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 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; and
• 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 a 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 carrier to add a family member when there is already family coverage.

Contact your employing or retirement office if you are changing from Self to Self Plus One or Self and Family or to add a family member if you currently have a Self Only plan.

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

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

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

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

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

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

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

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

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 2023 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 2022 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

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

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

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 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).

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

If you leave Federal service, 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 26, regardless of marital status, etc.  

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

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

Alternatively, you can buy coverage through the Health 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 FEHBP coverage.

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

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions. When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 800-638-8432 or visit our website at www.rcbphealth.com

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

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 800-638-8432 or write to us at Rural Carrier Benefit Plan, 1630 Duke Street, 2nd Floor, Alexandria, VA 22314-3466.  You may also request replacement cards through our website: www.rcbphealth.com.    

You can get care from any “covered provider” or “covered facility”. How much we pay – and you pay – depends on the type of covered provider or facility you use. If you use our preferred providers, you will pay less.

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

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

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 800-638-8432 for assistance.

Covered facilities include:

Hospital:

1. An institution that is accredited as a hospital under the hospital accreditation program of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO); or
2. Any other institution that is operated pursuant to law, under the supervision of a staff of doctors and with 24-hour-a-day nursing service, and that is primarily engaged in providing:

• 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
• 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:

1. Is used principally as a convalescent facility, rest facility, nursing facility, or facility for the aged;
2. Furnishes primarily domiciliary or custodial care, including training in the routines of daily living; or
3. 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 abuse. RTCs provide 24-hour residential evaluation, treatment and comprehensive specialized services relating to the individual’s medical, physical, mental health, and/or substance abuse therapy needs all under the active participation and direction of a licensed physician who is practicing 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 that provides convalescent skilled nursing care 24 hours a day and is certified (or is qualified and could be certified) as a skilled nursing facility under Medicare.

Birthing Center: A licensed facility that is equipped and operated solely to provide prenatal care, to perform uncomplicated spontaneous deliveries, and to provide immediate post-partum care.

Hospice: A public or private agency or organization that:

1. Administers and provides hospice care; and
2. Meets one of the following requirements:

• Is licensed or certified as a hospice by the State in which it is located;
• Is certified (or is qualified and could be certified) to participate as a hospice under Medicare;
• Is accredited as a hospice by the JCAHO; or
• Meets the standards established by the National Hospice Organization.

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, or
• lose access to your network specialist because we terminate our contract with your specialist for reasons other than for cause,

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 800-638-8432. 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.

FEHB Carriers must have clauses in their in-network (participating) providers 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.

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 or precertification for certain services. Failure to do so may result in a minimum $500 penalty to be taken from any inpatient or Skilled Nursing facility benefits provided by the Plan.  Please see warning under this Section. In addition, we may deny benefits for services listed in this Section under Other services.

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

Your in-network physician or hospital will take care of requesting precertification. You should always ask your physician or hospital 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, Skilled Nursing Facility stay or residential treatment care by $500 if no one contacts us for precertification. 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 outside the United States.
• 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, then we will become the primary payor and you do need precertification.

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

Please call 800-638-8432 for approval for: 

• Ambulance – prior approval required for transportation by fixed-wing aircraft (plane)
• Autologous chondrocyte implantation, Carticel
• BRCA genetic testing
• Cardiac rhythm implantable devices
• Cataract surgery
• Certain mental health services, inpatient admissions, Residential treatment center (RTC) admissions, Transcranial magnetic stimulation (TMS) and Applied Behavior Analysis (ABA)
• 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 outside of the 50 United States
• Gene therapy, gene editing and gene silencing
• Hip and knee arthroplasties
• Hip surgery to repair impingement syndrome
• Hyperbaric oxygen therapy
• Iatrogenic Infertility
• 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 24 hours or more
• Orthognathic surgery procedures, bone grafts, osteotomies and surgical management of the temporomandibular joint (TMJ)
• Out-of-network freestanding ambulatory surgical facility services, when referred by an in-network provider
• Osseointegrated implant
• Osteochondral allograft/knee
• Pain Management
• Pediatric Congenital Heart Surgery
• Polysomnography (attended sleep studies)
• Proton beam radiotherapy
• Radiation oncology
• Reconstructive or other procedures that maybe 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 medications*
• Spinal procedures, such as:
  • Artificial intervertebral disc surgery
  • Cervical, lumbar and thoracic laminectomy/laminotomy procedures
  • Sacroiliac joint fusions
  • Spinal fusion surgery
  • Vertebral corpectomy
• Uvulopalatopharyngoplasty, including laser-assisted procedures
• Ventricular assist devices

Note: We only cover medically necessary procedures and services. We encourage you to contact the Plan to confirm coverage for proposed treatment prior to incurring services.

*Note: Some specialty medications must be dispensed through CVS Specialty Pharmacy and requires prior authorization. See Section 5(f), Prescription drug benefits. Call CVS Specialty Pharmacy Services at 866-814-5506 to obtain prior authorization.

First, you, your representative, your physician, or your hospital must call us at 800-638-8432 before admission or services requiring prior approval 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 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 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 800-638-8432.  You may also call OPM’s FEHB 2 at 202-606-3818 between 8 AM and 5 PM Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us at 800-638-8432. 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 admission 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 doctor  or the hospital must contact us for precertification  of additional days. Further, if your baby stays after you are discharged, your doctor or the hospital must contact us for precertification of additional days for your baby.

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

• 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 us at 800-292-4182. 

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.

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.

After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure.

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

Example: When you see your In-network physician you pay a copayment of $20 per visit for a primary care provider and $35 per day for a specialist provider. If you see more than one In-network physician on the same day, you pay one copayment for each different physician seen on that day. When you have a stay in an In-network hospital, you pay $200 for the first day of your hospital stay and for an Out-of-network hospital; you pay $400 for the first day of your hospital stay. The $400 does not apply to out-of-network hospital stays for mental health and/or substance use disorders.

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. 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.

• The calendar year deductible for In-network services is $350 per person and for Out-of-network services it is $800 per person. 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 $350 for In-network services or $800 for Out-of-network services under High Option. 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 $700 for In-network services or $1,600 for Out-of-network services under High Option. 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 $700 for In-network services and $1,600 for Out-of-network services.  Any expenses incurred that apply toward deductibles for in-network or out-of-network apply toward both in-network and out-of-network limits.
• We have a separate prescription drug deductible of $200 per person each calendar year that applies to all covered prescription drugs that you purchase at a retail drugstore or pharmacy.  The prescription drug deductible of $200 does not apply to members who have Medicare A and B as primary coverage.
• We also have a separate deductible for dental care of $50 per person each calendar year.

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.

Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance does not begin until you have met your calendar year deductible.

Example: You pay 30% of our allowance for office visits under our Out-of-network benefit.

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 physician ordinarily charges $100 for a service but routinely waives your 30% coinsurance, the actual charge is $70. We will pay $49.00 (70% of the actual charge of $70).

In some instances, a provider may ask you to sign a “waiver” prior to receiving care. This waiver may state that you accept responsibility for the total charge 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 800-638-8432.

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.

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.

When you live in the Plan’s network area, you should use an In-network provider whenever possible. 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 that you pay will usually be much less.

• In-network providers agree to limit what they will bill you. Because of that, when you use a network provider, your share of covered charges consists only of your deductible and coinsurance or copayment. Here is an example about coinsurance:  You see an In-network physician 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 – 15% of our $100 allowance ($15). Because of the agreement, your In-network physician will not bill you for the $50 difference between our allowance and the bill.

Follow these procedures when you use an In-network provider to receive In-network benefits: 

• Verify with us that your home address is correct
• When you make an appointment, verify that the physician or facility is still a network provider
• Present your Rural Carrier Benefit Plan ID card at the time that you receive services to receive In-network benefits
• Generally, you do not pay an in-network provider at the time of service, except for any copayment that you owe. In-network providers must bill us directly. We must reimburse the provider directly.  In-network providers will then bill you for any balance due after our payment to them.
• Out-of-network providers, on the other hand, have no agreement to limit what they will bill you. 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 who charges $150 and our allowance is again $100. Because you’ve 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 and us, the physician can bill you for the $50 difference between our allowance and the bill.

Participating providers agree to limit what they can collect from you. You will still have to pay your deductible and coinsurance. These providers agree to write off the difference between billed charges and the discount amount.

The following illustrates the examples of how much you have to pay out-of-pocket for services from a network physician vs. an out-of-network physician. The table uses our example of a service for which the physician charges $150 and our allowance is $100. The following shows the amount you pay if you have met your calendar year deductible.

EXAMPLE

Network physician

Physician's charge: $150
Our allowance: We set it at $100
We pay: 85% of our allowance: $85
You owe: Coinsurance: 15% of our allowance: $15
+ Difference up to charge? No;$0
Total You Pay: $15

Out-of-network physician

Physician's charge: $150
Our allowance: We set it at $100
We pay: 70% of our allowance: $70
You owe: Coinsurance: 30% of our allowance: $30
+Difference up to charge? Yes; $50
Total You Pay: $80

You should also in see this section under Important Notice About Surprise Billing - Know Your Rights that describes your protection against surprise billing under the No Surprises Act. 

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:

• $5,000 for Self Only enrollment or $10,000 for Self Plus One or Self and Family enrollment when you use In-network providers/facilities and CVS Health In-network retail and/or mail service pharmacy, or
• $7,000 for Self Only enrollment or $14,000 for Self Plus One or Self and Family enrollment when you use Out-of-network providers/facilities and CVS Health Out-of-network retail and/or mail service pharmacy combined.  Any expenses incurred that apply toward the catastrophic out-of-pocket maximum for in-network or out-of-network apply toward both in-network and out-of-network limits.
• 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 cost-sharing amounts for eligible medical expenses 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.

Your out-of-pocket maximum does not include the following:  

• Expenses for dental care
• Expenses in excess of our allowances or maximum benefit limits
• Any penalty you pay for failing to get approval for a hospital stay or residential treatment care
• Any amount you pay for failing to get approval for additional days in the hospital after the initial length of a hospital stay is approved
• Expenses you pay for services, supplies and drugs not covered by us
• Expenses covered by specialty drug copay assistance cards 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 cost-sharing amounts for eligible medical expenses 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. 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 cost-sharing amounts for eligible medical expenses 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.

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

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

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” under certain circumstances. A surprise bill is an unexpected bill you receive from an out-of-network healthcare provider, facility, or air ambulance service for healthcare. Surprise bills can happen when you receive emergency care – when you have little or no say in the facility or provider from whom you receive care. They can also happen when you receive non-emergency services at participating facilities, but you receive some care from out-of-network providers. 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.  

Balance billing happens when you receive a bill from the out-of-network provider, facility, or air ambulance service for the difference between the out-of-network 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 unexpected 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.rcbphealth.com or contact the health plan at 800-638-8432.

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

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

Professional services of physicians, telemedicine consultations (except surgery)

• In physician’s office
• Medical consultations
• In dentist’s office in relation to covered oral and maxillofacial surgical procedures
• Hearing treatment related to non- auditory illness or disease
   

Note: Primary care physicians are limited to general practitioners, family practitioners, internists and pediatricians.

Note: Preauthorization is required for certain specialty drugs. See Section 3, How you get care for information on specialty drugs administered in your physician's office or an outpatient setting.

Note: We pay for surgery services by a physician under Section 5(b), Surgical services.

Supplies, other than diabetic supplies, provided by a physician during an office visit are covered under Section 5(a) of the brochure. See Section 5(a), under durable medical equipment for coverage of diabetic supplies.

Outpatient physical therapy, occupational therapy, and speech therapy are covered under Section 5(a).

Treatment for Mental and Behavioral Health Disorders and Substance Use Disorder is covered under Section 5(e). 

In-network primary care provider: $20 copayment (No deductible)

In-network specialist provider: $35 copayment (No deductible)

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

• Injections

In-network: 15% of the Plan allowance

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

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

Note: we pay medical supplies, medical equipment, prosthetic and orthopedic devices for use at home under Section 5(a), Medical services and supplies.

