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

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

Our health coverage meets the minimum value standard of 60% established by the ACA. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.

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

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

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

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

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

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

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

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

Contact your carrier to add a 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 any changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26.

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

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

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

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

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

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

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

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

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

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

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

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

• If you have no FEHB coverage, your employing office will enroll you 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 the benefits of the Plan during the continuation of the confinement but not beyond the 60th day after the end of the 31-day temporary extension.

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

If you are divorced from a Federal employee, or an 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 enrollee's 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.

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

• Your coverage under TCC or the spouse equity law ends;
• You decide not to receive coverage under TCC or the spouse equity law; or
• You are not eligible for coverage under TCC or the spouse equity law.

You must contact us in writing within 31 days after you are no longer eligible for coverage. For assistance in finding coverage, please contact us at 866-368-7227 option 3 or visit our website at www.compassrosebenefits.com.

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

If you would like to purchase health insurance through the ACA's 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 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 888-438-9135 or write to us at Compass Rose Health Plan, P.O. Box 8095, Wausau, WI 54402-8095. 

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.

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.

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 www.compassrosebenefits.com/livingwell for assistance.

We consider the following physicians to be primary care physicians: family practitioner, general practitioner, internal medicine, pediatrician, OBGYN, nurse practitioner, physician assistant and certified nurse midwife. Mental health visits are also considered primary care. We consider other all other types of providers to be specialists. 

Physician: Doctors of medicine or psychiatry (M.D.), osteopathy (D.O.), dental surgery (D.D.S.), medical dentistry (D.M.D.), podiatric medicine (D.P.M.), chiropractic (D.C.), and optometry (O.D.) when acting within the scope of their license or certification.

Qualified Clinical Psychologist: An individual who has earned either a Doctoral or Master's Clinical Degree in psychology or an allied discipline and who is licensed or certified in the state where services are performed. This presumes a licensed individual has demonstrated to the satisfaction of state licensing officials that he/she, by virtue of academic and clinical experience, is qualified to provide psychological services in that state.

Nurse Midwife: A person who is certified by the American College of Nurse Midwives or is licensed or certified as a nurse midwife in states requiring licensure or certification.

Nurse Practitioner/Clinical Specialist: A person who 1) has an active R.N. license in the United States, 2) has a baccalaureate or higher degree in nursing, and 3) is licensed or certified as a nurse practitioner or clinical nurse specialist in states requiring licensure or certification.

Clinical Social Worker: A social worker that 1) has a Master’s or Doctoral degree in social work, 2) has at least two years of clinical social work practice, and 3) in states requiring licensure, certification or registration, is licensed, certified, or registered as a social worker where the services are rendered.

Speech, Occupational and Physical Therapists: A professional who is licensed or meets state requirements where the services are performed to provide Speech, Occupational or Physical therapy services.

Physician Assistant: A person who is licensed, registered, or certified in the state where services are performed.

Licensed Professional Counselor or Master’s Level Counselor: A person who is licensed, registered, or certified in the state where services are performed.

Audiologist: A person who is licensed, registered, or certified in the state where services are performed.

Licensed Acupuncturist (L.A.C.): A person who has completed the required schooling and licensure to perform acupuncture in the state where services are performed (see definition of acupuncture benefits, Section 5(a)).

Christian Science Practitioner: If you choose to visit a Christian Science practitioner instead of a physician, the charges are still considered allowable expenses. To qualify for benefits, you must make this choice annually. The benefits will then apply to all subsequent expenses incurred during the year. You can change your mind only at the time of your first claim each year. The practitioner you choose must be listed as such in the Christian Science Journal that is current at the time the service is provided. Your choice will not apply to, or prevent payment of, a physician’s maternity charges.

Lactation Consultant: A person who is licensed as a Registered Nurse in the United States (or appropriate equivalent if providing services overseas) and is licensed or certified as a lactation consultant by a nationally recognized organization.

Covered facilities include:

Hospital

1) An institution that is accredited as a hospital under the hospital accreditation program of the Joint Commission; or

2) Any other institution that is operated pursuant to law, under the supervision of a staff of doctors with 24-hour-a-day nursing service, and that is primarily engaged in providing:

a) General patient care and treatment of sick and injured persons through medical, diagnostic and major surgical facilities, all of which facilities must be provided on its premises or under its control; or

b) Specialized inpatient medical care and treatment of sick or injured persons through medical and diagnostic facilities (including X-ray and laboratory) on its premises, under its control, or through a written agreement with a hospital (as defined above) or with a specialized provider of those facilities.

3) For inpatient and outpatient treatment of mental health and substance abuse, the term hospital also includes a freestanding residential treatment center facility approved by the Joint Commission or Commission on Accreditation of Rehabilitation Facilities (CARF).

In no event shall the term hospital include a convalescent nursing home or institution or part thereof that:

• is used principally as a convalescent facility, rest facility, nursing facility or facility for the aged;
• furnishes primarily domiciliary or custodial care including training in the routines of daily living;
• or is operated as a school.

Nursing School Administered Clinic: A clinic that is

• licensed or certified in the state where the services are performed, and
• provides ambulatory care in an outpatient setting—primarily in rural or inner city areas where there is a shortage of physicians. Services billed for by these clinics are considered outpatient ‘office’ services rather than facility charges.

Skilled Nursing Facility: An institution, or the part of an institution that provides skilled nursing care 24 hours a day and is classified as a skilled nursing facility under Medicare.

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

Hospice: A provider that meets all of the following:

1) primarily provides inpatient and outpatient hospice care to terminally ill persons;

2) is certified by Medicare as such, or is licensed or accredited as such by the jurisdiction it is in;

3) is supervised by a staff of M.D.’s or D.O.’s, at least one of whom must be on call at all times;

4) provides 24-hour nursing services under the direction of an R.N. and has a full-time administrator; and

5) provides an ongoing quality assurance program.

Freestanding Ambulatory Facility:  A facility which is licensed by the state as an ambulatory surgery center or has Medicare certification as an ambulatory surgical center, has permanent facilities and equipment for the primary purpose of performing surgical and/or renal dialysis procedures on an outpatient basis, provides treatment by or under the supervision of doctors and nursing services whenever the patient is in the facility, does not provide inpatient accommodations, and is not, other than incidentally, a facility used as an office or clinic for the private practice of a doctor or other professional.

If you have a chronic and disabling condition and lose access to your specialist because we:

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

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

- reduce our Service Area and you enroll in another FEHB plan;

you may be able to continue seeing your specialist and receiving any PPO 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 PPO 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 888-438-9135. If you are new to the FEHB Program, we will reimburse you for your covered expenses while you are in the hospital beginning with the effective date of your coverage.

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

• You are discharged, not merely moved to an alternative care center;

• The day your benefits from your former plan run out; or

• The 92nd day after you become a member of this Plan, whichever happens first.

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

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

You must get prior approval for certain services. Failure to do so will result in a maximum $500 penalty.

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

In most cases, your physician or hospital will take care of requesting precertification. Because you are still responsible for ensuring that your care is precertified, you should always ask your physician or hospital whether or not they have contacted us.

We will reduce our benefits for the inpatient hospital stay by $500 if no one completes a 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 are held harmless when PPO hospitals do not contact the Plan for precertification for inpatient hospitalizations.

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 payer for the hospital stay.

•Medicare Part A is the primary payer 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 payer and you do need precertification.

Your primary care physician has authority to refer you for most services. For certain services, however, prior approval must be obtained from us. Because you are still responsible for ensuring that your care is precertified, you should always ask your physician if they have contacted us. Call UMR at 888-438-9135 for prior authorization for services such as:

Section 5(a)

• Applied Behavior Analysis

• Chemotherapy

• Dialysis

• Durable medical equipment over $500 for rental or $1,500 for purchase

• Genetic testing - all genetic testing must be prior authorized through eviCore at 888-209-5761, option 1

• Home healthcare

• Infusion therapy

• Orthotic and prosthetic devices over $2,000

• Pain management injections (such as epidural or facet)

• Physical, occupational and speech therapy - after your 12th visit

• Private duty nursing

• Radiation

• Sleep studies - all sleep studies must be prior authorized through eviCore at 888-209-5761, option 2

Section 5(b)

• Bariatric surgery

• Biopsy procedures

• Oral maxillofacial surgeries

• Surgical procedures performed outside a doctor's office (screening colonoscopies do not require prior authorization)

• Transgender surgical and non-surgical treatments and procedures

• Transplants

• Varicose vein surgery

Section 5(c)

• Chemotherapy

• Dialysis

• Hospice care

• Inpatient hospital treatment

• Non-emergency air ambulance

• Radiation

• Skilled nursing facilities

Section 5(e)

• Inpatient mental health and substance abuse treatment

• Partial hospitalization 

• Residential treatment services

Section 5(f)

• Some prescription drugs

Note: We will reduce our benefits for any outpatient services requiring prior approval by $500 if no one completes a review prior to your receiving the services. In most cases, your physician or provider will take care of requesting prior approval. Because you are still responsible for ensuring that your care is prior approved, you should always ask your physician or provider if they have contacted us.

First, you, your representative, your physician, or your hospital must call 800-808-4424 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

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

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 extension and the date when a decision is expected.

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

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

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide the required information. We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of 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 888-438-9135. You may also call OPM's FEHB 2 at 202-606-3818 between 8 a.m. and 5 p.m. Eastern Standard 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 888-438-9135. 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 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 admissions earlier in this Section and If your hospital stay needs to be extended below.

You do not need precertification of a maternity admission for a routine delivery.  However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days.  Further, if your baby stays after you are discharged, your physician or the hospital must contact us for precertification of additional days for your baby.

Note: When a newborn requires definitive treatment 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.

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

• For the part of the admission that was medically necessary, we will pay inpatient benefits, but
• For the part of the admission that was not medically necessary, we will only pay for 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 accordance with the procedures detailed below. If your claim is in reference to a contraceptive, call 877-438-4449.

