing Better Program

The Healing Better Program provides support and educational resources for total knee or hip replacement surgery. The program gives you the tools and resources you need to prepare for a successful surgery and healthy recovery. It provides you access to benefit information specific to joint services, holistic overview of pain management options, digital, personalized education on recovery resources, and mental and physical health tips.

Participation in the CM Programs is voluntary. The participant and their physician or healthcare professional remain in charge of the treatment Plan.

If you would like to contact the Plan for more information about the CM Programs, 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).

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 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 such as heart disease, diabetes, chronic pain or infertility. The program also provides support for behavioral health conditions such as depression, anxiety and panic disorder, stress, and substance use disorder. Additionally, the program assists members with life challenges such as losing a loved one, having a baby, military transitions, and even caregiving. 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 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 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 their 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 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 their 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.

Livongo weight management program is available through Express Scripts.

Eligible candidates will be contacted and asked to participate in the virtual program based on claims data. Participation is voluntary. Once enrolled, the program will run at least 12 months.

The program provides:

• Dedicated, personalized coaching from registered dieticians, nutritionists and exercise physiologists
• Access to a comprehensive, evidence-based lifestyle change curriculum
• A cellular-connected scale that automatically transfers weigh-ins to a coach for review
• Peer support through a virtual community of 15 – 20 individuals on their own journeys to better health. Members can challenge and encourage each other through in-app messaging.

For more information visit stepin.livongo.com or call 800-945-4355.

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.

The Plan has special arrangements with The Clinic by Cleveland Clinic and Children’s National Hospital to provide patients who receive treatment in foreign countries access to Virtual Second Opinions. This program allows you to have your medical diagnosis and treatment reviewed by expert specialists from the Cleveland Clinic and Children’s National Hospital who can help you with many health challenges.

To request a virtual second opinion for treatment received outside the U.S., email the Plan at secondopinion@aetna.com. The Plan will review your request and if you qualify for the virtual second opinion, you will be sent instructions for where to submit medical history information and answer questions specific to your diagnosis. You also may need to gather information from your local physician or hospital, such as pathology (biopsy) slides or X-rays to send with your request.

You will be matched to the most appropriate expert specialist who will review your medical history and original tests before rendering an educational second opinion. You will be notified by e-mail within three to five days that the opinion is ready and can be viewed on the secure patient portal. The second opinion will assist you in deciding on the care path that is right for you, whether it is proceeding with the original treatment plan or pursuing an alternative treatment plan.

Aetna's secure member website - web based customer service

Access Aetna's secure member website through our link at www.AFSPA.org/FSBP. At the top menu bar, select the “Member Resources” tab, and then under “Online Portals” select “Aetna 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 healthcare 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, healthcare 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 data rates may apply).

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 “Prescription Coverage” under "Finding Care." 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.

The Plan has special agreements with facilities to provide services and supplies related to GCIT™. The GCIT™ Designated Network was designed to provide high quality medical care for patients who have been diagnosed with certain genetic conditions. 

Note: If a qualified gene therapy service is medically necessary, performed at one of the GCIT™ facilities and the Plan is the primary payor, you may be eligible for reimbursement of some expenses for travel and lodging for the gene therapy recipient and one family member or caregiver. If the gene therapy recipient is 21 or younger, we may pay eligible travel costs for the patient and two caregivers.

Reimbursement is subject to IRS regulations.

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

See Section 5(a), Treatment therapies and Section 5(c) Outpatient hospital or ambulatory surgical center for the Plan’s gene therapy 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).

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

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

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

AFSPA offers four (4) life insurance options:

• Accidental Death & Dismemberment (AD&D) protects worldwide, up to $600,000, against loss due to accidental injury or death.
• Critical Illness Insurance coverage offers additional financial protection for those who are medically diagnosed with a serious illness such as a heart attack, stroke, or cancer.
• 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.

AFSPA’s disability plan pays 60% of your salary (up to $5,000 or $7,500 /month), if you cannot work for an extended period, due to illness or injury.

AFSPA offers three (3) travel medical insurance plans for members of your household who are traveling outside of their home country and are not eligible for FEHB.

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

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

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 (healthcare 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 Massage Therapy License Number (if a United States provider and applicable per state law).
• 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 healthcare 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.

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).

Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the following year after 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.

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, Thailand, 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 (healthcare providers)

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

You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us. For urgent care claims, a healthcare professional with knowledge of your medical condition will be permitted to act as your authorized representative without your express consent. For the purposes of this Section, we are also referring to your authorized representative when we refer to you.

The Secretary of Health and Human Services has identified counties where at least 10% 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 healthcare 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.