In-network: $35 copayment (No deductible)

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

Professional services of physicians (except in an urgent care center)

• During a hospital or observation stay
• In a skilled nursing facility
• Initial examination of a newborn child covered under a family enrollment
• In your home 

Note:  We cover contraceptive drugs under Prescription Drug Benefits, Section 5(f).

In-network: 15% of the Plan allowance

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

Professional non-emergency services provided in a walk-in clinic (except in a MinuteClinic®), including telemedicine visits (see Definitions, Section 10)

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

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

Out-of-network: 30% of the Plan allowance and any difference between our allowance and the billed amount.

Professional non-emergency services provided in a MinuteClinic®, including telemedicine visits

In-network: Nothing (No deductible).

Out-of-network: No Benefit

If you are provided drugs (including diabetic drugs) directly by a physician, infusion care provider or durable medical equipment (DME) provider.

In-network: 15% of the Plan allowance

Out-of-network: 30% of the Plan allowance and any difference between our allowance and the billed amount.

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

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

See www.teladoc.com/Aetna or call 855-835-2362 (855-Teladoc) for information regarding consults.

See Section 5(h), Wellness and Other Special Features for additional information.

In-network: Nothing (No deductible)

Out-of-network: No benefit    

Not covered: Phone consultations, mailing, faxes, emails or any other communication to or from a physician, hospital or other medical provider except as provided under Diagnostic and treatment services and Telehealth services.

All Charges

Tests, such as:

• Blood tests 
• Urinalysis
• Non-routine Pap test
• Pathology
• X-ray
• Non-routine mammogram
• CT/CAT Scan
• MRI
• Ultrasound
• Electrocardiogram and EEG
• Sonograms
• Hearing test for non-auditory illness or disease
• Medically appropriate genetic counseling and testing

Note: Urine drug testing/screening is covered only as described in "FEHBP Urine Drug Testing Coverage", available on our website, www.RCBPhealth.com, or by calling us at 800-638-8432.

Note: The Plan offers confidential phone 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.  For more information or to schedule an appointment for genetic counseling, call Informed DNA at 800-975-4819.

In-network: 15% of Plan allowance

Out-of-network: 30% of the Plan allowance and any difference between our allowance and the billed amount.  

Note: If your network provider uses an out-of-network lab or radiologist, we will pay out-of-network benefits for any lab and X-ray charges.

Note: For genetic testing for prescription drugs see Section 5(h), Wellness and Other Special features.

• CT/CAT scans, CTA, MRA, MRI, NC, PET, SPECT, provided at a stand-alone imaging center or clinic

Note: Prior approval for these procedures is required except in the case of an accident or medical emergency. Call us at 800-638-8432 prior to scheduling. See Radiology Imaging under You need prior Plan approval for certain services, Section 3, Other services.

Note: If a stand-alone in-network imaging center or clinic is not used, the regular Lab, X-Ray and diagnostic tests benefits above apply.  Call us at 800-638-8432 for more details and information about stand-alone imaging centers. 

Note: Expenses for related professional services are covered under this benefit.

In-network: 5% of Plan allowance

Out-of-network: 30% of the Plan allowance and any difference between our allowance and the billed amount.

In-network: Nothing (No deductible)

Out-of-network: No benefit

Note: This benefit applies to expenses for lab tests 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 applicable deductibles and coinsurance.

A routine physical exam – one per person each calendar year.

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

Note: Lab tests and X-rays are covered under Lab, X-ray and other diagnostic tests, Section 5(a), unless coded as routine.

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

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

• Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations.
• Colorectal cancer screening, including:
  - Fecal occult blood test
  - Sigmoidoscopy screening - every five years
  - Colonoscopy screening - every ten years
• Dietary and nutritional counseling, up to 26 visits combined per calendar year

• Individual counseling on prevention and reducing health risks

• Prostate cancer screening (PSA) - once per calendar year for members age 40 -69

• 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 go to the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women.
• Routine mammogram

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

To build your personalized list of preventive services go to https://health.gov/myhealthfinder.

In-network: Nothing (No deductible)

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

Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules

Note: Influenza and pneumococcal vaccines are available at most CVS Health participating (In-network) pharmacies without cost to our Plan members. To find a CVS Health participating pharmacy near you, call 800-292-4182.

In-network: Nothing (No deductible)

Out-of-network: Nothing up to the Plan allowance then any difference between our allowance and the billed amount (No deductible)

Not covered:

• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
• Immunizations, boosters, and medications for travel or work-related exposure.

All charges

For covered dependent children under age 22:

• Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org.
• Immunizations such as DTaP, Measles, Mumps, Polio and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at www.cdc.gov/vaccines/schedules/index.html
• Body mass index (BMI) testing for children under age 22
• Dietary and nutritional counseling, unlimited
• Hearing screening exam testing, diagnosis and treatment (including hearing aids for hearing loss)
• Retinal screening exam performed by an opthamologist for infants with low birth weight,  less than 1 year of age and with unstable clinical course

You may also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-and-brecommendations.

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

To build your personalized list of preventive services go to https://health.gov/myhealthfinder.

In-network: Nothing (No deductible)

Out-of-network: Nothing up to Plan allowance then the difference between our allowance and the billed amount (No deductible)

Not covered:

• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic  exams or travel.
• Immunizations, boosters, and medications for travel or work-related exposure.

All charges

Complete maternity (obstetrical) care, such as:

• Screening for gestational diabetes
• Prenatal care (including laboratory tests) 
• Delivery
• Anesthesia
• Postpartum care
• Sonograms

Note: For facility care related to maternity, see Section 5(c), Services Provided by a Hospital or Other Facility, and Ambulance Services.

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

In-network: Nothing (No deductible)

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

Note: If your child is not covered under a Self and Family enrollment, you pay all of your child’s charges after your discharge from the hospital.

Physical and emotional support provided during pregnancy, childbirth and postpartum by a certified doula

In-network and out-of-network: Nothing up to the Plan maximum of $1,200 per person, per calendar year; then all charges (No deductible)

Medically appropriate genetic counseling and testing is covered under Maternity care for maternity related genetic tests.

Note: The Plan offers confidential phone 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.  For more information or to schedule an appointment for genetic counseling, call Informed DNA at 800-975-4819.

In-network: Nothing (No deductible)

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

Note: If your child is not covered under a Self and Family enrollment, you pay all of your child’s charges after your discharge from the hospital.

• Breastfeeding support and counseling for each birth
• Breastfeeding equipment rental or purchase

Note: Breast pump and supplies are limited to the purchase or rental of standard and hospital grade breastfeeding equipment to an amount no greater than what we would have paid if the equipment had been purchased. We will cover only the cost of standard and hospital grade equipment, which includes the items included in the initial supply kit provided with a new pump order.

Note: Breastfeeding supplies such as maternity bras, nursing pads or additional bottles are not covered.  

Note: When breastfeeding equipment and supplies are purchased at a CVS Pharmacy, you pay nothing (No deductible).

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, such as extended stays for you or your baby.
• 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, but you, your representative, your physician or your hospital must precertify the extended stay.
• We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
• We cover the initial routine examination of your newborn infant covered under your family enrollment.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• For services related to an accidental injury or medical emergency, see Section 5(d).
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).    

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

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 they 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.

In-network: Nothing (No deductible)

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

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

In-network: Nothing

Out-of-network: Nothing

A range of voluntary family planning services, including patient education and counseling, limited to:

• Voluntary sterilization (See Section 5(b), Surgical procedures)
• Injection of contraceptive drugs (such as Depo-Provera)
• Intrauterine devices (IUDs)
• Diaphragms

Note: We cover oral contraceptive drugs, diaphragms, cervical caps, vaginal rings and contraceptive hormone patches, see Section 5(f), Prescription drug benefits.

Note: Surgically implanted, fitting, insertion or removal of contraceptive devices is covered under Surgical Services, Section 5(b).

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

In-network: Nothing (No deductible)

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

Not covered:

• Reversal of voluntary surgical sterilization
• Assisted reproductive technology (ART) procedures, such as:
  • Artificial insemination (AI)
  • In vitro fertilization (IVF)
  • Embryo transfer and gamete intrafallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
  • Intracytoplasmic sperm injection (ICSI)
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)
• Services and supplies related to ART procedures, including preimplantation genetic testing
• Infertility drugs used in conjunction with ART procedures
• Cost of donor sperm or egg

Diagnosis and treatment of infertility (See Definitions, Section 10), except as shown in Not covered.

• Initial diagnostic tests and procedures done only to identify the cause of infertility.
• Fertility drugs, hormone therapy and related services
• Medical or surgical procedures done to create or enhance fertility
• Fertility preservation procedures (retrieval of and freezing of eggs or sperm) for members facing the possibility of infertility caused by chemotherapy, pelvic radiotherapy, other gonadotoxic therapies, or ovary or testicle removal for treatment of disease

Note: Fertility preservation procedures requires prior approval, please call 800-638-8432.

Note: Preauthorization is required for certain specialty drugs. See Section 3, How you get care for information on specialty drugs administered in your physician's office or an outpatient setting.

In-network: 15% of the Plan allowance

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

Not covered:

• Infertility services after voluntary sterilization
• Assisted reproductive technology (ART) procedures, such as:
  • Artificial insemination (AI)
  • In vitro fertilization (IVF)
  • Embryo transfer and gamete intrafallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
  • Intracytoplasmic sperm injection (ICSI)
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)
• Services and supplies related to ART procedures, including preimplantation genetic testing; except as stated above
• Infertility drugs used in conjunction with ART procedures
• Cost of donor sperm
• Cost of donor egg 
• Elective fertility preservation, such as egg freezing sought due to natural aging
• Infertility treatments such as in vitro fertilization that might be needed after the necessary medical intervention
• Storage costs

• Testing, including the RAST test, and treatment, including materials (such as allergy serum)

Note: If your physician uses the Quest Diagnostics or LabCorp to test your specimen, you will pay nothing for the lab test.

Note: The allergy services are included in the office visit copayment if performed during an office visit with a network provider.

In-network: Services in a physician’s office --$20 copayment (No deductible)

Services outside the physician’s office—15% of the Plan allowance

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

• Allergy injections

In-network: 15% of the Plan allowance

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

Not covered:

• Food tests
• End point titration techniques
• Sublingual allergy desensitization
• Hair analysis

• Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed on pages 46-49.

• Intravenous (IV)/infusion therapy – home IV and antibiotic therapy
• Human growth hormone therapy (HGHT)
• Respiratory and inhalation therapies
• Cardiac rehabilitation therapy

Note: We cover only Phase 1 and 2 for cardiac rehabilitation therapy.

• Biofeedback only when treating incontinence, migraines, pain management, temporomandibular joint (TMJ) and irritable bowel syndrome (IBS).

Note: Applied Behavioral Analysis (including the assessment) is covered under Section 5(e), Mental Health and Substance Use Disorder Benefits and requires prior approval.  See Section 3, under How you get care.     

Note: Preauthorization is required for certain specialty drugs. See Section 3, How you get care for information on specialty drugs administered in your physician's office or an outpatient setting.

In-network: 15% of the Plan allowance

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

Note: The Plan pays for services, supplies, and tests rendered for the direct treatment of cancer under Wellness and Other Special features, Section 5(h).

Note: The Plan pays for services, supplies, and testing for kidney (renal) dialysis under Wellness and Other Special features, Section 5(h).

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

• Gene therapy (examples: Zolgensma, Luxturna)
• Cellular therapy (example: CAR-T treatments)
• Manipulation of gene expression (example: Spinraza)
• Gene editing (example: CRISPR technology)

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 800-638-8432 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 and may provide travel assistance, see Section  5(h), Wellness and Other Special Features, GCIT Designated Network.  For additional information regarding the GCIT Designated Network, please call 800-638-8432.

GCIT Designated Network: 15% of the Plan allowance

Out-of-network: No benefit

For physical therapy, speech therapy and occupational therapy:

• 90 total combined visits per calendar year

Note: We provide physical, occupational and speech therapy for those diagnosed with Autism.