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.

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services. You will only be responsible for one (1) copayment per day per provider.

Example: When you see your PPO physician you pay a copayment of $15 per day, and when you go in a PPO hospital, you pay a copayment of $200 per hospital stay.

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, with the exception of Essential Health Benefits copayments, 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 PPO is $350 per person and for non-PPO services it is $400 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 PPO and $400 for non-PPO. 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 PPO and $800 for non-PPO. Under a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $700 for PPO and $800 for non-PPO services.

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

Example: If the billed amount is $100, the provider has an agreement with us to accept $80, and you have not paid any amount toward meeting your deductible, you must pay $80. We will apply $80 to your deductible. We will begin paying benefits once the remaining portion of your calendar year deductible of $350 for PPO or $400 for non-PPO has been satisfied.

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

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 10% coinsurance of our allowance for an X-ray at a PPO provider.

Note: 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.

In some instances, a UnitedHealthcare 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 888-438-9135.

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 PPO area, you should use a PPO provider. The following two examples explain how we will handle your bill when you go to a PPO provider and when you go to a non-PPO provider. When you use a PPO provider, the amount you pay is much less.

• PPO providers agree to limit what they will bill you. Because of that, when you use a preferred provider, your share of covered charges consists only of your deductible and coinsurance or copayment. Here is an example using coinsurance: You see a PPO physician who charges $350, but our allowance is $300. If you have met your deductible, you are only responsible for your coinsurance. That is, you pay just 10% of our $300 allowance ($30). Because of the agreement, your PPO physician will not bill you for the $50 difference between our allowance and the bill.

Follow these steps when you use a PPO provider in order to receive PPO benefits:

• When you call for an appointment, verify that the physician or facility is still a PPO provider and;
• Present your PPO ID card confirming your PPO participation in order to receive PPO benefits.

• Non-PPO providers, on the other hand, have no agreement to limit what they will bill you. For instance, when you reside in the PPO network area and use a non-PPO 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 a non-PPO physician who charges $350 and our allowance is again $300. Because you have met your deductible, you are responsible for your coinsurance, so you pay 30% of our $300 allowance ($90). Plus, because there is no agreement between the non-PPO physician and us, the physician can bill you for the $50 difference between our allowance and the bill.

The following table illustrates the examples of how much you have to pay out-of-pocket for services from a PPO physician vs. a non-PPO physician when you reside in the PPO network area. The table uses our example of a service for which the physician charges $350 and our allowance is $300. The example shows the amount you pay if you have met your calendar year deductible. 

EXAMPLE

PPO physician

Physician’s charge: $350

Our allowance: We set is at $300

We pay: Allowance less copay: 90% of our allowance: $270

You owe: Coinsurance: 10% of our allowance: $30

+Difference up to charge: No: $0

TOTAL YOU PAY: $30

Non-PPO physician

Physician’s charge: $350

Our allowance: We set it at: $300

We pay: Allowance less copay: 70% of our allowance: $210

You owe: Coinsurance: 30% of our allowance: $90

+Difference up to charge:  Yes: $50

TOTAL YOU PAY: $140

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

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

• Medical PPO and Pharmacy Network providers: $5,000 for Self Only and $7,000 for Self Plus One or Self and Family;

• Medical, Non-PPO providers: $7,000 for Self Only and $9,000 for Self Plus One or Self and Family;

Out-of-pocket expenses are:

• Your $350 Self/$700 Self Plus One/$700 Self and Family calendar year deductible for PPO and $400 Self/$800 Self Plus One/$800 Self and Family for non-PPO;

• The percentage you pay for covered services after you have met your deduct­ibles;

• The percentage you pay for surgery, anesthesia and extended medical care after an accidental injury;

• Copayments for Essential Health Benefits;

• Your copayment for hospital stays;

The following cannot be included in your out-of-pocket expenses:

• Expenses in excess of the Plan allowance or maximum benefit limitations;
• Non-covered services and supplies;
• Expenses for dental care including the $200 copayment you pay for dental care after an accidental injury; or
• Any amounts you pay if benefits have been reduced because of noncompliance with our precertification, prior authorization or prior approval requirements.

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

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 covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

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

Facilities of the Department of Veterans 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 a nonparticipating health care 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 nonparticipating providers.

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

Your health plan must comply with the NSA protections that hold you harmless from unexpected bills. 

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.compassrosebenefits.com or contact the health plan at 888-438-9135. 

• 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 (not including surgery)

• In physician’s office or convenient care center

- office visits

- clinic visits

- consultations (to include second surgical opinion)

Note: No referral required to see a specialist.

Note: Supplies provided by the physician are covered under Section 5(a).

PPO: $15 copayment (No Deductible) $25 copayment for Specialist (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

$15 copayment (No Deductible) for providers used outside the 50 United States

Professional services of physicians (not including surgery)

• In a hospital (Inpatient or Outpatient)
• In an urgent care center
• In a skilled nursing facility
• At home
• Advance care planning including end-of-life counseling

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

10% of the Plan allowance for providers used outside  the 50 United States

• Telehealth

Please note, we pay for telehealth services outside of office visits under the appropriate plan benefit.

Note: Doctor On Demand physicians treat hundreds of conditions, including providing mental health counseling. For more information on telehealth benefits, please see Section 5(h) Wellness and other special features. 

PPO and Doctor on Demand: Nothing (No Deductible) $25 copayment for Specialist (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Nothing (No Deductible) for providers used outside the 50 United States 

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap tests
• Pathology
• Electrocardiogram and EEG
• Sleep studies*

• Genetic testing*

• Genetic counseling*

*Note: All sleep studies and genetic testing must be prior authorized through eviCore at 888-209-5761, or are subject to the maximum $500 not prior authorized penalty. See Section 3 for more details.

Note: Genetic testing is covered when medically necessary. The test must not be considered experimental, investigational, or unproven. The test must be performed by a CLIA-certified laboratory. The test result must directly impact or influence the disease treatment of the Covered Person. Genetic testing must also meet at least one of the following: the patient has current signs and/or symptoms (i.e., the test is being used for diagnostic purposes), conventional diagnostic procedures are inconclusive, the patient has risk factors or a particular family history that indicates a genetic cause, the patient meets defined criteria that place him or her at high genetic risk for the condition. 

Note: Genetic counseling is covered when associated with a covered genetic test.

PPO services: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

10% of the Plan allowance for providers used outside the 50 United States

Nothing for covered tests if LabCorp or Quest are used for Laboratory Services (No Deductible)

Note: You may elect to go to a LabCorp or Quest facility and/or you must notify your provider to submit your lab work to LabCorp or Quest for processing to obtain the 100% benefit for allowable charges.

Note: If your PPO provider uses a non-PPO lab or radiologist, we will pay non-PPO benefits for any lab and X-ray charges.

Note: This benefit applies to non-routine tests and is separate from Preventive routine tests listed in Section 5(a).

Imaging, such as:

• X-rays
• Non-routine mammograms
• Ultrasounds
• Sonograms

Note: The first mammogram of the calendar year is covered under preventive care.

PPO services in free-standing imaging center: Nothing (No Deductible)

PPO services outside free-standing imaging center: 10% of the Plan allowance

Non-PPO services: 30% of the Plan allowance and any difference between our allowance and the billed amount

Nothing (No Deductible) in free-standing imaging center and 10% of the Plan allowance outside free-standing imaging center for providers used outside the 50 United States

Advanced imaging, such as: 

• MRI
• MRA
• SPECT
• CTA
• PET
• CT

Note: Prior authorization is required for advanced imaging. See Section 3 for details. Failure to prior authorize a service may result in a non-prior authorization penalty of a maximum $500 per episode of care.

PPO services in free-standing imaging center: 10% of the Plan allowance (No Deductible)

PPO services outside free-standing imaging center: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

10% of the Plan allowance (No Deductible) in free-standing imaging center and 10% of the Plan allowance outside free-standing imaging center for providers used outside the 50 United States

Not covered:

Some allergy tests, see Allergy care, Page (Applies to printed brochure only). 

• Routine physical every year

The following preventive services are covered at the time interval recommended at each of the links below.  

• 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/
• Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. You may also find a complete list of services under the U.S. Preventive Services Task Force (USPSTF) A and B recommendations online at https://www.uspreventiveservicestaskforce.org 
• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of preventive care benefits for women go to the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder

PPO Services in physician’s office: Nothing (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

Nothing (No Deductible) for providers used outside the 50 United States

The following are paid in addition to the above benefit:

• First mammogram of the calendar year
• First colonoscopy of the calendar year (no age limit)
• Immunizations required for travel
• Exams and immunizations for work
• Exams and immunizations for sports

Note: Your physician’s bill must clearly state “Routine Physical Exam.” If a medical diagnosis is provided on the bill, those services will be paid under the medical benefit.

Note: We cover related services under the applicable benefits section (i.e., for facility charge, see Section 5(c)).

PPO: Nothing (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

Nothing (No Deductible) for providers used outside the 50 United States

Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule. 

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

PPO: Nothing (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

Nothing (No Deductible) for providers used outside the 50 United States

• 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 Future Guidelines, go to https://brightfutures.aap.org  
• Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html 
• You may also find a complete list of services under the U.S. Preventive Services Task Force (USPSTF) A and B recommendations online at https://www.uspreventiveservicestaskforce.org

Note: Your physician's bill must clearly state "Routine Physical Exam." If a medical diagnosis is provided on the bill, those services will be paid under the medical benefit.