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

a) Pay the claim; or

b) Write to you and maintain our denial; or

c) Ask you or your provider for more information.

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

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

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

You must write to OPM within:

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

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employees Insurance Operations, 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 healthcare professional with knowledge of your medical condition may act as your authorized representative without your express consent.

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

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

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

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

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

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

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines. For more information on NAIC rules regarding the coordinating of benefits, visit our website at www.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 processes the benefit, 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 is the healthcare program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. If TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

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

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

We do not cover services that:

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

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

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

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

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.

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.

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 (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 on the previous page, 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 healthcare 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 healthcare 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 following examples which 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 Provider
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: $0

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

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.

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 their “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.

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

To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (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 our Medicare Advantage plan: You may enroll in FSBP – Aetna Medicare Advantage Plan if you are an annuitant or former spouse with Medicare Parts A and B as your primary payor. Enrollment in the FSBP – Aetna Medicare Advantage Plan is voluntary. Only eligible enrollees can voluntarily opt into the Plan and may opt out at any time. Our Medicare Advantage Plan will enhance your FEHB coverage by lowering/eliminating cost-sharing for certain services and/or adding benefits at no additional FEHB Premium cost.  FSBP – Aetna Medicare Advantage is subject to Medicare rules. You can enroll in our FSBP – Aetna Medicare Advantage plan with no additional FEHB Premium. If you are already enrolled in this Plan and would like to understand your additional benefits in more detail, please call us at 1-866-241-0262 (TTY: 711) or go to aetnaretireehealth.com/fsbp, or you may refer to your Medicare plan’s Evidence of Coverage. Once you enroll in our FSBP – Aetna Medicare Advantage Plan, we will send you additional information.

When you are enrolled in the FSBP – Aetna Medicare Advantage you receive the following benefits. 

• No deductible
• No copays or coinsurance for covered services (office visits or telehealth, preventive care, inpatient/outpatient hospital care, emergency room/urgent care, etc.)
• Catastrophic Protection Out-of-Pocket Maximum of $2,000 per person annually
• Prescription drug copay or coinsurance per 30-day supply –
• Generic drug copays - $0 at preferred pharmacies, $2 at standard pharmacies, $10 at all other pharmacies
• Preferred Brand- copays $40
• Non-Preferred Brand - copays $75
• Specialty Drug copays - $25% coinsurance up to $150 maximum
• Additional benefits such as non-emergency transportation program, SilverSneakers® (a registered trademark of Tivity Health Inc.), Resources for Living, meal benefit delivery program following inpatient hospitalization, etc. 

Part B Premium Reduction

We will reduce the Part B premium that you pay to the Social Security Administration by $75 per month. If you pay your Part B premium on a monthly basis, you will see this dollar amount credited in your Social Security check. If you pay your Part B premium quarterly, you will see an amount of $225 in reductions credited on your quarterly Part B premium statement. It may take a few months to see these reductions credited to either your Social Security check or premium statement, but you will be reimbursed for any credits you did not receive during this waiting period.

The Medicare Income-Related Monthly Adjustment Amount (IRMAA) is an amount you pay in addition to your Part B and D premium if your income is above a certain level. Social Security makes this determination based on your income. For additional information concerning the IRMAA, contact the Social Security Administration.

Important Information on Enrollment in our FSBP – Aetna Medicare Advantage

FSBP – Aetna Medicare Advantage is a Medicare contract separate from the FEHB FSBP High Option Plan and depends on contract renewals with CMS. For a copy of the Evidence of Coverage go to the following link, www.medicare.gov. The Evidence of Coverage contains a complete description of the plan benefits, exclusions, limitations and conditions of coverage under FSBP – Aetna Medicare Advantage.

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 or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.

When we are the primary payor, we process the claim first. If you enroll in Medicare Part D and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan. 

If you are enrolled in Medicare, and are not enrolled in a Medicare Advantage Plan (Part C), you have the opportunity to enroll in the Medicare Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP). The PDP EGWP is a prescription drug benefit for FEHB covered annuitants and their FEHB covered family members who are eligible for Medicare.  This allows you to receive benefits that will never be less than your coverage that is available to members with only FEHB but more often you will receive benefits that are better than members with only FEHB.

This Plan and our PDP EGWP: If you choose to enroll in our PDP EGWP, you also will continue to remain enrolled in our FEHB Plan. Participation in the PDP EGWP is voluntary, and you have the choice to opt in or disenroll at any time. To opt in or disenroll, please call 202-833-4910 or complete and submit the secure form available at afspa.org/pdp. 