Note: Inpatient physical, occupational and speech therapies are covered under Section 5(c).

In-network: 15% of the Plan allowance

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

Not covered:

• Long-term rehabilitative therapy
• Exercise programs

• Routine hearing exam, including evaluation and diagnostic hearing tests performed by an M.D.,D.O. or audiologist

Note: For routine hearing screening performed during a child’s preventive care visit, see Section 5(a), Preventive care, children.

Note: For benefits for adult hearing devices, see Section 5(a), Orthopedic and prosthetic devices. 

In-network: Nothing (No deductible)

Out-of-network: Nothing (No deductible)    

Not covered:

• Hearing aids and related expenses, except as noted above

• One pair of eyeglasses with standard frames or contact lenses (including fitting) to correct a change in sight caused directly by an accidental eye injury or intraocular surgery (such as for cataracts), within one year of the injury or surgery

Note: See Orthopedic and prosthetic devices in this section for intraocular lens coverage.

Note: Diabetic retinal eye exams are covered under Section 5(a), Diagnostic and treatment services.

In-network: 15% of the Plan allowance

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

Routine eye exam, including refractions

Note: The itemized bill must show that you had a routine eye exam to qualify for this benefit.

In-network: Nothing up to $45, then all charges (No deductible)

Out-of-network: Nothing up to $45, then all charges (No deductible)

Not covered:

• Eyeglasses or contact lenses , except as shown above
• Deluxe lens features for eyeglasses or contact lenses such as special coatings, polarization and UV treatment 
• Eye exercises and orthoptics
• Refractive eye surgery and related expenses 
• All refractive corneal or intraocular surgeries for vision correction without an underling medical condition

In-network: 15% of Plan allowance

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

Not covered:

• Treatment or removal of corns and calluses, or trimming of toenails, except as stated above 
• Orthopedic shoes and other devices to support the feet, except as shown in Section 5(a), Orthopedic and prosthetic devices

• 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 intraocular lens (IOLs), cochlear implants, bone anchored hearing aids (BAHA), artificial joints, pacemakers and surgically implanted breast implant following mastectomy

Note: Multifocal, accommodating, toric, or other premium intraocular lenses (IOLs) including Crystalens, ReStor, and ReZoom are covered.

Note: See Section 5(b) for coverage of the surgery to insert the device and Section 5(c) for services provided by a hospital.

In-network: 15% of the Plan allowance

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

• Up to $500 for wigs needed as a result of chemotherapy or radiation treatment for cancer

Note: This benefit is available once per calendar year.

In-network: Nothing up to $500, then all charges (No deductible)

Out-of-network: Nothing up to $500, then all charges (No deductible)

Hearing aids for adults

• Adult hearing aids and related services.

Note: This benefit is available once every three years.

In-network: Nothing up to $3,000 per adult, then all charges (No deductible)

Out-of-network: Nothing up to $3,000 per adult, then all charges (No deductible)

Foot orthotics

• Prescribed by a physician
• Custom fitted, including necessary repair and adjustment
• Impression casting
• Corrective shoes to treat malformation and weakness of the foot

In-network: 15% of the Plan allowance

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

Not covered:

• Corsets, trusses, and other supportive devices, unless we determine their medical necessity

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

• Are prescribed by your attending physician (i.e., the physician 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;
• Have a 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:

• Oxygen
• Dialysis equipment
• Hospital beds
• Wheelchairs
• Crutches
• Walkers
• Colostomy and ostomy supplies
• Diabetic supplies
• Elastic stockings and support hose that require a physician’s or other healthcare professional’s written prescription
• Medical foods and nutritional supplements when administered by catheter or nasogastric tube
• Seat lift mechanism on a lift chair provided that all of the following criteria are met:
  • The patient has severe arthritis of the hip or knee or a severe neuromuscular disease
  • The seat lift mechanism is part of a physician's treatment plan and is prescribed to improve the patient's condition or stop or delay deterioration in the patient's condition
  • The patient is incapable from standing up from any chair in the home
  • After standing, the patient must be able to walk

Note: Coverage is limited to the seat lift mechanism only, even if the mechanism is part of a chair. 

Note: We will only cover the cost of standard equipment. Coverage for specialty items such as all terrain wheelchairs is limited to the cost of the standard equipment. 

Note: We cover durable medical equipment (DME) at the In-network benefit level only when you use an In-network DME provider. In-network physicians, facilities, and pharmacies are not necessarily In-network DME providers.

Note: We will cover charges for service contracts for medically necessary durable medical equipment that is purchased or rented.

In-network: 15% of the Plan allowance

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

Augmentative and alternative communications (AAC) devices such as:

• Computer story boards
• Light talkers
• Enhanced vision systems
• Speech aid prosthesis for pediatrics
• Speech aid prosthesis for adults
• Magnifier viewing system
• Script talk reader devices 

In-network: Nothing up to a maximum of $1,000 per device per calendar year (No deductible)

Out-of-network: Nothing up to a maximum of $1,000 per device per calendar year (No deductible)

Note: Limited to one device per person per calendar year

Not covered:

• Sun or heat lamps, whirlpool bath, heating pads, air purifiers, humidifiers, air conditioners and exercise devices
• Desktop and laptop computers, pagers, personal digital assistants (PDAs), smart phones, and tablet devices (e.g., iPad), 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 doctor prescribes them or if a prescription is required  under your state law

We pay for up to 90 visits per person per calendar year when:

• A registered nurse (R.N.), licensed practical nurse (L.P.N.) or licensed vocational nurse (L.V.N.) provides the services;
• The attending physician orders the care;
• The physician identifies the specific professional skills required by the patient and the medical necessity for skilled services; and
• The physician indicates the length of time the services are needed.

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

Note:  For physical, occupational and/or speech therapy services performed during a home health visit see Section 5(a), Physical, occupational and speech therapy.

In-network: 15% of the Plan allowance (No deductible).  You pay all charges after 90 visits per calendar year.

Out-of-network: 30% of the Plan allowance and any difference between our allowance and the billed amount (No deductible). You pay all charges after 90 visits per calendar year.

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient’s family;
• Services  consisting of only hygiene, feeding, exercising, moving the patient, homemaking, companionship, or giving oral medication;
• Custodial care as defined in Section 10

• Manipulation of the spine and extremities

In-network: $20 copayment per visit (No deductible)

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

Acupuncture for:

• Anesthesia
• Pain relief
• Therapeutic purposes

Note: Please see the definition of acupuncture in Section 10.

In-network: 15% of the Plan allowance for up to 30 visits per person each calendar year (No deductible). After 30 visits, you pay all charges.

Out-of-network: 30% of the Plan allowance and any difference between our allowance and the billed amount for up to 30 visits per person each calendar year (No deductible). After 30 visits, you pay all charges. 

Massage therapy only when performed by a covered provider (see Section 3) limited to 30 visits per person, per calendar year

Note: Massage therapy is limited to one visit per day.

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: 15% of the Plan allowance for up to 30 visits per person each calendar year (No deductible). After 30 visits, you pay all charges. 

Out-of-network: 30% of the Plan allowance and any difference between our allowance and the billed amount for up to 30 visits per person each calendar year (No deductible). After 30 visits, you pay all charges.

Not covered:

• Naturopathic services
• Chelation therapy, except for arsenic, gold, lead or mercury poisoning and the use of desferoxamine for iron poisoning 
• Rolfing
• Cupping

Tobacco Cessation Program

• Two quit attempts per calendar year as part of the Plan’s tobacco and nicotine cessation Program. The quit attempts include proactive phone counseling and up to four tobacco cessation counseling sessions of at least 30 minutes each in each quit attempt. 

Note: Over-the-counter (OTC) and prescription medications approved by the FDA to quit smoking (vaping) or other nicotine use can be obtained at no charge, see Section 5(f), Prescription drug benefits for more details. 

Note: To enroll in the program, contact a Health Coach at 866-533-1410. Coaches are available Monday – Friday from 8:00 a.m. – 9:00 p.m. E.T.  You may also enroll online at www.myactivehealth.com/RCBP.

In-network: Nothing (No deductible) 

Out-of-network: Nothing (No deductible)

Diabetic education

• One diabetic education and training program per person each calendar year.

In-network: 15% of the Plan allowance (No deductible)

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

Telephonic Health Coach Program

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

• Tobacco cessation 

• Weight management 

• Exercise 

• Nutrition 

• Stress management 

• Pain management and opioid support

• High blood pressure

• High cholesterol 

See the Plan’s benefit, Telephonic Health Coach Program, in Section 5(h), Wellness and Other Special features.

In-network: Nothing (No deductible) 

Out-of-network: No benefit

Not covered:

• Body composition analysis
• Nutritional supplements or food, except those covered under Section 5(a), Durable medical equipment
• Non-prescription drugs or supplies
• Exercise or weight loss programs and exercise equipment
• Services that are not medically necessary

A comprehensive range of services, such as:

• Surgical procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Circumcision
• Treatment of burns

In-network: 15% of the Plan allowance (No deductible)

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

Gender affirming surgery is considered medically necessary for the following services when all criteria has been met:

- 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)

Note: Prior approval is required. Call us at 800-638-8432 or see our  clinical policy bulletin for more information. See Section 3, Other services.

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

In-network: 15% of the Plan allowance (No deductible)

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

Surgical treatment of morbid obesity (Bariatric surgery)-- a condition in which a person (1) has a Body Mass Index (BMI) equal to or greater than 40 or a BMI equal to or greater than 35 with other illnesses such as hypertension, heart disease, diabetes, sleep apnea, nonalcoholic steatohepatitis (NASH) or hyperlipidemia, and; (2) has been under at least one physician 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 800-638-8432 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

In-network: 15% of the Plan allowance (No deductible)

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

• Voluntary male sterilization (e.g., vasectomy)
• Voluntary female sterilization (e.g., tubal ligation)
• Surgically implanted contraceptives
• Intrauterine devices (IUDs)  

Note: For related and necessary services to voluntary sterilization, such as anesthesia and outpatient facility charges, we cover 100% of the Plan allowance for In-network care. 

In-network: Nothing (No deductible)

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

When multiple or bilateral surgical procedures are performed during the same operative session by the same surgeon, our benefits are:

• For the primary procedure: the Plan's allowance 
• For the secondary procedure: 50% of the Plan allowance (unless the network contract or other participating provider 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: 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: 15% of the Plan allowance for the primary procedure (No deductible)

Out-of-network: 30% of the Plan allowance for the individual procedure and any difference between our allowance and the billed amount

Co-surgeons

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 a single surgeon for the same procedure(s), unless the network contract or other participating provider contract provides for a different amount.

In-network: 15% of the Plan allowance (No deductible)

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

Assistant Surgeons

Assistant surgical services provided by a surgeon    (M.D. or D.O.) 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 is 12% of the allowance for the surgery when provided by a non-physician (such as but not limited to physician assistant, nurse practitioner, or clinical nurse specialist) or when minimum surgical assistant services are provided (unless the network contract or other participating provider contract provides for a different amount).

In-network: 15% of the Plan allowance (No deductible)

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

Not covered:

• Reversal of voluntary sterilization
• All refractive eye surgeries and similar services
• Dental appliances, study models, splints, and other devices or service related to the treatment of TMJ dysfunction
• Treatment or removal of corns and calluses, or trimming of toenails
• Mutually exclusive procedures-- surgical procedures that are not generally performed on one patient on the same day

• Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury and 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 on the previous page.

• 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 the surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers or toes.
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • Surgery to produce a symmetrical appearance of breasts;
  • treatment of any physical complications, such as lymphoedema;
  • breast prostheses; and surgical bras and replacements (see Section 5(a), 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: 15% of the Plan allowance (No deductible)

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

Not covered:

• Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury and 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 on the previous page

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion
• Removal of stones from salivary ducts
• Excision of pathological tori, tumors, and premalignant and malignant lesions
• Excision of impacted (unerupted) teeth, including anesthesia 
• Excision of cysts and incision of abscesses when done as independent procedures
• Oral surgical biopsy
• Surgical correction of temporomandibular joint (TMJ) dysfunction
• Frenectomy and frenotomy not as a result of orthodontic care  

In-network: 15% of the Plan allowance (No deductible)

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

Not covered:

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

These solid organ transplants are covered. These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan.  Please see Section 3, Other services for prior approval procedures. 