PPO: Nothing (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

Nothing (No Deductible) for providers used outside the 50 United States

• Examinations, limited to:

  - Examinations for amblyopia and strabismus - limited to one screening examination (ages 3 through 5)

  - Examinations done on the day of immunizations (ages 3 up to age 22)

• Childhood obesity screening programs and treatment interventions

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

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

PPO: Nothing (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

Nothing (No Deductible) for providers used outside the 50 United States

Note: PPO services outside physician's office Nothing (No Deductible)

Complete maternity (obstetrical) care such as:

• Prenatal care (to include laboratory tests)

• Amniocentesis

• Delivery

• Initial, routine examination of your newborn infant covered under your family enrollment

• Postnatal care

• One routine sonogram - additional sonograms may be covered when medically necessary

• Screening for Human Immunodeficiency Virus (HIV)

• Counseling and interventions for pregnant and postpartum persons who are at risk of perinatal depression

• Early screening for syphilis in all pregnant individuals

• Screening for gestational diabetes for pregnant individuals

• Preeclampsia screening

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

Note: For assistance locating a PPO provider, please call 888-438-9135.

Note: Here are some things to keep in mind

• You do not have to precertify your vaginal delivery; see page (Applies to printed brochure only) for other circumstances, such as extended stays for you or your baby.

• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will cover an extended stay if medically necessary and precertified.

• 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 enrollment or Self and Family enrollment. If your baby stays in the hospital after your discharge and is covered under your Self Plus One enrollment or Self and Family enrollment, you must precertify the extended stay and pay a separate hospital stay copayment. See Section 5(c).

• Surgical benefits, not maternity benefits, apply to circumcision. 

• Bassinet or nursery charges on which you and your baby are confined are considered your maternity expenses, not your baby's.

• Sonograms and other related tests that are not included in your routine prenatal or postnatal care are covered in Lab, X-Ray, and other diagnostic tests, see page (Applies to printed brochure only).

• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.

• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b) for non-PPO providers.

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

Note: 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.

PPO: Nothing (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Nothing (No Deductible) for providers used outside the 50 United States

• Childbirth education classes

PPO, Non-PPO and Providers Used Outside the 50 United States: Nothing (No Deductible) up to the Plan maximum of $100 per calendar year; and all charges above $100 per calendar year

• Doula

Note: Doula coverage is provided when service is performed by a certified doula through DONA International. To locate a certified doula, go to https://www.dona.org/what-is-a-doula/find-a-doula

PPO, Non-PPO and Providers Used Outside the 50 United States: Nothing (No Deductible) up to the Plan maximum of $1,000 per calendar year; and all charges above $1,000 per calendar year

• Blood Pressure Monitor

Note: Allowance of 1 blood pressure monitor in pregnant individuals per pregnancy

PPO, Non-PPO and Providers Used Outside the 50 United States: Nothing (No Deductible) up to the Plan maximum of $50 per pregnancy; and all charges above $50 per pregnancy

Not Covered:

Routine sonograms to determine fetal age, size or sex; or procedures, services, drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest.

A range of voluntary family planning services, limited to:

• Voluntary sterilization, male and female (limited to vasectomies and tubal ligations)

• Surgically implanted contraceptives

• Fitting, inserting or removing intrauterine devices (such as diaphragms and IUDs)

• Sterilization procedures, and patient education and counseling for all individuals with reproductive capacity

• Injection of contraceptive drugs (such as Depo Provera)

Note: We cover oral contraceptives under the prescription drug benefit.

PPO: Nothing (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

Nothing  (No Deductible) for providers used outside of the 50 United States

• Contraceptive counseling on an annual basis
• All Food and Drug Administration (FDA) approved contraceptive medications and devices
• The morning after pill

 Note: FDA-approved prescription drugs and devices for birth control require a physician's prescription. 

PPO: Nothing (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

Nothing (No Deductible) for providers used outside the 50 United States

Not covered:

Reversal of voluntary surgical sterilization, genetic counseling (unless specifically noted as covered).

Diagnosis and treatment of infertility 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

Note: We will pay up to $5,000 per person per calendar year for covered infertility services, including prescription drugs.

Note: The Plan will provide Infertility benefits as outlined in Section 5(a), Infertility services, if the couple has a relationship under which the FEHB Program recognizes each partner as a spouse of the other.

Note: Refer to Section 10 for Definition of Infertility.

PPO, Non-PPO and providers used outside the 50 United States: 10% of billed charges and charges in excess of $5,000 per calendar year. 

• Fertility preservation services

We will pay up to $5,000 per person per calendar year for fertility preservation services and storage costs for persons when medically necessary. Coverage for storage costs is limited to 1 year.

Note: Prior authorization is required for fertility preservation services. Fertility preservation services is covered for persons facing the possibility of iatrogenic infertility, including infertility associated with medical and surgical gender transition treatment.

PPO, Non-PPO and providers used outside the 50 United States: 10% of billed charges, charges in excess of $5,000 per calendar year and all storage costs after 1 year.

 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 intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)

- Intravaginal insemination (IVI)

- Intracervical insemination (ICI)

- Intrauterine insemination (IUI)

Allergy testing, injections and treatment (including allergy serum, RAST tests, and Food tests).

PPO services in physician’s office: 10% of the Plan allowance (No Deductible)

PPO services outside physician’s office: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

10% of the Plan allowance (No Deductible) in physician's office and 10% of the Plan allowance outside physician's office for providers used outside the 50 United States

Note: Office visits and consultations by a physician are covered under professional services of physicians, see page (Applies to printed brochure only).

Not covered:

• EndPoint titration techniques

• Sublingual allergy desensitization

• Hair Analysis

• Chemotherapy and radiation therapy

Note: Prior authorization is required for chemotherapy and radiation therapy. See Section 3 for details. Failure to prior authorize a service may result in a maximum non-prior authorization penalty of $500 per episode of care.

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

• Intravenous (IV) Infusion Therapy Home IV and antibiotic therapy

Note: Prior authorization is required for infusion therapy, including chemotherapy. See Section 3 for details. Failure to prior authorize a service may result in a non-prior authorization penalty of a maximum $500 per episode of care.

• Renal Dialysis 

Note: Prior authorization is required for renal dialysis. See Section 3 for details. Failure to prior authorize a service may result in a maximum non-prior authorization penalty of $500 per episode of care.

• Respiratory and inhalation therapies

• B12 injections

• Pain management injections

Note: Prior authorization is required for pain management injections. See Section 3 for details. Failure to prior authorize a service may result in a maximum non-prior authorization penalty of $500 per episode of care.

• Growth hormone therapy (GHT)

Note: We only cover GHT when you obtain prior approval. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment.  We will only cover GHT services that we determine are medically necessary. See Other services under You need prior Plan approval for certain services on page (Applies to printed brochure only).

• Applied Behavior Analysis (ABA) - Children up to age 18 years with autism spectrum disorder 

ABA services must be performed by a licensed healthcare professional practicing within the scope of his or her license or certification (preferably a Board Certified Behavior Analyst).

Note: Prior authorization is required for ABA. See Section 3 for details. Failure to prior authorize a service may result in a non-prior authorization penalty of a maximum $500 per episode of care. Treatment plans specific to ABA therapy with goals-progress and updates are required at least every 6 months for review of ongoing therapy to evaluate continued medical necessity.

Note: Treatment with ABA is subject to all other Plan provisions as applicable, such as experimental, investigational, unproven treatment, custodial care, nutritional or dietary supplements, or educational services that should be provided through the school district. 

Note: We cover drugs administered for therapies listed above in Section 5(f). 

Note: Specialty drugs that are received under the medical benefit and available under Section 5(f) must be obtained through Accredo after 2 courtesy fills (see Section 5(f))

Note: We cover cardiac rehabilitation following qualifying event/condition in Section 5(c), pages 60-64. 

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

10% of the Plan allowance for providers used outside the 50 United States

• Medical food formulas ordered by a healthcare provider that are medically necessary to treat inborn errors of metabolism.

Note: Prior authorization is required for medical food.

Refer to Section 10 for Definition of medical food. 

PPO, Non-PPO and providers used outside the 50 United States: 10% of billed charges and charges in excess of $1,000 per calendar year. 

Not Covered:

• Grocery food items

• Medical foods for conditions other than inborn errors of metabolism

All charges

• 90 total combined outpatient physical, speech and occupational therapy visits per calendar year for the following:

- Physicians

- Qualified physical therapists

- Speech therapists

- Occupational therapists

- Chiropractors

Note: Prior authorization for physical, occupational and speech therapy visits is required after your 12^th visit. See Section 3 for details. Failure to prior authorize a service may result in a non-prior authorization penalty of a maximum $500 per episode of care.

Note: 90 total combined visits does not include inpatient physical, speech and occupational therapy, which is covered under Section 5(c) hospital or facility coverage.

Note:  We only cover therapy when a provider:

- orders the care;

- identifies the specific professional skills the patient requires and the medical necessity for skilled services; and

- indicates the length of time the services are needed.

Note: Inpatient rehabilitative services are covered under Section 5(c)

Note: Physical, speech and occupational therapy visits must be medically necessary to achieve significant improvement in function.

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

10% of the Plan allowance for providers used outside the 50 United States

Not covered:

• Long-term rehabilitative therapy
• Exercise programs
• Services deemed not medically necessary

Hearing Exam

For treatment related to illness or injury, 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.

PPO: Nothing (No Deductible)

Non-PPO: Any difference between our allowance and the billed amount (No Deductible)

Nothing (No Deductible) for providers used outside of the 50 United States

Hearing aids for adults and children - one hearing aid and related services per ear every five calendar years when prescribed by an M.D., D.O., or Audiologist.

• External hearing aids

Medicare B Primary

Hearing aids for adults when Medicare Part B is primary - one hearing aid and related services per ear every three calendar years when prescribed by an M.D., D.O., or Audiologist.

• External hearing aids

PPO, non-PPO and providers used outside the 50 United States: All charges over $1,200 for one hearing aid per ear, every five calendar years.

Medicare B Primary

PPO, non-PPO and providers used outside the 50 United States: All charges over $1,200 for one hearing aid per ear, every three calendar years.