In the case of those with higher incomes you may have a separate premium payment for your PDP EGWP benefit. Please refer to the Part D-IRMAA section of the Medicare website: https://www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/monthly-premium-for-drug-plans to see if you would be subject to an additional premium.

This Plan and our Prescription Drug Plan (PDP): If you are Medicare eligible, retired and receiving your FEHB coverage through a retirement benefit, and age 65 and above with Medicare Parts A and/or B you can enroll in the FSBP - Express Scripts Medicare® PDP option. Our PDP option will enhance your FEHB prescription drug coverage by lowering cost-sharing for your prescription drugs at no additional FEHB premium. Our FSBP - Express Scripts Medicare® PDP option is subject to Medicare rules. If you are already enrolled in this PDP option and would like to understand your benefits in more detail, please call us at 855-690-8353, 24 hours a day, 7 days a week. You will also be able to register online at www.express-scripts.com or download the mobile app to access the tools and resources available to you upon enrollment in the FSBP – Express Scripts Medicare® PDP.

 When you are enrolled in the FSBP – Express Scripts Medicare^® PDP, you receive the following benefits:

• No deductible on your prescription drugs
• Out-of-Pocket Prescription Maximum of $2,000 per person annually on Medicare Part D drugs
  will accrue towards the Plan’s FEHB accumulative Catastrophic Protection
• No gap in coverage
• Prescription drug copayments or coinsurance per 30-day supply:
  • Generic (preferred, non-preferred, and non-formulary) drug copays– $2
  • Preferred Brand drug copays - $40
  • Non-preferred and non-formulary brand drug copays - $ 75
  • Specialty drug copays – 25% coinsurance up to a $150 maximum

 Part D Premium

You may be subject to an additional Part D Premium when you are enrolled in the FSBP – Express Scripts Medicare^® PDP.  The Medicare Income-Related Monthly Adjustment Amount (IRMAA) is an amount you pay in addition to your Part D premium if your income is above a certain level. Social Security makes this determination based on your income. For additional information concerning the IRMAA, contact the Social Security Administration.

Important Information on Enrollment in our FSBP – Express Scripts Medicare^® Prescription Drug Plan (PDP)

Express Scripts Medicare® PDP is prescription drug plan with a Medicare contract. Enrollment in Express Scripts Medicare depends on contract renewal between Express Scripts and Medicare. It is a separate contract from the FEHB FSBP High Option Plan. Contact Express Scripts at 855-690-8353 or visit www.express-scripts.com for a copy of the Evidence of Coverage.  The Evidence of Coverage contains a complete description of the prescription benefits, exclusions, limitation and conditions of coverage under FSBP – Express Scripts Medicare^® PDP.

• You have FEHB coverage on your own or through your spouse who is also an active employee

• You have FEHB coverage through your spouse who is an annuitant

• It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)

• It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD

• This Plan was the primary payor before eligibility due to ESRD (for 30-month coordination period)

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

• Medicare based on ESRD (for the 30-month coordination period)

• Medicare based on ESRD (after the 30-month coordination period)

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.

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

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

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.

See Section 4, Coinsurance.

See Section 4, Copayment.

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.

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.

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.

Healthcare coverage that you are eligible for because of employment, membership in, or connection with, a particular organization or group that provides payment for any healthcare 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.

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

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 healthcare services that we determine are appropriate to diagnose or treat your condition, illness, or injury and that:

1. Are consistent with standards of good medical practice in the United States;
2. Are clinically appropriate, in terms of type, frequency, extent, site, and duration; and considered effective for the patient’s illness, injury, disease, or its symptoms;
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.

For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community and physician specialty society recommendations.  

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.

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

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 72 and 73 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.

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. You should also see Important Notice About Surprise Billing – Know Your Rights in Section 4 that describes your protections against surprise billing under the No Surprises Act.

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.

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.

Healthcare services provided to an individual without apparent signs and symptoms of an illness, injury, or disease for the purpose of identifying or excluding an undiagnosed illness, disease or condition.

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

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

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

Urgent care claims usually involve pre-service claims and not post-service claims.  We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine. If you believe your claim qualifies as an urgent care claim, please contact 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.

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*

35-39

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

60-69

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

70-72

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*

72-73

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

75-76

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*

76

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

77

In-network (includes Guam): Nothing

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

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

81

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

81-82

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)

91

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

92

The difference between our scheduled allowances and the actual billed amounts

98

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

98

• Care Management Programs
• myStrength™ on-line mental health support program
• AbleTo on-line treatment support
• Institutes of Excellence for tissue and organ transplants
• Gene-Based, Cellular and other Innovative Therapies (GCIT™) Designated Network
• 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

99-
114

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.

28-29