Solid organ transplants limited to:

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

In-network: 15% of the Plan allowance (No deductible)

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

These tandem blood or marrow stem cell transplants for covered transplants are not subject to medical necessity review by the Plan. Please see 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)

In-network: 15% of the Plan allowance (No deductible)

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

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
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Acute myeloid leukemia 
  • Advanced Myeloproliferative Disorders (MPDs)
  • Amyloidosis 
  • Chronic lymphocytic leukemia/small lymphocytic leukemia (CLL/SLL)
  • Hemoglobinopathy
  • Infantile malignant osteopetrosis
  • Leukocyte adhesion deficiencies
  • Kostmann’s symdrome
  • Marrow failure and related disorders (i.e., Fanconi's, Paroxysmal nocturnal hemoglobinuria, Pure Red Cell Aplasia)
  • Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  • Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s syndrome, Sanfilippo’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
  • Medullablastoma
  • Ewing’s sarcoma
  • Multiple myeloma
  • Neuroblastoma
  • Pineoblastoma
  • Testicular, Mediastinal, Retroperitoneal and Ovarian germ cell tumors
  • Waldenstorm’s macroglobulinemia

In-network: 15% of the Plan allowance (No deductible)

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

Mini-transplants (non-myeloblative reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan. Please see Section 3, Other services for prior approval procedures.

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic leukemia (CLL/SLL)
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e. Fanconi’s, PNH, Pure Red Cell Aplasia)-Paroxysmal Nocturnal Hemoglobinuria-Severe or very severe aplastic anemia
  • Severe combined immunodeficiency
  • Myelodysplasia/Myelodysplastic syndromes
• 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
  • Neuroblastoma

In-network: 15% of the Plan allowance (No deductible)

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

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

• Allogeneic transplants for:
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Beta Thalassemia Major
  • Chronic inflammatory demyelination polyneuropathy (CIDP)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Sickle Cell anemia

• Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning or RIC) for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Breast cancer
  • Chronic lymphocytic leukemia
  • Chronic myelogenous leukemia
  • Colon cancer
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Myeloproliferative disorders (MDDs)
  • Myelodysplasia/Myelodysplastic Syndromes
  • Non-small cell lung cancer
  • Ovarian cancer
  • Prostate cancer
  • Renal cell carcinoma
  • Sarcomas
  • Sickle cell anemia

• Autologous transplants for:
  • Advanced Hodgkin’s lymphoma
  • Advanced Ewing sarcoma
  • Advanced Childhood kidney cancers
  • Advanced non-Hodgkin’s lymphoma
  • Aggressive non-Hodgkin’s lymphomas
  • Breast cancer
  • Childhood rhabdomyosarcoma
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Epithelial ovarian cancer
  • Mantle Cell (Non-Hodgkin lymphoma)
  • 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.

Note: All allowable charges incurred for a surgical transplant, whether incurred by the recipient or donor, will be considered expenses of the recipient and will be covered the same as for any other illness or injury subject to the limits stated above. This benefit applies only if we cover the recipient and if the donor's expenses are not covered under any other health plan for transplants.

Note: We cover donor screening and search expenses for up to four (4) candidate donors per transplant in addition to testing family members.    

Note: Aetna has special arrangements with  transplant facilities to provide services for tissue and organ transplants (see Section 5(h), Wellness and Other Special features, Institutes of Excellence).  The transplant network is designed to give you the 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 physician can coordinate arrangements by calling Aetna at 800-638-8432.

In-network: 15% of the Plan allowance (No deductible)

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

Not covered:

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

Professional services provided in:

• Hospital (inpatient)
• Hospital outpatient department
• Skilled nursing facility
• Ambulatory surgical center
• Physician's office

Note: When multiple anesthesia providers are involved during the same surgical session, the Plan’s allowance for each anesthesia provider will be determined using the Center for Medicare and Medicaid (CMS) guidelines.

In-network: 15% of the Plan allowance (No deductible)

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

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: An overnight stay in a hospital does not always mean you are admitted as an inpatient. You are considered an inpatient the day your physician formally admits you to a hospital with a doctor's order. Whether you are an inpatient or outpatient affects your out-of-pocket expenses. Always ask if you are an inpatient or outpatient at the hospital.  

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Rehabilitative services
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Blood or blood plasma, if not donated or replaced
• Dressings, splints, casts, and sterile tray services

Note: We base payment on whether the facility or a healthcare professional bills for the services or supplies. For example, when the anesthesiologist bills, we pay Anesthesia benefits. If preadmission testing is performed in the hospital as inpatient then we pay pre-admission tests at the same coinsurance rate as inpatient miscellaneous charges, unless billed by the facility.

In-network: $200 copayment for each hospital admission (copayment waived for a maternity stay) 

Out-of-network: $400 copayment for each hospital admission and 30% of the Plan allowance

Not covered:

• Any part of a hospital admission that is not medically necessary (see definition in Section 10), 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 other medically necessary services and supplies you received other than room and board and in-hospital physician care at the inpatient level.
• Hospital charges for non-covered surgery 
• Custodial care (see definition in Section 10) even when provided in a hospital 
• Non-covered facilities, such as nursing homes, rest homes, convalescent homes, facilities for the aged, and schools
• Personal comfort items, such as phone, television, radio, newspapers, air conditioner, beauty and barber services, guest meals and beds
• Private nursing care during a hospital stay 

• Operating, recovery, and other treatment rooms, including observation care less than 24 hours
• Prescribed drugs and medications
• Diagnostic laboratory tests, X-rays , and pathology services
• Administration of blood, blood plasma, and other biologicals
• Blood and blood plasma, if not donated or replaced
• Pre-surgical testing
• Dressings, casts, and sterile tray services
• Medical supplies, including oxygen

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.

We base payment on whether the facility or a healthcare professional bills for the services or supplies. For example, when the physician bills for surgery, we pay Surgery benefits.

In-network: 15% of the Plan allowance (calendar year deductible applies) (cost-share is waived for maternity services)

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

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

• Gene therapy (examples: Zolgensma, Luxturna)
• Cellular therapy (example: CAR-T treatments)
• Manipulation of gene expression (example: Spinraza)
• Gene editing (example: CRISPR technology)

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 800-638-8432 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 and may provide travel assistance, see Section  5(h), Wellness and Other Special Features, GCIT Designated Network.  For additional information regarding the GCIT Designated Network, please call 800-638-8432.

GCIT Designated Network: 15% of the Plan allowance (calendar year deductible applies)

Out-of-network: No benefit

Not covered:

• Outpatient hospital services/supplies for surgery we do not cover except as noted above.

We cover semiprivate room, board, services and supplies in a Skilled Nursing Facility (SNF) for up to 60 days per calendar year when:

• The stay is medically necessary
• The stay is supervised by a physician  

Note: If Medicare pays first for your care, the first 20 days of your stay (paid in full by Medicare) do not count toward the 60-day benefit limit each calendar year.

Note: Skilled nursing facility admissions require precertification; failure to do so will result in a minimum $500 penalty.

In-network: $200 copayment for each admission and all charges in excess of the 60-day maximum 

Out-of-network: $400 copayment for each admission, 30% of the covered charges and all charges in excess of the 60-day maximum and the difference between the Plan allowance and the billed amount

Not Covered:

• Custodial care

Hospice is a coordinated program of maintenance and supportive care designed to provide palliative and supportive care to members with a projected life expectancy of six (6) months or less due to a terminal medical condition, as certified by the member’s physician or specialist and provided by a medically supervised team under the direction of a Plan-approved independent hospice administration.

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

Note: See Section 5(h), Wellness and Other Special Features, Care Management Program for more information on advance care planning.

In-network: 15% of the Plan allowance (No deductible)

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

Not covered: 

• Private duty nursing
• Custodial care

• Homemaker services

• Home hospice care (e.g., care given by a home health aide) that is provided and billed for by other than the approved home agency when the same type of care is already being provided by the home hospice agency.

• Professional ambulance service to the nearest facility equipped to handle the patient's condition, including air ambulance when medically necessary.

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

Note: See Section 5(d) for emergency ambulance service. 

In-network: 15% of the Plan allowance (No deductible) 

Not covered:

• Ambulance transportation for your own or your family's convenience
• Transportation to other than a hospital, skilled nursing facility, dialysis, hospice or urgent care medical facility
• Ambulance and any other modes of transportation to or from services including, but not limited to, physician appointments, or diagnostic tests, except as part of covered inpatient hospital care

If you or a family member is accidentally injured, the Plan will pay up to the Plan allowance for:

• Covered services and supplies provided in an initial emergency room facility visit for an accidental injury; or
• Covered services and supplies provided in an initial urgent care center visit for an accidental injury; or 
• Covered services and supplies provided during the initial visit to a physician's office for an accidental injury, including related services outside the physician's office. Services must be provided the same day as the initial office visit. We pay for services performed after the initial visit, such as x-rays, laboratory tests, drugs, or any supplies or other services under Section 5(a); 
• Series of Rabies vaccinations

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.

In-network: Nothing (No deductible)

Plan benefits are paid for care you receive because of a medical emergency (non-accident) like a heart attack or stroke, including anesthesia.

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

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: Services in a primary care provider’s office--$20 copayment (No deductible)

In-network: Services in a specialist provider’s office-$35 copayment (No deductible)

Out-of-network: 15% of the Plan allowance and any difference between our allowance and the billed amount (No deductible)

In-network: Services outside the primary care provider's or specialist provider's office— $200 copayment (No deductible)  

Out-of-network: Services outside the primary care provider's or specialist provider's office— $200 copayment and any difference between our allowance and the billed amount (No deductible)  

Services you receive for your medical emergency in an urgent care center.

Note: We pay medical supplies, medical equipment, prosthetic and orthopedic devices for use at home under Section 5(a), Medical services and supplies.

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

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

• Professional ambulance service to the nearest facility equipped to handle the patient's condition, including air ambulance when medically necessary.

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

Note: See 5(c) for non-emergency service.

In-network: 15% of the Plan allowance (No deductible) 

Not covered: 

• Ambulance transport for your own or your family's convenience
• Transportation to other than a hospital, skilled nursing facility, dialysis, hospice or urgent care medical facility

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

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

• Psychiatric office visits to behavioral health practitioner
• Substance Use Disorder (SUD), including detoxification, treatment and counseling
• Behavioral therapy
• Telemedicine consultations

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

In-network: $20 copayment (No deductible)

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

Applied Behavioral Analysis (ABA)

The Plan covers medically necessary applied behavioral analysis therapy including the assessment 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 analyst certified by the Behavior Analyst 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.

NOTE: Assessment and treatment for ABA requires prior approval. See Section 3, How you get care for information on how to precertify and obtain prior approval for your care.

In-network: 15% of the Plan allowance (No deductible)

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

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 a stay in 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: 15% of the Plan allowance (No deductible)

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

Telehealth consultations are available to members in the 50 United States through Teladoc® such as:

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

See www.teladoc.com/Aetna or call 855-835-2362 (855-Teladoc) for information regarding consults.

See Section 5(h), Wellness and Other Special Features for additional information.

In-network: Nothing (No deductible)

Out-of-network: No benefit

AbleTo is a web-based video conferencing personalized 8-week treatment support designed to address the unique emotional and behavioral health needs of individuals learning to live with conditions like heart disease, type 2 diabetes, chronic pain or life events like losing a loved one or having a baby.

Note: AbleTo support is available to all members in the 50 United States.

Note: See Section 5(h), AbleTo Support Program for additional information about this program.

In-network: Nothing (No deductible)

Out-of-network: No benefit

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

In-network: 15% of the Plan allowance

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

In-network: 15% of the Plan allowance (No deductible)

Inpatient services provided and billed by a hospital or other covered facility, including an overnight residential treatment facility (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 but not limited to: 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: $200 copayment for each hospital admission (No deductible)

Out-of-network: 30% of the covered charges (No deductible)

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

All other outpatient mental health treatment, including:

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

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.