Not covered:

Hearing services that are not shown as covered

One (1) pair of eyeglasses with standard frames or one (1) pair of contact lenses per incident to correct an impairment directly caused by:

• Accidental ocular injury or

• Surgery in connection with the following diagnosis specifically ordered by the physician:

• Cataract
• Keratoconus or
• Glaucoma

Note: Services must be received within one year of the date of accident or surgery.

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

10% of the Plan allowance for providers used outside the 50 United States

Not covered:

• Eyeglasses or contact lenses and examinations for them, except for accidental injury and intraocular surgery
• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery
• Eye refractions
• Routine vision benefits

Prescription Foot Orthotics

Note: You must submit a claim form with receipt for reimbursement of Non-Prescription Foot Orthotics

Note:  Non-routine foot conditions with a medical diagnosis are considered for coverage as outlined in Sections 5(a) and 5(b).

PPO: 10% of the Plan allowance 

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

10% of the Plan allowance for providers used outside the 50 United States

Non-Prescription Foot Orthotics (Instore and Online Retailer): $50 allowance per person per calendar year

Not Covered:

We do not provide benefits for routine foot care, such as:

• Treatment or removal of corns and calluses, or trimming of toenails unless at least part of the nail root is removed or when needed to treat a metabolic or peripheral vascular disease
• Orthopedic shoes

All Charges

•Artificial limbs and eyes

•Prosthetic sleeve or sock

•Externally worn breast prostheses 

• Surgical bras (four per year), including necessary replacements following a mastectomy.

•Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implants following mastectomy. 

•Braces, including necessary adjustments to shoes to accommodate braces, which are used for the purpose of supporting a weak or injured part of the body.

•Cranial helmets and similar devices when ordered as part of treatment for a medical illness or injury.

•Lumbosacral supports

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

Note: A $500 maximum penalty is applied if items over $2,000 are not prior authorized. See Section 3 for more information.

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

10% of the Plan allowance for providers used outside the 50 United States

Diabetic shoes

•One pair of diabetic shoes per person.  Replacements allowed annually.

PPO, Non-PPO and providers used outside the 50 United States: All charges in excess of $150 (No Deductible)

Wigs, toupees, hairpieces up to $400 while covered under this Plan, when required due to hair loss in connection with cancer treatment or alopecia related to a medical condition.

PPO, Non-PPO and providers used outside the 50 United States: All charges in excess of $400 for 1 item per calendar year.

Not covered:

•Orthopedic and corrective shoes, arch supports, foot orthotics unless attached to a brace, heel pads and heel cups

•Over-the-counter lumbosacral supports

•Corsets, trusses, elastic stockings, support hose (except for the diagnosis of Lymphedema), and other supportive devices

•Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

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

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

We cover purchase or rental up to the purchase price, at our option, including repair and adjustment, of durable medical equipment. We will pay only for the cost of the standard item. Coverage for specialty equipment such as all-terrain wheelchairs is limited to the cost of the standard equipment. Under this benefit, we also cover:

• Oxygen;
• Hospital beds;
• Dialysis equipment;
• Glucose monitors;
• Approved insulin pumps;
• Respirators;
• Ostomy supplies;
• Wheelchairs, crutches, canes, walkers, casts;
• Compression stockings (for the diagnosis of lymphedema) - two pair per year;
• Cervical collars and traction kits;
• Batteries and maintenance supplies for cochlear implants;
• Splints; and
• CPAP and BiPAP machines

Note: Individual DME items costing $500 or more to rent or $1500 or more to purchase require prior authorization. If these items are not prior authorized, you will be subject to a no prior authorization penalty of a maximum $500 per item.

Note: For assistance locating a PPO provider, please call 888-438-9135.

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

10% of the Plan allowance for providers used outside the 50 United States

We cover the purchase of augmentative and alternative communication devices such as:

• Computer story boards
• Light talkers
• Enhanced vision systems
• Speech aid prosthesis for pediatrics
• Speech aid prosthesis for adults

Not covered:

• Sun or heat lamps, whirlpool baths, heating pads, air purifiers, humidifiers, air conditioners, and exercise devices

• Safety, hygiene, and convenience equipment and supplies

• Lifts, such as seat, chair or van lifts

• Computer items other than those specifically listed as covered

• All equipment/supplies from an online retailer (does not include non-prescription foot orthotics)

• Other items not meeting the definition of durable medical equipment 

For services provided on a part-time basis (less than an 8-hour shift):

If precertified, 90 visit maximum per calendar year when:

• A registered nurse (R.N.) or licensed practical nurse (L.P.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: A maximum $500 penalty is applied if services are not prior authorized. See Section 3 for more information.

Note: Home health physical, occupational and speech therapy are covered under Section 5(a) physical, occupational and speech therapies. 

PPO: 10% of the Plan allowance (No Deductible) with a 90-visit maximum. All charges over the visit maximum.

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible) with a 90-visit maximum. All charges over the visit maximum.

10% of the Plan allowance (No Deductible) with a 90-visit maximum. All charges over the visit limit for providers used outside the 50 United States.

For private duty nursing provided on a full-time basis (more than an 8-hour shift) by a Registered Nurse (R.N.) or Licensed Practical Nurse (L.P.N.) when:

• the care is ordered by the attending physician, and
• your physician identifies the specific professional nursing skills that you require, as well as the length of time needed. 

Note: Prior authorization is required for private duty nursing. See Section 3 for details. Failure to prior authorize a service may result in a maximum non-prior authorization penalty of $500 per episode of care.

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient’s family;
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative:
• Custodial care as defined in Section 10.

Covered services are limited to:

• Manipulation of the spine and extremities

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

Note: Physical, occupational and speech therapy provided by a chiropractor are covered under Section 5(a) physical, occupational and speech therapies.

PPO: 10% of the Plan allowance up to the Plan maximum of 24 visits per person per calendar year

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount up to the Plan maximum of 24 visits per person per calendar year

10% of the Plan allowance up to the Plan maximum of 24 visits per person per calendar year for providers used outside the 50 United States

Acupuncture:

•  Anesthesia
•  Pain Relief

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

PPO: 10% of the Plan allowance up to the Plan maximum of 24 visits per person per calendar year

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount up to the Plan maximum of 24 visits per person per calendar year

10% of the Plan allowance up to the Plan maximum of 24 visits per person per calendar year for providers used outside the 50 United States

• Massage Therapy

Note: Massage therapy coverage is provided when service is performed by a Medical Doctor, Doctor of Osteopathic Medicine, Physical Therapist, Occupational Therapist, Chiropractor, Acupuncturist or Massage Therapist. 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.

PPO, Non-PPO and Providers Used Outside the 50 United States: Nothing (No Deductible) up to the Plan maximum of $60 per visit; and all charges above 12 visits per person per calendar year

Not covered:

• Chelation therapy except for acute arsenic, gold, mercury, lead, or use of Deferoxamine in iron poisoning
• Naturopathic services
• Homeopathic services and medicines
• Treatment, services or supplies for holistic or homeopathic medicine, hypnosis, or other alternative treatment that is not accepted as medical practice as determined by the Plan.
  

Nutritional therapy

Coverage Limited to:

• Nutritional counseling

Note: Refer to preventive services for additional coverage information.

Note: We cover dieticians, nutritionists and diabetic educators who bill independently for nutritional counseling.

PPO, Non-PPO and providers used outside the 50 United States: $15 copayment. All charges in excess of 4 nutritional counseling sessions per year (No Deductible)

Diabetes training

 Note: Prescription drugs are covered under section 5(f).

PPO: $15 copayment (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

$15 copayment (No Deductible) for providers used outside the 50 United States

Tobacco Cessation

Tobacco Cessation Programs including individual phone counseling with a certified tobacco cessation specialist, physician written and prescribed over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence. 

Coverage is provided for:

• Up to five telephonic smoking cessation counseling sessions per quit attempt and two quit attempts per year.
• FDA-approved prescription and over-the-counter drugs for the treatment of tobacco dependence.

You can enroll in UMR's Tobacco Cessation Program by calling 800-207-7680.

PPO, Non-PPO and providers used outside the 50 United States: Nothing (No Deductible)

Nothing for physician prescribed OTC and prescription drugs approved by the FDA to treat tobacco dependence.

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Medically necessary non-routine colonoscopy services.
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Replacement batteries for covered implantable devices

Note: PPO surgical services related to maternity care are covered at 100%, see Section 5(a) maternity care.

Note: The first colonoscopy of the calendar year is covered under preventive care, see Section 5(a) preventive care

PPO: 10% of the Plan allowance (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

10% of the Plan allowance (No Deductible) for providers used outside the 50 United States

• Surgical treatment of morbid obesity (bariatric surgery) – a condition in which an individual is:

(1) a BMI of >40 kg/m² with no other health conditions or a BMI >35 kg/m² with at least one comorbidity; 

(2) have documentation of a motivated attempt of weight loss through a structured diet program, prior to bariatric surgery, which includes physician or other health care provider notes and/or diet or weight loss logs from a structured weight loss program for a minimum of 3 months and within the last 2 years;

 (3) a psychological evaluation within 12 months of surgery to rule out major mental health disorders which would contraindicate surgery and determine patient compliance with post-operative follow-up care and dietary guidelines and

(4) is age 18 or older.

Covered procedures include: gastric banding, adjustable gastric banding, gastric sleeve procedure, vertical banded gastroplasty, biliopancreatic bypass and biliopancreatic diversion with duodenal switch and gastric bypass.

 Note: The procedure must be performed at an Optum Bariatric Resource Services Center of Excellence provider to receive PPO level of benefit.

Note: You must enroll in the Optum Bariatric Resource Services (BRS) program.

Note: Limited to one surgery per lifetime. Surgical adjustment or alteration of a prior procedure for complications of the original surgery, such as stricture, obstruction, pouch dilatation, erosion, or band slippage when the complication causes abdominal pain, inability to eat or drink, or causes vomited of prescribed meals is covered at standard surgery level of benefits.