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. 

In-network: 15% of the Plan allowance (No deductible)

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

• Services we have not approved
• All charges (including room and board) for chemical aversion therapy, conditioned reflex treatments, narcotherapy, and similar aversion treatments
• Counseling or therapy for marital, educational, sexual paraphilias, behavioral diagnoses, or related to mental retardation and learning disorders 
• Community based programs such as self-help groups or 12-step programs

When you enroll in the Plan, you will receive a description of our prescription drug program, a combined prescription drug/Plan identification card, a mail service order form/patient profile and a preaddressed reply envelope for the mail service prescription program.

You may purchase the following medications and supplies prescribed by a physician from either a retail pharmacy or through the CVS Caremark mail service pharmacy: 

• Drugs and medications (including those administered during a non-covered admission or in a non-covered facility) that require a physician's written prescription under U.S. Federal law, except those listed as Not covered   
• Vitamins and minerals that require a physician's prescription for purchase under U.S. Federal law 
• Insulin and diabetic supplies such as test strips, lancets, etc. 
• Disposable needles and syringes for the administration of covered medications
• Drugs to treat gender dysphoria
  Note: Certain drugs to treat gender dysphoria are considered Specialty drugs, see Specialty drugs section.

• Tobacco cessation drugs and medications. See also Educational classes and programs in Section 5(a), Medical services and supplies for information about the Plan’s Tobacco Cessation Program
• Prescription drugs for weight management
• Medical foods, as defined by the U.S. Food and Drug Administration, that are consumed or administered enterally and are intended for the specific dietary management of a disease or condition for which there are distinctive nutritional requirements.

The Plan covers medical food formulas and enteral nutrition products that are ordered by a healthcare provider and are medically necessary to prevent clinical  deterioration in members at nutritional risk.(See Coverage below) Must meet the definition of medical food (see Definitions, Section 10,)

Must be receiving active, regular, and ongoing medical supervision and must be unable to manage the condition by modification of diet alone.

Coverage is provided as follows: 

Inborn errors of amino acid metabolism 

Food allergy with atopic dermatitis, gastrointestinal symptoms, IgE mediation, malabsorption disorder, seizure disorder, failure to thrive, or prematurity, when administered orally and is the sole source (100%) of nutrition. This once per lifetime benefit is limited to one year following the date of the initial prescription or physician order for the medical food (e.g., Neocate, in a formula form or powders mixed to become formulas)

Note: A prescription is required for medical foods provided under the pharmacy benefit.

Note: Prescription drugs for weight management require prior authorization.

Note: Colostomy and ostomy supplies are covered under Section 5(a), Durable medical equipment.

Note: A blood glucose meter can be provided at no charge. For more information on how to obtain a blood glucose meter, call toll-free: 800-588-4456.

Note: For long-term maintenance medications, you are limited to the initial prescription and two refills at a CVS In-network retail pharmacy or at an Out-of-network retail pharmacy. You must use the CVS Caremark mail service pharmacy or a CVS Pharmacy for a continuing supply of the medication after three fills.

In-network Retail, up to a 34-day supply: 

• Tier 1: 30% of cost; maximum $7.50 per prescription
• Tier II: 30% of cost; maximum $200 per prescription
• Tier III: 30% of cost; maximum $200 per prescription

In-network Retail, up to a 34-day supply, Medicare Part B primary payor:

• Tier 1: 30% of cost; maximum $7.50 per prescription (No deductible)
• Tier II: 30% of cost; maximum $200 per prescription (No deductible)
• Tier III: 30% of cost; maximum $200 per prescription (No deductible)

Out-of-network Retail: 30% of cost

Out-of-network Retail, Medicare Part B primary payor: 30% of cost (No deductible)

CVS Retail Pharmacy, 90-day supply or CVS Caremark mail service, up to 90-day supply: 

• Tier I: $10 generic (No deductible)
• Tier II: $50 brand name on primary drug list (No deductible)
• Tier III: $80 brand name not on primary drug list (No deductible)

CVS Retail Pharmacy, 90-day supply or CVS Caremark mail service, up to 90-day supply; Medicare Part B primary payor:

• Tier I: $10 generic (No deductible)
• Tier II: $40 brand name on primary drug list (No deductible)
• Tier III: $70 brand name not on primary drug list (No deductible)

Drugs and diabetic supplies (including insulin), when Medicare Part B is the primary payer.

Note: You must show your Medicare ID card at the pharmacy when purchasing these items and Medicare must pay first in order to receive the maximum benefit.

Nothing (No deductible) 

Specialty drugs are used to treat treat gender dysphoria, chronic complex conditions and require special handling and close monitoring and must be obtained from CVS Specialty Pharmacy.

Note: Preauthorization is required. Call CVS Specialty Pharmacy at 866-814-5506 for more information

CVS Caremark Specialty Pharmacy 30-day supply (includes when retired with Medicare Part B coverage):

• Tier IV: $70 Specialty generic drugs (No deductible)
• Tier V: $90 Specialty preferred brand drugs (No deductible)
• Tier VI: $120 Specialty non-preferred brand drugs (No deductible)

CVS Caremark Specialty Pharmacy 90-day supply (includes when retired with Medicare Part B coverage):

• Tier IV: $100 Specialty generic drugs (No deductible)
• Tier V: $125 Specialty preferred brand drugs  (No deductible)
• Tier VI: $250 Specialty non-preferred brand drugs  (No deductible)

Narcan (rescue agent)

Note: If you are in a state that requires a prescription in order to purchase Narcan, you will have to obtain one from your healthcare provider. Otherwise, you may purchase Narcan without a prescription. Please contact your local network pharmacy for more information.

In-Network Retail: Nothing (No deductible)

Out-of-network Retail: Nothing (No deductible)

CVS Caremark mail service: Nothing (No deductible)

Over-the-counter (OTC) nicotine replacement therapy or prescription drugs approved by the FDA to treat and nicotine dependence.  A doctor's written prescription is required. See also Educational classes and programs in Section 5(a), Medical services and supplies for information about the Plan’s Tobacco Cessation Program.   

In-Network Retail: Nothing (No deductible)

Out-of-network Retail: Nothing (No deductible)

CVS Caremark mail service: Nothing (No deductible)

• Medications to promote better health as recommended by ACA and the U.S. Preventive Services Task Force (USPSTF) with a rating of “A” or “B”
• CVS Caremark ACA No-Cost Preventive Services List

Drugs and supplements on the lists are covered even if they are listed as over-the-counter. Your doctor must write a prescription for these preventive services and they must be filled at a network pharmacy.

Note: A complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) with a rating of “A” or “B” is available online at www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-and-b-recommendations.

Note: A complete list of CVS Caremark No-Cost preventive care services is available online at www.caremark.com.

In-network Retail:  Nothing

Out-of-network Retail:  All Charges

Contraceptive drugs and devices as listed in the ACA/HRSA site, coverage includes:

• Oral contraceptives
• Emergency Contraceptives
• Injectable Contraceptives
• Miscellaneous Contraceptives —Intrauterine Devices, Subdermal Rods & Vaginal Rings
• Contraceptive transdermal patches
• Barrier Methods- Cervical Caps and Diaphragms
• OTC—Contraceptives (requires prescription)
• Vaginal pH Modulators

Call us at 800-292-4182 for our contraceptive exception process or for information on our reimbursement for OTC contraceptives (prescription required).

In-Network Retail: Nothing (No deductible)

Out-of-network Retail: Nothing (No deductible)

CVS Caremark mail service: Nothing (No deductible)

• Drugs and supplies for cosmetic purposes
• Drugs to treat impotence and sexual dysfunction
• Medical foods and nutritional supplements, except as described in Section 5(a), Durable medical equipment
• Nonprescription (over-the-counter) medications, except as noted above

All Charges

The Plan will pay for the treatment or repair (including root canal therapy and crowns) of an accidental injury to sound natural teeth (not from biting or chewing).

The services and supplies must be provided within one year of the accidental dental injury and the Patient must be a Plan member when the dental services are received.

Note: We may request dental records, including X-rays, to verify the condition of your teeth before the accidental injury. Charges covered for dental accidents cannot be considered under Dental benefits.

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

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

The Plan  pays actual charges for up to
two preventive care visits per person
each calendar year up to the scheduled
Plan allowance (No deductible).

Note: You are responsible for all charges that exceed the Plan's scheduled allowance for the service listed below.

$12.50 twice each calendar year

Prophylaxis, adult and child

$22.00 twice each calendar year

• Prophylaxis with fluoride treatment (thru age 22)

$24.00 twice each calendar year

Space maintainer

$88.00

Complete X-ray series

$34.00

Panoramic X-ray

$34.00

Single intraoral X-ray/bitewing single film

$5.50

Each additional intraoral X-ray (up to 7)

$4.00

$9.00

$14.00

After a deductible of $50 per person during the calendar year, the Plan pays actual charges up to the scheduled allowance for each service. There is no annual limit on the amount of services you receive.

Note: You are responsible for all charges that exceed the Plan's scheduled allowance for the service listed below.

Restorations - 1 surface permanent

$14.00

Restorations - 2 surface permanent

$20.50

Restorations - 3 or more surface permanent

$26.50

Restorations - Gold restoration

$103.50

Extractions - Single tooth

$16.00

Extractions - Pulp capping-direct

$9.50

Extractions - Pulpotomy-vital

$21.00

Root canal therapy - one root
This includes the actual root canal treatment  and any replacements

$106.00

Root canal therapy - Two roots
This includes the actual root canal treatment  and any replacements

$126.00

Root canal therapy - Three or more roots
This includes the actual root canal treatment  and any replacements

$170.00

Periodontics - Periodontal scaling and root planning

$26.50

Crowns/abutments - Resin and Resin with metal

$120.00

Crowns/abutments - Porcelain

$113.50

Crowns/abutments - Porcelain with gold

$120.00

Crowns/abutments - Gold (full cast and 3/4 cast)

$120.00

Crowns/abutments - Prefabricated resin and stainless steel

$21.50

Pontics - Porcelain and Porcelain with gold

$120.00

Dentures - Complete upper and lower

$126.00

Dentures - Partial without bar

$138.00

Dentures - Partial with bar

$157.00

Dentures - Repairs (dentures and partials)

$14.00

Dentures - Denture relining

$40.50

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 claims process (see Section 8). 

The Plan has special arrangements with facilities to provide services for tissue and organ transplants only. The transplant network was designed to give you the 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 Institutes of Excellence (IOE) network facilities, you may be eligible for reimbursement of some related expenses for travel and lodging for the transplant recipient and one family member or caregiver. We may also assist you and one family member or caregiver with travel and lodging arrangements. This benefit does not apply to normal in-network facilities but only to the IOE network facilities.

Reimbursement is subject to IRS regulations.

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

You or your physician can coordinate arrangements by calling a case manager in Aetna's Medical Management Department at 800-638-8432. For additional information regarding the Aetna Transplant Network, please call toll-free 800-638-8432.

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 800-638-8432 for more information. We are available to assist you Monday through Friday from 6:00 a.m. to 5:00 p.m. Mountain Standard Time (MST).

No benefit, except as shown in Section 5(a), Hearing services.

Informed Health® Line provides eligible members with phone 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 and can be reached by calling 800-638-8432. We provide TDD service for the hearing and speech-impaired. We also offer foreign language translation for non-English speaking members. Informed Health Line nurses cannot diagnose, prescribe medication or give medical advice.

Members also may e-mail a nurse by clicking on the “Talk to a Nurse” link on the Aetna member website at www.RCBPhealth.com.  Nurses respond to these online member inquiries within 24 hours.

The online Healthwise Knowledgebase is an online education support resource available to members through the Aetna 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.

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

You have access to Aetna's Healthy Maternity Program, which provides educational material and support to pregnant members. Contact Customer Service toll-free at 800-638-8432 for more information.