PPO: 10% of the Plan allowance (No Deductible) when an Optum Bariatric Resource Services program provider is used

Non-PPO: 100%

10% of the Plan allowance (No Deductible) for providers used outside the 50 United States

• Treatment of burns

• Surgical treatment of bunions or spurs

• Assistant surgeons - we cover up to 20% of our allowance for the surgeon’s charge

• Varicose vein surgery

Prior authorization is required for varicose vein surgery. See Section 3 for details. Failure to prior authorize a service may result in a maximum non-prior authorization penalty of $500 per episode of care.

Note: For related services, see applicable benefits section (i.e., for inpatient hospital benefits, see Section 5(c)).

PPO: 10% of the Plan allowance (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

10% of the Plan allowance (No Deductible) for providers used outside the 50 United States

• Gender Affirmation Procedures 

In order for the Plan to consider  benefits, all of the following Plan requirements must have been met:

1. Twelve months of living in a gender role that is congruent with their gender identity (real life experience), and
2. Two referral letters from qualified mental health professionals, one in a purely evaluative role, and
3. Persistent, well-documented gender dysphoria, and
4. Capacity to make a fully informed decision and to consent for treatment, and
5. Age of majority (18 years or older), and
6. If significant medical or mental health concerns are present, they must be reasonably well controlled, and
7. You have obtained preauthorization for the surgery even if the proposed treatment is outside of the 50 United States and services are deemed medically necessary.

Medical necessity: See Section 10, page (Applies to printed brochure only). 

Covered surgical procedures, limited to:

• For female to male surgery: mastectomy, hysterectomy, vaginectomy, salpingo-oophorectomy, metoidioplasty, phalloplasty, urethroplasty, scrotoplasty, and placement of testicular and erectile prosthesis.
• For male to female surgery: penectomy, orchidectomy, vagnoplasty, clitoroplasty, and labiaplasty

Not covered: 

• Rhinoplasty, face-lifting, lip enhancement, facial bone reduction, blepharoplasty, breast augmentation, liposuction of the waist (body contouring), reduction thyroid chondroplasty, hair removal, voice modification surgery (laryngoplasty or shortening of the vocal cords), and skin resurfacing, which have been used in feminization, are considered cosmetic. 
• Similarly, chin implants, nose implants, and lip reduction, which have been used to assist masculinization, are considered cosmetic.

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.

PPO: 10% of the Plan allowance (No Deductible) 

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

10% of the Plan allowance for providers used outside the 50 United States (No Deductible) 

When multiple or bilateral surgical procedures performed during the same operative session add time or complexity to patient care, our benefits are:

For the primary procedure:

    - PPO: 90% of the Plan allowance (No Deductible)

    - Non-PPO: 70% of the Plan allowance (calendar year deductible applies)

For the secondary procedure(s):

    - PPO: 90% of one-half of the Plan allowance  (No Deductible)

    - Non-PPO: 70% of one-half of the Plan allowance (calendar year deductible applies)

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.

PPO: 10% of the Plan allowance for the primary procedure and 10% of one-half of the Plan allowance for the secondary procedure(s) (No Deductible)

Non-PPO: 30% of the Plan allowance for the primary procedure and 30% of one-half of the Plan allowance for the secondary procedure(s); and any difference between our payment and the billed amount

10% of the Plan allowance for the primary procedure and 10% of one-half of the Plan allowance for the secondary procedure(s) (No Deductible) for providers used outside the 50 United States

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

Not covered:

Services of a standby surgeon, except during angioplasty or other high risk procedures when we determine standbys are medically necessary.

• Surgery to correct a functional defect

• Surgery to correct a condition caused by injury or illness if:

    - the condition produced a major effect on the member’s appearance and;

    - the condition can reasonably be expected to be corrected by such surgery.

• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of the congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birthmarks; and webbed fingers and toes.

PPO: 10% of the Plan allowance (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

10% of the Plan allowance (No Deductible) for providers used outside the 50 United States

All stages of breast reconstruction surgery following a mastectomy, such as:

• surgery to produce a symmetrical appearance of breasts
• treatment of any physical complications, such as lymphedemas
• breast prostheses; and surgical bras and replacements (see Prosthetic devices for coverage)

Note: Internal breast prostheses are covered under Section 5(a).

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.

PPO: 10% of the Plan allowance (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed

10% of the Plan allowance (No Deductible) for providers used outside the 50 United States

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

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 leukoplakia or malignancies
• Excision of cysts and incision of abscesses when done as independent procedures
• Surgical correction of temporomandibular joint (TMJ) dysfunction
• Surgical removal of impacted teeth, including anesthesia charges
• Other surgical procedures that do not involve the teeth or their supporting structures

Note: Prior authorization is required for oral and maxillofacial surgery. See Section 3 for details. Failure to prior authorize a service may result in a maximum non-prior authorization penalty of $500 per episode of care.

PPO: 10% of the Plan allowance (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

10% of the Plan allowance (No Deductible) for providers used outside the 50 United States

Not covered:

• Oral implants, transplants and related services 
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone), including Apicoectomy (the excision of the tooth root without the extraction of the entire tooth)
• Pre- and post-operative examinations in preparation for surgical removal of impacted teeth

These solid organ transplants are covered. These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. See Other services under You need prior Plan approval for certain services on page (Applies to printed brochure only). Solid organ transplants are limited to:

• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
• Cornea
• Heart
• Heart-Lung

• Intestinal transplants

  - Isolated small intestines

  - Small intestines with the liver

  - Small intestines with multiple organs, such as the liver, stomach, and pancreas

• Kidney
• Kidney-pancreas
• Liver
• Lung single/bilateral/lobar
• Pancreas

PPO: 10% of the Plan allowance (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

10% of the Plan allowance (No Deductible) for providers used outside the 50 United States

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Other services in Section 3 for prior authorization procedures.

• Autologous tandem transplants for:

- AL Amyloidosis

- Multiple myeloma (de novo and treated)

- Neuroblastoma

- Pediatric brain tumors

- Recurrent germ cell tumors (including testicular cancer)

PPO: 10% of the Plan allowance (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

10% of the Plan allowance (No Deductible) for providers used outside the 50 United States

Blood or marrow stem cell transplants 

The Plan extends coverage for the diagnoses as indicated below.

• Allogenic transplants for:

- Acute lymphocytic or non-lymphocytic (i.e. myelogenous) leukemia

- Acute myeloid leukemia

- Hodgkin's lymphoma with recurrence (relapsed)

- Non-Hodgkin's lymphoma with recurrence (relapsed)

- Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)

- Chronic myelogenous leukemia

- Hemoglobinopathies

- Infantile malignant osteoporosis 

- Immune deficiency disease other than SCID (e.g., Wiskott-Aldrich syndrome, Kostmann’s syndrome, Leukocye Adhesion Deficiencies) not amenable to more conservative treatments.

- Kostmann's syndrome

- Leukocyte adhesion deficiencies

- Marrow failure and related disorders (i.e., Fanconi's, Pure Red Cell Aplasia)

- Mucolipidosis (e.g., Gaucher's disease, metachromatic leukodystrophy, adrenoleukodystrophy)

- Mucopolysaccharidosis (e.g., Hunter's syndrome, Hurler's syndrome, Sanfilippo syndrome, Maroteaux-Lamy syndrome variants)

- Myelodysplasia/Myelodysplastic syndromes

- Myeloproliferative disorders

- Paroxysmal Nocturnal Hemoglobinuria

- Phagocytic/Hemophagocytic deficiency diseases 

- Severe combined immunodeficiency

- Severe aplastic anemia

- Sickle cell anemia

- X-linked lymphoproliferative syndrome

 • Autologous transplants for:

- Chronic myelogenous leukemia

- Hodgkin's lymphoma with recurrence (relapsed)

- Non-Hodgkin's lymphoma with recurrence (relapsed)

- Aggressive non-Hodgkin's lymphoma

- Amyloidosis

- Ependymoblastoma

- High-risk Ewing's sarcoma

- Medulloblastoma

- Multiple myeloma

- Neuroblastoma

- Oligodendroglioma

- Pineoblastoma

- Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

- Waldenstrom’s macroglobulinemia

PPO: 10% of the Plan allowance (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

10% of the Plan allowance (No Deductible) for providers used outside the 50 United States

Reduced intensity conditioning transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan. 

Refer to Other services in Section 3 for prior authorization procedures:

• Allogeneic transplants for

- Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia

- Acute myeloid leukemia

- Advanced Myeloproliferative Disorders (MPDs)

- Amyloidosis

- Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)

- Hemoglobinopathies

- Marrow failure and related disorders (i.e., Fanconi’s, Pure Red Cell Aplasia)

- Myelodysplasia/Myelodysplastic syndromes

- Severe combined immunodeficiency

- Severe or very severe aplastic anemia

• Autologous transplants for:

- Chronic myelogenous leukemia

- Advanced childhood kidney cancers

- Hodgkin’s lymphoma with recurrence (relapsed)

- Advanced neuroblastoma

- Non-Hodgkin’s lymphoma with recurrence (relapsed)

- Amyloidosis

- Childhood rhabdomyosarcoma

- High-risk Ewing's sarcoma

- Mantle Cell (Non-Hodgkin's lymphoma)

- Neuroblastoma

PPO: 10% of the Plan allowance (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

10% of the Plan allowance (No Deductible) for providers used outside the 50 United States

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

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

• Allogeneic transplants for

- Beta Thalassemia Major

- Early stage (indolent or non-advanced) small cell lymphocytic lymphoma

- Multiple myeloma

- Multiple sclerosis

- Sickle Cell 

• Reduced intensity conditioning transplants (non-myeloablative allogeneic) for:

- Chronic leukemia

- Hodgkin’s lymphoma with recurrence (relapsed)

- Non-Hodgkin’s lymphoma with recurrence (relapsed)

- Chronic lymphocytic leukemia

- Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL) relapsed/refractory disease

- Chronic myelogenous leukemia

- Early stage (indolent or non-advanced) small cell lymphocytic lymphoma

- Multiple myeloma

 -Multiple sclerosis

- Myelodysplasia/Myelodysplastic Syndromes

- Myeloproliferative disorders (MDDs)

- Sarcomas

- Sickle Cell

• Autologous Transplants for

- High-risk childhood kidney cancers

- High-risk Ewing sarcoma

- Hodgkin’s lymphoma

- High-grade (Aggressive) Non-Hodgkin’s lymphoma

- Aggressive non-Hodgkin's lymphomas

- Breast cancer

- Childhood rhabdomyosarcoma

- Epithelial Ovarian Cancer

- Mantle Cell (Non-Hodgkin's lymphoma)

- Multiple sclerosis

- Scleroderma-SSc (severe, progressive)

- Systemic sclerosis

PPO: 10% of the Plan allowance (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

10% of the Plan allowance (No Deductible) for providers used outside the 50 United States

Not covered:

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

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 below. This benefit applies only if we cover the recipient and if the donor’s expenses are not otherwise covered.

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

PPO: 10% of the Plan allowance (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

10% of the Plan allowance (No Deductible) for providers is used outside the 50 United States (No Deductible)

Not covered:

• Services or supplies for or related to surgical transplant procedures (including administration of high-dose chemotherapy) for artificial or human organ/tissue transplants not listed as specifically covered.
• Donor screening tests and donor search expenses, except those performed for the actual donor
• Donor search expense for bone marrow transplants

Limited Benefits:

• The process for preauthorizing organ transplants is more extensive than the normal precertification process. Before your initial evaluation as a potential candidate for a transplant procedure, you or your doctor must contact the Plan's Medical Management Program so we can arrange to review the clinical results of the evaluation and determine if the proposed procedure meets our definition of “medically necessary” and is on the list of covered transplants. Coverage for the transplant must be authorized in advance, in writing by the Plan's Medical Management Program.
• We will pay for a second transplant evaluation recommended by a physician qualified to perform the transplant, if the transplant diagnosis is covered and the physician is not associated or in practice with the physician who recommended and will perform the organ transplant. A third transplant evaluation is covered only if the second evaluation does not confirm the initial evaluation.
• The transplant must be performed at a Transplant Center of Excellence to receive maximum benefits. 
• If benefits are limited to $100,000 per transplant, included in the maximum are all charges for hospital, medical and surgical care incurred while the patient was hospitalized for a covered transplant surgery and subsequent complications related to the transplant. Outpatient expenses for chemotherapy and any process of obtaining stem cells or bone marrow associated with bone marrow transplant (stem cell support) are included in benefits limit of $100,000 per transplant. Tandem bone marrow transplants approved as one (1) treatment protocol are limited to $100,000 when not performed at a Transplant Center of Excellence expenses for aftercare such as outpatient prescription drugs are not a part of the $100,000 limit.
• Chemotherapy and procedures related to bone marrow transplantation must be performed only at a Transplant Center of Excellence to receive maximum benefits.
• Simultaneous transplants such as kidney/pancreas, heart/lung, heart/liver are considered as one transplant procedure and are limited to $100,000 when not performed at a Transplant Center of Excellence.

Transportation Benefit

• We will also provide up to $15,000 per covered transplant for transportation (mileage or airfare) to a Transplant Center of Excellence and reasonable temporary living expenses (i.e., lodging and meals) for the recipient and one other individual (or in the case of a minor, two other individuals), if the recipient lives more than 50 miles from the designated transplant facility.
• Transportation benefits are payable for follow-up care up to one year following the transplant. You must contact Customer Service for what are considered reasonable temporary living expenses.

PPO: 10% of the Plan allowance (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

10% of the Plan allowance (No Deductible) for providers used outside the 50 United States

Note: If prior approval is not obtained or a Transplant Center of Excellence is not used, our allowance will be limited for hospital and surgery expenses up to a maximum of $100,000 per transplant. If we cannot refer a member in need of a transplant to a designated facility, the $100,000 maximum will not apply.

Professional services provided in:

• Hospital (inpatient)

• Hospital outpatient department

• Skilled nursing facility

• Ambulatory surgical center

• Office

PPO: 10% of the Plan allowance (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

10% of the Plan allowance (No Deductible) for providers used outside the 50 United States

Covered services provided in a PPO facility by a Non-PPO anesthesiologist or certified registered nurse anesthetist will be paid at 90% of the Plan allowance (No Deductible).

Room and board, such as

• Ward, semiprivate or intensive care accommodations

• General nursing care

• Meals and special diets

• Operating, recovery, and other treatment rooms

• Rehabilitative services

• Phase 1 of cardiac rehabilitation 

• 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

• Medical supplies and equipment, including oxygen

• Anesthetics

Note: Take-home drugs are covered under Section 5(f).

Note: Medical supplies, medical equipment, prosthetic and orthopedic devices and any covered items billed by a hospital for use at home are covered under Section 5(a) and the calendar year deductible and coinsurance apply.

Note: PPO inpatient hospital services related to maternity care are covered at 100%, see Section 5(a) maternity care.

PPO: $200 copayment per hospital stay (No Deductible)

Non-PPO: $400 copayment per hospital stay and 30% of the Plan allowance and any difference between the Plan allowance and the billed amount (No Deductible)

$200 copayment per hospital stay for providers used outside the 50 United States (No Deductible)

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 the acute hospital inpatient (overnight) setting but could receive care in some other setting without adversely affecting your condition or the quality of the medical care. Note: In this event, we pay benefits for services and supplies, excluding room and board and inpatient physician care, at the level of benefits that would have been covered if provided in another approved setting.
• Inpatient hospital services and supplies for surgery that we do not cover
• Custodial care (see definition, Section 10) even when provided by a hospital
• Non-covered facilities, such as nursing homes, rest homes, places for the aged, convalescent homes or any place that is not a hospital, skilled nursing facility, or hospice
• Personal comfort items, such as radio, television, phone, beauty and barber services
• Private nursing care
• Long term rehabilitative therapy

• Operating, recovery, and other treatment room charges

• Prescribed drugs and medications for use in the facility

• X-ray, laboratory and pathology services, and machine diagnostic tests

• Administration of blood, blood plasma, chemotherapy and other biologicals

• Blood and blood plasma, if not donated or replaced

• Dressings, casts, and sterile tray services

• Medical supplies, including oxygen

• Anesthetics and anesthesia service

• Phase II of cardiac rehabilitation - 12-week program provided by a hospital or medical center program on an outpatient basis beginning anywhere between 7 to 30 days after discharge from hospital

Note: Take-home drugs are covered under Section 5(f).

Note: Medical supplies, medical equipment, prosthetic and orthopedic devices and any covered items billed by a hospital for use at home are covered under Section 5(a) and the calendar year deductible and coinsurance apply.

Note: We cover hospital services related to dental procedures (even though the dental procedure itself may not be covered) only when a non-dental physical impairment exists that makes hospitalization necessary to safeguard your health.

Note: Hospital observation care that exceeds 24 hours will be paid under the inpatient hospital benefit. 

Note: Specialty drugs that are received under the medical benefit and available under Section 5(f) must be obtained through Accredo after 2 courtesy fills (see Section 5(f)).

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between the Plan allowance and the billed amount

10% of the Plan allowance for providers used outside the 50 United States

Not Covered:

• Phase III of cardiac rehabilitation - a maintenance program that is not considered treatment of an illness

All Charges

• Operating, recovery, and other treatment room charges

PPO: 10% of the Plan allowance (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between the Plan allowance and the billed amount (No Deductible)

10% of the Plan allowance for providers used outside the 50 United States (No Deductible) 

• Prescribed drugs and medications for use in the facility

• X-ray, laboratory and pathology services, and machine diagnostic tests

• Administration of blood, blood plasma, chemotherapy and other biologicals

• Blood and blood plasma, if not donated or replaced

• Dressings, casts, and sterile tray services

• Medical supplies, including oxygen

• Anesthetics and anesthesia service 

Note: Specialty drugs that are received under the medical benefit and available under Section 5(f) must be obtained through Accredo after 2 courtesy fills (see Section 5(f))

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between the Plan allowance and the billed amount

10% of the Plan allowance for providers used outside the 50 United States

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

1. Skilled Nursing Facility stay is medically necessary and;
2. When the Skilled Nursing Facility is under the supervision of a physician.

Note: A maximum $500 penalty is applied if services are not pre-certified. See Section 3 for more information

PPO: Charges in excess of 90-day maximum after deductible

Non-PPO: 30% of the Plan allowance and any difference between our allowance and billed charges. Charges in excess of the 90-day maximum.

Charges in excess of 90-day maximum after deductible for providers used outside the 50 United States

• Custodial care

Hospice is a coordinated inpatient and outpatient program of maintenance and supportive care for the terminally ill provided by a medically supervised team under the direction of a Plan-approved independent hospice administration.

All Hospice benefits must be precertified. A penalty maximum of $500 per confinement or episode of care will be applied for services not precertified.

Respite care – if you are under hospice care, inpatient respite care is covered up to 2 times a year for up to 5 days at a time. 

Note: Bereavement counseling is covered under Section 5 (e). Mental Health and Substance Use Disorder Benefits

Inpatient:

PPO: $200 copayment per confinement (No Deductible)

Non-PPO: $400 copayment per confinement and 30% of the Plan Allowance and any difference between the Plan allowance and the billed amount (No Deductible)

$200 copayment per confinement for providers used outside the 50 United States (No Deductible)

Outpatient:

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and billed charges

10% of the Plan allowance for providers used outside the 50 United States.

• Professional ambulance service (including air ambulance when medically necessary) to or from the nearest hospital equipped to handle your condition.
• Professional ambulance service for transport (local) immediately following an inpatient admission when medically necessary.

Note: All non-emergency air ambulance transportation must be prior authorized or is subject to a maximum $500 penalty for non prior authorization. See Section 3 for more details.