PinnacleCare provides expert medical guidance when you and your covered dependents are faced with a serious or complicated medical condition and might not know where to turn. We are here to help you find the right specialist, get a second opinion, and navigate the medical system. PinnacleCare saves you time and helps you avoid unnecessary medical procedures by making sure you see the right in-network provider, when needed.

Our customized services may include:

• Expert medical opinion/confirmation of your diagnosis
• Research on your diagnosis and treatment options
• Customized report identifying top local, regional, or national specialists to fit your needs
• Facilitated appointments with top specialists or Centers of Excellence
• Gathering, organizing, and forwarding of your key medical records
• Virtual consultation for second medical opinion if the specialist you need is out of your area

PinnacleCare representatives are available to assist you Monday through Friday 8 a.m. - 6 p.m. (EST) at 888-442-7380 or PinnacleCare.com/support. Let us guide you to the best healthcare possible.

AccordantCare offers programs for the following complex chronic medical conditions:

• Seizure disorders (Epilepsy)
• Rheumatoid Arthritis (RA)
• Multiple Sclerosis (MS)
• Crohn's Disease
• Parkinson's Disease (PD)
• Systemic Lupus Erythematosus (SLE)
• Myasthenia Gravis (MG)
• Sickle Cell Disease (SCD)
• Cystic Fibrosis (CF)
• Hemophilia
• Scleroderma
• Gaucher Disease
• Polymyositis
• Amyotrophic Lateral Sclerosis (ALS-Lou Gehrig's Disease)
• Dermatomyositis
• Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP)
• Ulcerative Colitis
• Human Immunodeficiency Virus (HIV)
• Chronic Kidney Disease (CKD)
• Pulmonary Arterial Hypertension (PAH)

For more information on the AccordantCare programs, please call toll-free 866-380-6295.

For your health needs and concerns, RCBP offers several resources through our Care Management Program to assist you with your care coordination for acute and/or chronic condition(s). This program provides education, clinical support, and access to support and well-being tools to help you better manage your health.

Our Care Management Program offers:

• 1:1 support with a clinical nurse who can help you:
  • Assistance in developing a plan to address your specific health needs and achieve your goals
  • To help you understand your benefit offerings
  • To answer your health-related questions
• Group Coaching
• Digital support 
• Customized health action plans based on your needs and preferences
• Personalized communications to assist you with making informed health decisions

To start using our digital support tools, log in to the Aetna member website from RCBPhealth.com. First-time users will need to register. 

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 assessment – 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. 
• Online coaching programs – find dynamic health coaching programs that give you personalized support.
• Aetna Health Dashboard–view your health information, and find entry points to health and wellness programs and resources.
• Additional member resources such as: Cancer Support, Joint Pain Support, and Maternity Support.

Our Care Management Program includes the following programs and services. For more information about our Care Management Program or services, please call 800-638-8432 and select the correct prompt. We are available to assist you Monday-Friday from 6:00 a.m. to 5 p.m.  Mountain Time (MST).

Provides digital support for members dealing with musculoskeletal (MSK) issues, acute and chronic pain, and either taking opioids or trying to avoid opioids. The program helps you improve your quality of life by helping you manage and reduce your chronic MSK pain, without surgery or drugs. If RCBP identifies that there is an opportunity to help you improve your care, you will be invited to participate. Eligible participants will receive access to exercise therapy, motivational coaching, 1:1 support and education that is tailored to the participant’s specific needs.

RCBP provides resources and support to help you address mental health or behavioral health conditions like anxiety, depression, substance use disorders, domestic violence and more. Our team will work with you, help you understand your benefits and guide you through the wellness programs we offer. We are here to support you, get you connected with a clinical social worker, psychologist or other behavior health professional to obtain the right treatment, the best services and resources to manage the daily obstacles that may be keeping you from achieving a healthier happy life.

Provides dedicated proactive support to individuals along their cancer journey.  We understand that a cancer diagnosis is life changing and can be overwhelming, and we are here to help you. 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 will also receive care management support for holistic care, treatment side effects, and medication management.

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 advanced planning for the kind of issues often associated with an advanced illness, such as living wills, advance directives, and tips on how to begin conversations about these issues with loved ones. This program is designed to provide quality of life improvement through health condition management and to reduce costs for you and your family at the end of life through timely member and caregiver education.

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, mental and physical health tips and more.

Is designed to assist you in improving your quality of life by taking steps to help you locate the right resources.  Social Workers can help connect you with community resources that can provide you services 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 with experience in a variety of settings, including government and non-profit organizations, hospitals, schools and clinics.

Helps members keep their diabetes and hypertension in check. The program uses medical claims, pharmacy claims, biometric screening data, and lab results to identify opportunities to help members improve their health.  Members are provided personal guidance in five areas of focus: medication adherence, taking the right medication, self-monitoring of blood glucose and blood pressure, lifestyle and comorbidity management and recommended screenings, which all are based on the member’s specific needs. You do not need to enroll in this program.  If RCBP identifies there is an opportunity to help you improve your care, we will contact you by phone, letter, email, or even in person by a CVS pharmacist or MinuteClinic provider. 

The Lab Savings program gives you the option of having covered outpatient laboratory testing paid at 100%, if your covered provider sends your lab work to Quest Diagnostics or LabCorp for processing.

The Lab Savings program is an optional program. If you or your provider chooses not to participate in the Lab Savings Program, you will not be penalized. You will simply receive the regular Plan benefit for lab tests (see page 28).

The Lab Savings program covers most outpatient laboratory testing covered by the Plan provided that the tests are ordered by a covered provider and processed by Quest Diagnostics or LabCorp. Outpatient lab work covered by the Lab Savings Program includes: blood tests (e.g., cholesterol, CBC, thyroid), urine testing (e.g., urinalysis), cytology and pathology (e.g., pap smear, biopsy) and cultures (e.g., throat culture).

The Lab Savings program does not cover: lab tests ordered during a hospital stay, lab work needed on an emergency (STAT) basis and time sensitive lab tests such as fertility testing, bone marrow studies and spinal fluid tests. Lab Savings program also does not cover X-rays, imaging tests (e.g., CT scans, MRI scans, PET scans), mammography, dental work or lab testing processed by another lab testing company.

If you have one or more of the following chronic conditions, you have the opportunity to discuss one-on-one with a CVS Health pharmacist any questions or concerns about the medication(s) you are taking. Please call toll-free 866-624-1481.

• Diabetes
• Congestive Heart Failure (CHF)
• Coronary Artery Disease (CAD)
• Hypertension (high blood pressure)
• Dyslipidemia (high cholesterol)
• Asthma
• Chronic obstructive pulmonary disease (COPD)
• Depression
• Osteoporosis
• Breast cancer

Aetna member website - Secure Member Portal

Access the Aetna member website by visiting www.RCBPhealth.com, then click on “Aetna member website” under “Member Resources”. This provides you secure access to a broad range of your personal health information after you register.

The Aetna 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.
• 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.

After registration/log-in 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, emergency room
• 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.

How to Access:

• Android: Go to Play Store and search for Aetna Health.
• iPhone: Go to App Store and search for Aetna Health.
• Text”Aetna” to 90156 to receive a link to download the Aetna Health app (message and data rates may apply)

Supported Devices:

• Android

• iPhone®

Members (over 18 years of age) who participate in the Wellness Incentive programs can earn up to $400 in rewards per calendar year.  

Complete the Health Risk Assessment (HRA) and $100 will be deposited on a PayFlex® debit card to use for certain eligible medical expenses.  The questions help you uncover your health risks so you’re better able to manage them before they get out of control.  Plus, once you take your HRA you receive a personalized health summary to help you better understand your health risks.  

Complete a biometric screening through Quest Diagnostics by November 30th and have your routine physical exam with your primary care physician by December 31st of the calendar year and $100 will be deposited on a PayFlex debit card to use for certain eligible medical expenses.  You can obtain the biometric screening at a Quest Diagnostics Patient Service Center (PSC), through your physician by having your physician complete a Biometric Screening Physician Results Form and fax it back by the date above or through an at-home collection materials.  To register for your screening or request an at-home collections materials call 855-623-9355 or to print a copy of the Biometric Screening Physician Results Form to take to your physician, visit  My.QuestforHealth.com  and enter the registration key: RCBP.   

Once your biometric screening is complete, your results will be available at My.QuestforHealth.com and will also be mailed to you to help you better understand your health risks.

Members with the following conditions may be eligible to earn up to $50 for each incentive to be deposited on a PayFlex debit card:

• Controlling Blood Pressure for members with high blood pressure

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:

Dietary and nutritional counseling (obtain three counseling visits, which includes individual and group behavioral counseling). See Section 5(a).

Telephonic Health Coach Program (Tobacco Cessation, Weight Management, Exercise, Nutrition and Stress Management). 

• Controlling A1c Hemoglobin (HbA1c) levels for members with diabetes

If you are identified as having diabetes, ask your provider to submit your HbA1c laboratory results. Your HbA1c laboratory results must be less than 8% during the calendar year for you to earn the incentive.

If your HbA1c is greater than or equal to 8%, you will receive the incentive if one of the following is completed: 

Dietary and nutritional counseling (obtain three counseling visits, which include individual and group behavioral counseling). See Section 5(a).

Diabetic Education or Training. See Section 5(a).

Enroll in the Transform Care Programs and check blood glucose using the meter four times per continuous calendar month for four months. Note: You always should follow directions from your healthcare provider with respect to the frequency of use and glucose testing.

Telephonic Health Coach Program (Tobacco Cessation, Weight Management, Exercise, Nutrition and Stress Management). 

• Prenatal Care for members who are pregnant

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

• Eliminating tobacco use for tobacco users

If you are identified as a tobacco user you can participate in the Plan's Tobacco Cessation Program (see Section 5(a)).  You must complete:

- At least two quit attempts as part of our Tobacco Cessation Program.  The quit attempt must include tobacco cessation counseling sessions of at least 30 minutes each.  

Note: To earn the incentive for the conditions outlined above, documentation needs to be mailed by December 31st of the calendar year to: Rural Carrier Benefit Plan C/O Wellness Incentive, P.O. Box 14079, Lexington, KY 40512-4079.

Complete any of the following Healthy Actions to earn additional incentives:  

• Get your breast cancer screening and earn $50
• Get your cervical cancer screening (pap smear) and earn $50
• Get your colorectal cancer screening and earn $50
• Get your flu shot and earn $25
• Participate in our Telephonic Health Coaching Program and complete 6 coaching sessions (see elsewhere in this section) and earn $75
• Select a primary care physician (PCP) and earn $25

To select your PCP:

• Step 1: go to RCBPhealth.com and select “Aetna Secure Member Website” under Member Resources.  Register or login, then click on View your Providers on the home page, then select “Choose” Primary Care Physician Office.
• Step 2: Once you’ve selected your PCP, go to “Discover a Healthier You” under Health and Wellness.  Select Rewards at the top of the page and complete the PCP attestation activity.

Note: You need to complete both steps to earn the credit.

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.

After you have completed a wellness activity, the Plan will deposit the amount earned on your PayFlex debit card, at which time you will receive your reloadable PayFlex debit card. Any future wellness incentives will be loaded on the same card. Please allow at least 4 weeks after completing a wellness activity for incentives earned to be deposited. You can use your PayFlex debit card to pay for certain unreimbursed medical expenses such as deductible, coinsurance, copays and other eligible medical expenses approved by the IRS. To monitor the funds on your PayFlex debit card, call the number on the back of your PayFlex debit card, or visit www.Payflex.com. If you are enrolled in a Flexible Spending Account (FSA) and wellness incentives are deposited to a PayFlex card, you may not receive reimbursement from both FSA and PayFlex.  If you receive reimbursements from more than one plan or arrangement for the same qualified medical expense, the amount received in excess of the qualified medical expense may be taxable to you as income.

If you have any questions or would like more information about the program, please call customer service at 800-638-8432.

Our Lifestyle and Condition Coaching (LLC) Program provides you or your covered dependents personalized support that helps you manage existing conditions, learn new habits and stay on their path to better health. Our Health Coach will partner with you to transform your health goals into action. 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 health coaching work?

• You can talk with your Health Coach over the phone through conveniently scheduled appointments and create a plan that is right for you to meet your health goals. Everything in the program is tailored to you.
• You can explore ways to make changes in your behavior that will last.
• You will receive written materials from your Health Coach that can help you decide where you want to go with your health and how to get there.
• Appointments can range from 20 minutes to 30 minutes at least twice a month. How long and how often you meet with your Health Coach depends on your individual needs.

Our Lifestyle and Condition Coaching Program also provides pain management/opioid support. The program is designed for members with chronic pain and either taking opioids or trying to avoid opioids. Members enrolled will receive coaching and support, which includes assisting with identifying the availability of other treatment plans that may include non-pharmacologic modalities for the treatment of pain such as, but not limited to: injection therapies, cognitive therapies, psychosocial support, massage therapy, or physical therapy visits as applicable. The program also helps with psychological effects of chronic pain, reduction of opioid use, avoiding opioid use and resources for those who are dependent on opioid medications.

To self-refer or enroll in the program, contact LCC at 866-533-1410 or go to www.myactivehealth.com/RCBP. Our Health Coaches are available Monday through Friday from 8 a.m. – 9 p.m. Eastern Time (ET).

Make a difference in your health in just a few minutes by completing a simple Health Risk Assessment (HRA). It asks questions about your health history and habits.  It can:

• Help you learn more about your health risks, so you can take steps to lower them

• Provide strategies to improve your health and well-being

• Give you personalized health results to share with your doctor

To schedule an appointment to complete your telephonic HRA, contact a Health Coach at 866-533-1410. Our Health Coaches are available Monday through Friday from 8 a.m. – 9 p.m. Eastern Time (ET). You can also schedule an appointment online at www.myactivehealth.com/RCBP.

RCBP offers access to Teladoc® telemedicine consultations any time, 24/7/365 that is easy to use, private and secure. Teladoc is the nation’s leading virtual care provider with over 3,600 board certified, state-licensed, primary care physicians, pediatricians and specialists that have on average 20 years of experience and are available by web, phone and the Teladoc mobile app. With Teladoc, you can take care of most common issues such as: cold & flu symptoms, allergies, cough, sinus infection, respiratory infection, eye infection, skin problems and more. You can also see a therapist for ongoing counseling for concerns such as: depression, anxiety, stress, as well as for diet and nutrition assistance.

How to sign up:

1. Download the iOS or Android App by searching “Teladoc”
2. Sign-up on the web at www.teladoc.com/Aetna
3. Sign-up by phone, call 855-835-2362 (855-Teladoc)

Note: Teladoc does not replace your primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulations, see below. Teladoc does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services.

General Medical (via phone and video): Our general medical service is available in all 50 states, including D.C., and 4 U.S. territories (Puerto Rico, Guam, US Virgin Islands, Northern Mariana Islands).

Dermatology (via phone and video): Our dermatology service is available in all 50 states, including D.C.

Nutritional (via phone and video): Our nutritional service is available in all 50 states, including D.C.

Mental Health Care (via video only): Our mental health service is available in all 50 states, including D.C.

If you have any questions or would like more information about the program, please call us at 800-638-8432.

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

There are several ways we identify members that 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’s determined that you can benefit from AbleTo
• If identified, an Engagement Specialist from AbleTo will contact you to introduce the treatment

If you feel you would benefit from this program, would like more information, or enroll in this program please call 866-287-1802 or visit their website at www.AbleTo.com/Aetna.

The Plan may offer a number of programs and services to members to maximize optimal health, reduce out of pocket costs, and assist with special conditions and needs as they become available during the year. Visit www.rcbphealth.com for a current list of programs, program criteria, and contact information.

Digital coaching 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.

This provides you secure access to a broad range of your personal health information after you register.

Access the Plan's website tool from your Aetna member website at www.rcbphealth.com. Select “Discover a Healthier You” under the Stay Healthy icon, then "Dashboard" and finally "Digital Coach”.

To obtain claim forms or other claims filing advice or answers about our benefits, contact us at 800-638-8432 or at our website at www.rcbphealth.com. 

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. For claims questions and assistance, call us at 800-638-8432.

When you must file a claim – such as for services you received overseas or when another group health plan is primary – submit it on the CMS-1500 or a claim form that includes the information shown below. Send your claims to:

Rural Carrier Benefit Plan
P O Box 14079
Lexington, KY 40512-4079

Bills and receipts should be itemized and show:

• Name of patient, date of birth and relationship to enrollee;
• Plan identification number of the enrollee;
• Name, address and tax identification number of the person or firm providing the services or supplies;
• Dates that services or supplies were furnished;
• Diagnosis;
• Valid medical or ADA dental code if it exists or a description of each service or supply; and 
• The charge for each service or supply.

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

In addition:

• Generally, you need to complete only one claim form each calendar year. You should also complete a new claim form if the claim is for an accidental injury, your mailing address changes, or if your other insurance/Medicare coverage changes.
• You must send a copy of the explanation of benefits (EOB) form you received from any primary payor (such as the Medicare Summary Notice (MSN)) with your claim. See Section 9 for Medicare claims.
• Claims for rental or purchase of durable medical equipment must include the price of the equipment, a prescription and a written statement from the provid specifying the medical necessity, including the diagnosis, and the estimated length of time needed.
• Claims for dental care must include a copy of the itemized bill from the dentist (including the information above) and the dentist's Federal Tax ID number. The Plan does not have a separate dental claim form.   

Please see Section 5(f), Prescription drug benefits for instructions on how to file a claim for prescription drugs that you buy at a non-participating (out-of-network) retail pharmacy.

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.

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

Send us all the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service. 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. Once we pay benefits, there is a three-year limitation on reissuing uncashed checks.

Follow the same procedures when submitting claims for overseas (foreign) services as you would when submitting claims for stateside services.  Claims for overseas services should include an English translation.  We will use the U.S. dollar exchange rate applicable on the date service was incurred if you do not supply us with a currency exchange rate along with a paid receipt.

Overseas providers (those outside the 50 United States) will be paid at the In-Network level of benefits for covered services. Overseas hospitals and physicians are under no obligation to file claims for you. You may be required to pay for the services at the time you receive them and then submit a claim to us for reimbursement. If you have questions about the processing of overseas claims, contact us at 800-638-8432.

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 ten percent (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: Rural Carrier Benefit Plan, P O Box 14079, Lexington, KY 40512-4079; 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.

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 Employee Insurance Operations, FEHB 2 1900 E Street, NW, Washington, DC 20415-3620.

Send OPM the following information:

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

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

Note:  You are the only person who has a right to file a disputed claim with OPM.  Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request.  However, for urgent care claims, a 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 within 60 days.  There are no other administrative appeals.

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

OPM may disclose the information it collects during the review 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 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.rcbphealth.com.  

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. After the primary plan processes the benefit, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance.

Note: The $200 deductible for prescriptions purchased at a network retail pharmacy does not apply when you have Medicare Parts A and B as primary coverage.

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.

Our right to pursue and receive subrogation and reimbursement recoveries is a condition of, and a limitation on, the nature of benefits or benefit payments and on the provision of benefits under our coverage. By accepting Plan benefits, you agree to the terms of this provision.

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

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

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

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

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

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:

• No-fault insurance and other insurance that pays without regard to fault, including personal injury protection benefits, regardless of any election made by you to treat those benefits as secondary to us.  When you are entitled to 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

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@estprs.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 (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 Plan will provide related care as follows, if it is not provided by the clinical trial:

• Routine care costs – costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition, whether the patient is in a clinical trial or is receiving standard therapy. 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. These costs are generally covered by the clinical trial. 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 800-MEDICARE (800-633-4227), (TTY 877-486-2048) or at www.medicare.gov.

Medicare is a health insurance program for:

• People 65 years of age or older
• Some people with disabilities under 65 years of age
• People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant)

Medicare has four parts:

• Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in Medicare-covered employment, you should be able to qualify for premium-free Part A insurance. (If you were a Federal employee at any time both before and during January 1983, you will receive credit for your Federal employment before January 1983.) Otherwise, if you are age 65 or older, you may be able to buy it. Contact 800-MEDICARE 800-633-4227, TTY: 877-486-2048 for more information.
• Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social Security check or your retirement check.
• Part C (Medicare Advantage). You can enroll in a Medicare Advantage Plan to get your Medicare benefits. Please review the information on coordinating benefits with Medicare Advantage Plans on the next page.
• Part D (Medicare prescription drug coverage). There is a monthly premium for Part D coverage.  Before enrolling in Medicare Part D, please review the important disclosure notice from us about the FEHB prescription drug coverage and Medicare.  The notice is on the first inside page of this brochure. For people with limited income and resources, extra help in paying for a Medicare prescription drug plan is available. For more information about this extra help, visit the Social Security Administration online at www.socialsecurity.gov, or call them at 800-772-1213, TTY: 800-325-0778.

The decision to enroll in Medicare is yours. We encourage you to apply for Medicare benefits 3 months before you turn age 65. It’s easy. Just call the Social Security Administration toll-free number 800-772-1213, TTY: 800-325-0778 to set up an appointment to apply. If you do not apply for one or more Parts of Medicare, you can still be covered under the FEHB Program.

If you can get premium-free Part A coverage, we advise you to enroll in it. Most Federal employees and annuitants are entitled to Medicare Part A at age 65 without cost. When you don’t have to pay premiums for Medicare Part A, it makes good sense to obtain the coverage. It can reduce your out-of-pocket expenses as well as costs to the FEHB, which can help keep FEHB premiums down.

Everyone is charged a premium for Medicare Part B coverage. The Social Security Administration can provide you with premium and benefit information. Review the information and decide if it makes sense for you to buy the Medicare Part B coverage. If you do not sign up for Medicare Part B when you are first eligible, you may be charged a Medicare Part B late enrollment penalty of a 10% increase in premium for every 12 months you are not enrolled.  If you did not take Part B at age 65 because you were covered under FEHB as an active employee (or you were covered under your spouse's group health insurance plan and they were an active employee), you may sign up for Part B (generally without an increased premium) within 8 months from the time you or your spouse stop working or are no longer covered by the group plan. You also can sign up at any time while you are covered by the group plan.

If you are eligible for Medicare, you may have choices in how you get your healthcare. Medicare Advantage is the term used to describe the various private health plan choices available to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits with Medicare, depending on whether you are in the Original Medicare Plan or a private Medicare Advantage plan.

(Please refer to page 98 for information about how we provide benefits when you are age 65 or older and do not have Medicare.)

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 except you do not need to get a hospital stay approved when Medicare pays first. We do not require preauthorization and concurrent review of mental health and substance misuse disorder treatment when Medicare Part B pays first. However, when Medicare stops paying benefits for any reason, you must follow our precertification, preauthorization and concurrent review procedures.

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

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

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 800-638-8432.

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

Benefit Description-Deductible
High Option You pay without Medicare In-Network: $350/$700
High Option You pay without Medicare Out-of-network: $800/$1600
High Option You pay with Medicare In-network: N/A
High Option You pay with Medicare Out-of-network: N/A 

Benefit Description - Catastrophic Protection  Out of pocket maximum
High Option You pay without Medicare In-Network: $5,000/$10,000
High Option You pay without Medicare Out-of-network: $7,000/$14,000
High Option You pay with Medicare In-network: $5,000/$10,000
High Option You pay with Medicare Out-of-network: $7,000/$14,000

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 In-network: N/A
High Option You pay with Medicare Out-of-network: N/A

Benefit Description - Primary care physician
High Option You pay without Medicare In-Network: $20 copay
High Option You pay without Medicare Out-of-network: 30% of Plan allowance and any difference after deductible
High Option You pay with Medicare In-network: Nothing
High Option You pay with Medicare Out-of-network: Nothing

Benefit Description - Specialist
High Option You pay without Medicare In-Network: $35 Copay
High Option You pay without Medicare Out-of-network: 30% of Plan allowance and any difference after deductible
High Option You pay with Medicare In-network: Nothing
High Option You pay with Medicare Out-of-network: Nothing

Benefit Description - Inpatient Hospital
High Option You pay without Medicare In-Network: $200 copay per admission
High Option You pay without Medicare Out-of-network: $400 copay per admission and any difference after deductible. The $400 does not apply to out-of-network hospital admissions for mental health and/or substance use disorders.
High Option You pay with Medicare In-network: Nothing
High Option You pay with Medicare Out-of-network: Nothing

Benefit Description - Outpatient Hospital
High Option You pay without Medicare In-Network: 15% of Plan’s allowance after calendar year deductible
High Option You pay without Medicare Out-of-network: 30% of Plan allowance and any difference after calendar year deductible
High Option You pay with Medicare In-network: Nothing
High Option You pay with Medicare Out-of-network: Nothing

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 In-network: N/A
High Option You pay with Medicare Out-of-network: N/A

Note: The $200 deductible for prescriptions purchased at a network retail pharmacy does not apply when you have Medicare Parts A and B as primary coverage.