Not covered:

• Ambulance/professional transport for you or your family’s convenience
• Medivans or similar services to or from doctor office appointments 

All charges

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

• Emergency room (ER) facility charge and ER physician’s charge or

• Initial office visit for accidental injury

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

Note: We pay for services in the ER, but billed separately from the hospital bill such as X-ray, laboratory, pathology and machine diagnostic tests under the appropriate Plan benefit (see Section 5(a)).

Note: We pay Hospital benefits as specified in Section 5(c) if you are admitted to the hospital.

Note: We pay for services performed at the time of the initial office visit such as X-ray, laboratory tests, drugs or any supplies or other services under the appropriate Plan benefit (see Section 5(a)).

PPO services in physician’s office: $15 copayment (No Deductible) $25 copayment for specialist (No Deductible)

PPO services outside physician’s office: $200 copayment per occurrence (No Deductible) (copayment is waived if admitted to the hospital)

Non-PPO service in physician’s office: 30% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

Non-PPO Services outside physician’s office: $200 copayment per occurrence (No Deductible) (copayment is waived if admitted to the hospital)

Services in physician’s office: $15 copayment (No Deductible) $15 copayment for Specialist (No Deductible) for providers used outside the 50 United States

Services outside physician’s office: $200 copayment per occurrence (No Deductible) (copayment is waived if admitted to the hospital) for services used outside the 50 United States

If you receive outpatient care for your accidental injury in an urgent care center, we cover:

• Non-surgical physician services and supplies
• Surgery and related services

PPO: $50 copayment per occurrence (No Deductible) (copayment is waived if admitted to the hospital)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

$50 copayment per occurrence for providers used outside of the 50 United States (No Deductible) (copayment is waived if admitted to the hospital)

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

• Emergency room (ER) facility charge and ER physician’s charge or

• Initial office visit for accidental injury

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

Note: We pay for services in the ER, but billed separately from the hospital bill such as X-ray, laboratory, pathology and machine diagnostic tests under the appropriate Plan benefit (see Section 5(a)).

Note: We pay Hospital benefits as specified in Section 5(c) if you are admitted to the hospital.

Note: We pay for services performed at the time of the initial office visit such as X-ray, laboratory tests, drugs or any supplies or other services under the appropriate Plan benefit (see Section 5(a)).

PPO services in physician’s office: $15 copayment (No Deductible) $25 copayment for Specialist (No Deductible)

PPO services outside physician’s office: $200 copayment per occurrence (copayment is waived if admitted to the hospital) (No Deductible)

Non-PPO in physician's office: 30% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

Non-PPO outside physician's office: $200 copayment per occurrence (copayment is waived if admitted to the hospital) (No Deductible)

Services in physician’s office: $15 copayment (No Deductible) $15 copayment for Specialist (No Deductible) for providers used outside the 50 United States

Services outside physician’s office: $200 copayment per occurrence for providers used outside the 50 United States (copayment is waived if admitted to the hospital) (No Deductible)

 If you receive outpatient care for your medical emergency in an urgent care center, we cover:

• Non-Surgical physician services and supplies
• Surgery and related services

PPO: $50 copayment per occurrence (No Deductible) (copayment is waived if admitted to the hospital)

Non-PPO: 30% of Plan allowance and any difference between our allowance and the billed amount (No Deductible)

$50 copayment per occurrence for providers used outside the 50 United States (No Deductible) (copayment is waived if admitted to the hospital)

• Professional ambulance service (including air ambulance when medically necessary) to or from the nearest hospital equipped to handle your condition.

Note: All non-emergency air ambulance transportation must be prior authorized or is subject to a maximum $500 penalty for non prior authorization. See Section 3 for more details.

Not covered:

• Ambulance/professional transportation from facility to home
• Ambulance/professional transport for you or your family’s convenience
• Medivans or similar services to or from doctor office appointments

We cover professional services 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 family therapists.

PPO services in physician's office: $15 copayment (No Deductible)

PPO services outside physician's office: 10% of the Plan allowance.

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

Services in physician's office: $15 copayment (No Deductible) for providers used outside the 50 United States.

Services outside physician's office: 10% of the Plan allowance for providers used outside the 50 United States.

• Telehealth

Note: Doctor On Demand physicians treat hundreds of conditions, including providing mental health counseling and medication management. For more information on telehealth benefits, please see Section 5(h) Wellness and other special features. 

PPO and Doctor On Demand: Nothing (No Deductible)

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount 

Nothing (No Deductible) for providers used outside the 50 United States

• Outpatient diagnostic tests are 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

PPO: 10% of the Plan allowance

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount

10% of the Plan allowance for providers used outside the 50 United States

• Inpatient services provided and billed by a hospital or other covered facility
• Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services
• Inpatient diagnostic tests provided and billed by a hospital or other covered facility

PPO: $200 copayment per hospital stay (No Deductible)

Non-PPO: $400 copayment per hospital stay and 30% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

$200 copayment per hospital stay for providers used outside the 50 United States (No Deductible)

• Outpatient services provided and billed by a hospital or other covered facility
• Services such as half-way house, full-day hospitalization, or facility-based intensive outpatient treatment

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

PPO: 10% of the Plan allowance

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

10% of the Plan allowance for providers used outside the 50 United States

Other Outpatient services including half-way house, full day hospitalization or facility based intensive outpatient treatment:

PPO: 10% of the Plan allowance (No Deductible) with a 90-visit maximum. All charges over the visit maximum.

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible) with a 90-visit maximum. All charges over the visit maximum.

10% of the Plan allowance (No Deductible) with a 90-visit maximum. All charges over the visit limit for providers used outside the 50 United States.

• Partial hospitalization 

Please note: Partial Hospitalization does not apply towards the Outpatient hospital or other covered facility 90-visit maximum.

Note: Subject to the maximum $500 penalty for partial hospitalization services if not precertified.

PPO: 10% of the Plan allowance (No Deductible) with a 90-visit maximum. All charges over the visit maximum.

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible) with a 90-visit maximum. All charges over the visit maximum.

10% of the Plan allowance (No Deductible) with a 90-visit maximum. All charges over the visit limit for providers used outside the 50 United States.

Residential treatment services

Note: Subject to the maximum $500 per admission penalty for Residential Treatment Services, if not precertified.

Note: Covered residential treatment center facilities are approved by the Joint Commission or Commission on Accreditation of Rehabilitation Facilities (CARF)

PPO: Charges in excess of the 90-day maximum after deductible

Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed charges. Charges in excess of the 90-day maximum

Charges in excess of the 90-day maximum after deductible for providers used outside the 50 United States

Not covered under mental health and substance use disorder :

• All charges for chemical aversion therapy, conditioned reflex treatments, narcotherapy or any similar aversion treatments and all related charges (including room and board)
• Any provider not specifically listed as covered
• Marital counseling
• Treatment for learning or mental disabilities
• Travel time to the patient's home to conduct therapy
• Services rendered or billed by schools or members of their staff
• Personality Disorders
• Behavior/Impulse Control Disorders

All charges

You may purchase the following medications and supplies prescribed by a physician from either a pharmacy or by home delivery:

• Drugs, vitamins and minerals that by Federal law of the United States require a doctor’s prescription for their purchase.
• Drugs to treat gender dysphoria
• Insulin
• Diabetic supplies limited to:
  • Disposable needles and syringes for the administration of covered medications
  • Supplies required for administration of injectable medication
  • Lancets and test strips

Note: Members with diabetes who have Medicare B as their primary insurer, must obtain their testing supplies through a diabetic supplier that coordinates benefits with Medicare. Please contact Express Scripts at 877-438-4449.

• FDA-approved drugs and devices requiring a physician’s prescription for the purpose of birth control. See Section 5(a) Family planning

• Needles and syringes for the administration of covered medications

Here are some things to keep in mind about our prescription drug program:

• A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. Your physician must specify “dispense as written” if a brand name drug is required.

• Brand/Generic Cost Differential: If there is a generic substitution available and you request a brand-name drug, you will be responsible for the brand copay plus the difference in the cost of the brand-name and generic drug. If your provider’s prescription is for the brand-name drug and indicates “Dispense as Written” you are responsible only for the brand copay.

• We use the Express Scripts National Preferred Formulary. If your physician believes a name brand product is necessary or there is no generic available, your physician may prescribe a name brand drug from a formulary list. To request a prescription drug formulary, call Customer Service at 877-438-4449.

Note: Refer to Section 6. General Exclusions - services, drugs and supplies we do not cover.

Network Retail 30-day supply:

Level 1 (Generics): $5 (No Deductible)

Level 2 (Formulary / Preferred Brand Name): $45 (No Deductible)

Level 3 (Non-Formulary / Non-Preferred Brand Name): 40% of the Plan cost or $75, whichever is greater (No Deductible)

Network Retail 30-day supply when Medicare Part B is primary: 

Level 1 (Generics): $3 (No Deductible)

Level 2 (Formulary / Preferred Brand Name): $25 (No Deductible)

Level 3 (Non-Formulary / Non-Preferred Brand Name): 35% of the Plan cost or $50, whichever is greater (No Deductible)

Network Home Delivery:

Level 1 (Generics): $10 (No Deductible)

Level 2 (Formulary / Preferred Brand Name): $90 (No Deductible)

Level 3 (Non-Formulary / Non-Preferred Brand Name): 40% of the Plan cost or $150, whichever is greater (No Deductible)

Network Home Delivery when Medicare Part B is primary:

Level 1 (Generics): $6 (No Deductible)

Level 2 (Formulary / Preferred Brand Name): $50 (No Deductible)

Level 3 (Non-Formulary / Non-Preferred Brand Name): 35% of the Plan cost or $100, whichever is greater (No Deductible)

Note: If there is no generic equivalent available, you will still have to pay the Level 2 or Level 3 copayment. 

Note: Medications that are a single unit of use (i.e., injectables, implants) may be dispensed with a day supply greater than 30 days from a retail pharmacy or Accredo and a day supply greater than 90 days from home delivery pharmacy may be subject to only one copay.