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. Should you sign an agreement, Medicare will not pay any portion of the charges, and we will not increase our payment. We will still limit our payment to the 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 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 (800-633-4227), (TTY: 877-486-2048) or at www.medicare.gov.

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

This Plan and our Medicare Advantage Plan: You may enroll in Rural Carrier Benefit Plan and our national Aetna Medicare Advantage for Rural Carrier Benefit Plan if you are an annuitant or former spouse with primary Medicare Parts A and B. Enrollment in the Aetna Medicare Advantage for Rural Carrier Benefit Plan is voluntary. Our Medicare Advantage plan will enhance your FEHB coverage by lowering/eliminating cost-sharing for services and/or adding benefits at no additional cost. Aetna Medicare Advantage for Rural Carrier Benefit Plan is subject to Medicare rules. You can enroll in our Medicare Advantage plan with no additional premium. If you are already enrolled and would like to understand your additional benefits in more detail, please call us at 866-241-0262, 8 a.m. to 5:30 p.m., Monday through Thursday or 8:30 am. to 5:30 p.m. on Fridays (Eastern standard time), go to www.aetnaretireehealth.com/rcbp, or you may also refer to your Medicare plan’s Evidence of Coverage. Once you enroll in our Aetna Medicare Advantage for Rural Carrier Benefit Plan, we will send you additional information.

When you are enrolled in the Rural Carrier Benefit Plan under the FEHB Program and Aetna Medicare Advantage for Rural Carrier Benefit Plan members receive the following enhanced benefits. Please note that Aetna Medicare Advantage features may vary by location or region.

• No deductible 

• No copays or coinsurance for covered services (office visits or telehealth, preventive care, surgical care, inpatient/outpatient hospital care, emergency room/urgent care, etc.)

• Catastrophic Protection Out-of-Pocket Maximum of $3,500 per person annually

• Prescription drug copay or coinsurance per 30-day supply - Generic copays of $0 Preferred Pharmacies, $2 Standard Pharmacies, $5 all other pharmacies; Preferred Brand $35; Non-Preferred Brand $40; and Specialty $70 

• 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 equaling three months of 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 Aetna Medicare Advantage for Rural Carrier Benefit Plan

Aetna Medicare Advantage for Rural Carrier Benefit Plan is a Medicare contract separate from the FEHB RCBP High Option Plan and depends on contract renewal with CMS. Contact us for a copy of the Evidence of Coverage for the Aetna Medicare Advantage for Rural Carrier Benefit Plan. You may also obtain a copy of the Evidence of Coverage at the following link, www.rcbphealth.com/retiree. The Evidence of Coverage contains a complete description of plan benefits, exclusions, limitations and conditions of coverage under Medicare Advantage for Rural Carrier Benefit Plan. 

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

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

• 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 the difference between the “limiting charge” or the physician’s charge (whichever is less) and our payment combined with Medicare’s payment.

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.

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 provide related care as follows, if it is not provided by the clinical trial:

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

Coinsurance is the percentage of our allowance that you must pay for your care. You may also be responsible for additional amounts. See page 20.

A copayment is a fixed amount of money you pay when you receive covered services. See page 20.

Treatment or services, no matter who recommends them or where you receive them, which a person without medical skills can provide safely and reasonably. In addition, treatment and services designed mainly to help the patient with daily living activities. These include:

• personal care like help in: walking; getting in and out of bed; bathing; eating (by spoon, gastrostomy or tube); exercising; dressing
• homemaking services, like preparing meals or special diets
• moving the patient
• acting as a companion or sitter
• supervising the taking of medication that can usually be self-administered; or
• treatment or services that anyone can perform with minimal training like recording temperature, pulse and respirations or administering and monitoring a feeding system.

We determine what treatments or services is custodial care.

A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. See page 20.

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

• reliable evidence shows that it is the subject of on-going 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
• 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 shall mean only 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.

The diagnosis, prognosis, management, and prevention of genetic disease for those patients who have no current evidence or manifestation of a genetic disease and those who we have not determined to have an inheritable risk of genetic disease.

The diagnosis and management of genetic disease for those patients with current signs and symptoms and for those who we have determined to have an inheritable risk of genetic disease.

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

A public agency or private organization under Medicare that is licensed as a home healthcare agency by the State and is certified as such.

A plan of continued care and treatment when you are under the care of a physician, and when certified by the physician that, without the home healthcare, confinement in a hospital or skilled nursing facility would be required.

The inability to conceive after 12 months of unprotected intravaginal sexual relations (or 12 cycles of artificial insemination) for women under age 35, and 6 months of unprotected intravaginal sexual relations (or 6 cycles of artificial insemination) for women age 35 and over.

Services, supplies, drugs or equipment provided by a hospital or covered provider of the healthcare services that we determine are appropriate to diagnose or treat your condition, illness, or injury and that:

• are consistent with standards of good medical practice in the United States;
• 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; and 
• are not primarily for the personal comfort or convenience of the patient, the family, or the provider; 
• are not a part of or associated with the scholastic or vocational training of the patient; and
• in the case of inpatient care, cannot be provided safely in an outpatient setting. 

The fact that a covered provider prescribes, recommends, or approves a service, supply, drug or equipment does not, by itself, make it a medical necessity.

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

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 the 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.

If you are in the hospital for more than a few hours, always ask your physician or the hospital staff  if your stay is considered inpatient or outpatient. 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. Since observation services are billed as outpatient care, outpatient facility benefit levels apply and your out-of-pocket expenses may be higher as a result.

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

Our Plan allowance is 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 – 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 – Our Plan allowance is the lesser of: (1) the provider’s billed charge; or (2) the Plan’s out-of-network (OON) fee schedule amount. The Plan’s OON fee schedule amount is equal to the 90th percentile amount for the charges listed in the Prevailing Healthcare Charges System, administered by Fair Health, Inc. The OON fee schedule amounts vary by geographic area in which services are furnished. We base our coinsurance of this OON fee schedule amount. This applies to all benefits in Section 5 of this brochure. For urine testing services, the Out-of-network allowance is the maximum Medicare allowance for such services.

If you receive services from other participating providers, the Plan’s allowance will be 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 the applicable deductibles, coinsurance and copayments.

For certain services, exceptions may exist to the use of the OON 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 OBRA ’90 and ’93, 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.

The plan allowance for prescription medications is based on the average wholesale price or an alternative pricing benchmark.

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.

A carrier's pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, and the terms of the carrier's health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.

Preventive services:

• We cover preventive services, counseling and screenings recommended under the Affordable Care Act (ACA). For a complete list of ACA preventive care services, visit: www.healthcare.gov/what-are-my-preventive-care-benefits. We cover preventive services, counseling and screenings that that have a recommendation of “A” or “B” from the United States Preventive Services Task Force (USPSTF). For a complete list of preventive care services with an “A” or “B” recommendation by the USPSTF visit www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/. If our preventive services, counseling and screening benefits are more generous than the ACA or USPSTF “A” or “B” recommendations, we pay under the appropriate benefit without cost sharing when delivered by an in-network provider.

Immunizations:

• We cover routine adult and childhood immunizations. See www.cdc.gov/vaccines/schedules/index.html.

A carrier's pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier's health benefits plan.

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 our Customer Service Department at 800-638-8432. 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.

A medical facility that accepts patients on a walk-in basis; no appointment is required. Provides non-emergency, basic healthcare services on a walk-in basis.  Examples include MinuteClinic® at CVS Pharmacy locations and Healthcare Clinics in Walgreens pharmacy locations. Urgent care clinics are not considered walk-in clinics.

In-network primary care provider: $20/office visit

In-network specialist provider: $35/office visit

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

 (Applies to printed brochure only)

In-network: 15% of our allowance 

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

(Applies to printed brochure only)

In-network:  Nothing if you contact Teladoc for services

Out-of-network: No benefit

(Applies to printed brochure only)

In-network: $20/office visit for primary care services; $35/office visit for specialist care services

Out-of-network: 30% of the Plan allowance* and any difference between our allowance and the billed amount

(Applies to printed brochure only)

In-network: $200 copayment per admission (waived for maternity stay)

Out-of-network: $400 copayment per admission; 30% of covered charges

(Applies to printed brochure only)

In-network: 15% of our allowance*

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

(Applies to printed brochure only)

Nothing for initial emergency room visit: or
initial urgent care visit; or
first physician office visit

(Applies to printed brochure only)

In-network: $200 copayment

Out-of-network: $200 copayment and any difference between our allowance and the billed amount

(Applies to printed brochure only)

In-network: 15% of the Plan allowance 

Out-of-network: 30% of the Plan allowance* and any difference between our allowance and the billed amount

(Applies to printed brochure only)

In-network: $200 copayment per admission

Out-of-network: 30% of the Plan allowance

(Applies to printed brochure only)

In-network: 15% of the Plan allowance*

Out-of-network: Physician Services--30% of the Plan allowance* and any difference between our allowance and the billed amount

Facility Charges:--30% of the Plan allowance* and any difference between our allowance and the billed amount

(Applies to printed brochure only)

30% of cost**

(Applies to printed brochure only)

Up to a 90 day supply: Tier I--$10/generic; Tier II--$50/preferred brand name; Tier III--$80/non-preferred brand name; Tier IV--Specialty Generic drugs $70 for a 30 day supply/$100 for a 90 day supply; Tier V--Specialty Preferred drugs $90 for a 30 day supply/$125 for a 90 day supply; Tier VI--Specialty Non-Preferred drugs $120 for a 30 day supply/$250 for a 90 day supply

(Applies to printed brochure only)

Up to a 90 day supply: Tier I--$10/generic; Tier II--$40/preferred brand name; Tier III--$70/non-preferred brand name: Tier IV--Specialty  Generic drugs $70 for a 30 day supply/$100 for a 90 day supply; Tier V--Specialty Preferred drugs $90 for a 30 day supply/$125 for a 90 day supply; Tier VI--Specialty Non-Preferred drugs $120 for a 30 day supply/$250 for a 90 day supply

(Applies to printed brochure only)

Any difference between our scheduled allowance and the billed amount

(Applies to printed brochure only)

Flexible benefits option; Cancer treatment benefit; Kidney dialysis benefit; 24 hour nurse line; Travel assistance program; Routine eye exam benefit; Healthy maternity program; Complex and Chronic Disease Management Program; Care Management Program; Livongo, a remote diabetes monitoring program; Lab Savings program; Smoking cessation program; Institutes of Excellence (IOE); Gene-Based, Cellular and Other Innovative Therapies (GCIT™) Designated Network; Genetic testing for prescription drugs; Pharmacy Advisor Program; Wellness Incentive program; Health Risk Assessment; Telephonic Health Coaching program; Telehealth program

(Applies to printed brochure only)

In-network: Nothing after $5,000 for Self Only enrollment or $10,000 for Self Plus One or Self and Family enrollment per calendar year including CVS Health In-network retail and/or mail service pharmacy.

Out-of-network: Nothing after $7,000 for Self Only enrollment or $14,000 for Self Plus One or Self and Family per calendar year including CVS Health In-network retail and/or mail service pharmacy.

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

(Applies to printed brochure only)