When purchasing drugs at a pharmacy, you must use your Health Insurance Card.

Narcan and Naloxone

Network Retail: 

• Nothing 

Voluntary Smart90: You have the option to obtain an 84 to 90-day supply at Walgreens and CVS retail pharmacies or use the Express Scripts home delivery pharmacy. You can also fill 30-day supplies of any medication at an in-network retail pharmacy.

Voluntary Smart90:

Level 1 (Generics): $10 (No Deductible)

Level 2 (Formulary / Preferred Brand Name): $90 (No Deductible)

Level 3 (Non-Formulary / Non-Preferred Brand Name): 40% of the Plan cost or $150, whichever is greater (No Deductible)

Voluntary Smart90 when Medicare Part B is primary:

Level 1 (Generics): $6 (No Deductible)

Level 2 (Formulary / Preferred Brand Name): $50 (No Deductible)

Level 3 (Non-Formulary / Non-Preferred Brand Name): 35% of the Plan cost or $100, whichever is greater (No Deductible)

Specialty medications are those injectable and oral drugs typically used to treat chronic or complex conditions. They have one or more of several key characteristics, including frequent dosing adjustments and intensive clinical monitoring to decrease the potential for drug toxicity and increase the probability for beneficial treatment outcomes; patient training and compliance assistance to facilitate therapeutic goals; specialized product handling and/or administration requirements.

• Antihemophilic factor
• Blood growth factors
• Calcimimetic agent
• Growth hormone medications
• Immunoglobulin preparations
• Immunosuppressive drugs
• Interferons
• Interleukin-receptor antagonist
• Monoclonal antibody
• Mucolytic enzyme
• Platelet aggregation inhibitor
• Prostaglandin drugs
• Synthetic nucleoside analog 
• Tumor necrosis factor modulators 

Drugs in these categories are subject to the Specialty Pharmacy Benefits. The medication examples provided are not all inclusive. Call our Customer Service department at 877-438-4449 to determine if other medications not listed apply to this benefit.

Specialty Generics: 10% of the plan cost up to a maximum of $100 for up to 30-day supply (No Deductible)

Specialty Formulary / Preferred Brand Name: 25% of the Plan cost up to a maximum of $250 for up to 30-day supply (No Deductible)

Specialty Non-Formulary / Non-Preferred Brand Name: 35% of the Plan cost up to a maximum of $500 for up to 30-day supply (No Deductible)

Note: Specialty medications are not eligible for the home delivery benefit of three months' supply for two copayments. 

Note: Medications that are a single unit of use (i.e., injectables, implants) may be dispensed with a day supply greater than 30 days from a retail pharmacy or Accredo and a day supply greater than 90 days from home delivery pharmacy may be subject to only one copay.

Obtaining Specialty Medication under the Plan:

Specialty medications are injectable and oral medications that are used to treat chronic health conditions including but not limited to such conditions as transplant recipients, immunological conditions, growth hormone, bleeding disorder, HIV/AIDS.

Please refer to your drug plan formulary to determine if the drug you have been prescribed by your physician needs to be filled by our network specialty pharmacy, Accredo at 800-803-2523.

If your medication has been identified as being a specialty medication, you will be required to call the number on your insurance card for instructions on how to arrange the filling and delivery of your specialty medication.

• Medications will be mailed to you at no additional cost
• For safety, all mailing will be shipped based on temperature requirements and considerations
• Specialty Medications cannot be obtained through the traditional 90-day home delivery program
• Unless on an emergency basis, the Plan will not pay for Specialty Medications through the retail pharmacy.

Specialty Generics: 10% of the plan cost up to a maximum of $100 for up to 30-day supply (No Deductible)

Specialty Formulary / Preferred Brand Name: 25% of the Plan cost up to a maximum of $250 for up to 30-day supply (No Deductible)

Specialty Non-Formulary / Non-Preferred Brand Name: 35% of the Plan cost up to a maximum of $500 for up to 30-day supply (No Deductible)

Note: Specialty medications are not eligible for the home delivery benefit of three months' supply for two copayments.

If you reside outside of the United States and do not order prescription drugs through the Home Delivery Prescription Drug Program.

10% of the total cost of the drug

Not covered:

• Drugs and supplies for cosmetic purposes
• Nonprescription medications unless specifically specified elsewhere
• Drugs to enhance athletic performance
• Vitamins, nutrients, medical foods, and food supplements not listed as a covered benefit even if a physician prescribes or administers them.
• Nutritional supplements and vitamins that do not require a prescription
• Medication that does not require a prescription under Federal law even if your physician prescribes it or a prescription is required under your State law
• Medical supplies such as dressings and antiseptics
• Medication for which there is a non-prescription equivalent available.
• Prescriptions received from non-participating pharmacies unless overseas or through a covered physician or facility. (Call 877-438-4449 to locate a participating pharmacy.)
• Drug copayments
• Fertility drugs are covered only under “Infertility services”  in Section 5(a)
• Drugs obtained at a non-Plan pharmacy; except for out-of-network area emergencies
• Drugs for sexual dysfunction, e.g., Viagra, Cialis, Muse, Caverject, etc.
• Drugs 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. 

Note: Only FDA-approved medications are covered by the Plan.

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation program benefits. (See page (Applies to printed brochure only)). 

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

You, your pharmacist, or your physician may call us at 800-753-2851 to complete the exception process. Reimbursement for OTC contraceptives is covered with a valid prescription. To submit a claim, refer to Section 7 regarding claims for prescription drugs.

Network Retail: 

• Nothing

Network Home Delivery: 

• Nothing

Preventive care medications

Medications and supplements to promote better health as recommended by ACA and USPSTF A and B recommendations are covered without cost-share, even if over-the-counter, when prescribed by a healthcare professional and filled at a network pharmacy. For a complete list of USPSTF A & B rated recommendations go to USPSTF website at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations 

Note: To receive this benefit a prescription from a doctor must be presented to a pharmacy. 

Network Retail:

• Nothing

Network Home Delivery:

• Nothing

We cover outpatient restorative services performed within 12 months of an accident to repair (but not replace) sound natural teeth.

The need for these services must result from an accidental injury from an external force such as a blow or fall that requires immediate attention (not from biting or chewing).

20% of the Plan allowance and any difference between our allowance and the billed amount (No Deductible)

$39 twice per year

$12

$19

$24

All charges in excess of the scheduled amounts listed to the left (No Deductible)

Flexible Benefits Option

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

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

Centers of Excellence

The Plan has special arrangements with facilities to provide services for tissue, organ transplants and bariatric surgery. The network was designed to give you an opportunity to access providers that demonstrate high quality medical care for transplant and bariatric patients. For additional information regarding our transplant network and bariatric network, please call UMR at 888-438-9135.

Medical Management

The Plan offers various medical management programs for members and covered dependents to help manage your health conditions.

If you would like more information about these programs available from the Compass Rose Health Plan, please call UMR at 888-438-9135.

Lifestyle Prescription Medications

Many lifestyle prescription drugs are available at a discounted rate through participating pharmacies and the Plan’s mail order program. You are responsible for the entire cost of the drugs; however, they are available to you at a discounted rate at certain participating pharmacies. The following lifestyle prescription drugs are covered under this program:

Cosmetic: Renova, Vaniqua, Propecia

Infertility: A.P.L., Chorex-5, Chorex-10, Chronon 10, Clomid, Clomiphene, Crinone gel, Fertinex, Follistem, Gonal-F, Gonic, HCG, Humegon, Pergonal, Pregnyl, Profasi, Repronex, Serophone

Sexual Dysfunction: Caverject, Edex, Muse, Viagra, Cialis, Addyi, and Testim

This list is subject to change and may be subject to medical necessity review if they are covered under another benefit provision (i.e., infertility).

If you have a question on drug coverage, call 877-438-4449.

Services Overseas

Our overseas customers receive the same PPO benefits and prompt customer service as their stateside counterparts. There may be additional claims processing time for foreign claims. The same medical necessity requirements for stateside claims apply to overseas claims.

The Lab Program

This program gives you and your dependents the option of receiving 100% benefit for covered outpatient laboratory testing if your doctor sends your lab work to LabCorp or Quest for processing.

This is an optional program. If you choose not to use the Lab Program, you will not be penalized. You will simply pay the deductible, coinsurance or copayment portion of your lab work.

The Lab Program does not replace your current healthcare benefits; it simply gives you and your covered family members the option of receiving 100% benefits for covered outpatient laboratory testing.

The Lab Program covers most outpatient laboratory testing included in your health insurance plan provided the tests are covered by the Plan, have been ordered by a physician and processed at the designated labs. Outpatient lab work includes: Blood testing (e.g., cholesterol, CBC), Urine testing (e.g., urinalysis), Cytology and pathology (e.g., pap smears, biopsies), Cultures (e.g., throat culture).

The Lab Program does not cover: lab work ordered during hospitalization, lab work needed on an emergency (STAT) basis and time sensitive, esoteric outpatient laboratory testing such as fertility testing, bone marrow studies and spinal fluid tests, non- laboratory work such as mammography, X-ray, imaging and dental work.

When Medicare is primary, the Program does not apply.

Tobacco Cessation Programs

The Plan is pleased to support its members wishing to quit smoking with a free program provided through UMR. Quitting smoking is one of the BEST things you can do to improve your health and the health of those around you. With determination, a positive attitude and a little help, you can do it! UMR's Tobacco Cessation Program is effective in helping participants break the habit and remain tobacco-free.

UMR's certified tobacco cessation specialists use proven behavior-change techniques to support participants in meeting their goals. They serve as partners in the change process and work with each participant to develop a personalized quit plan. They provide you and your covered dependents:

• Encouragement and accountability
• Education on the harmful effects of tobacco use
• Insight into your relationship with tobacco and personal triggers
• Follow-up support to prevent relapse
• Counseling sessions in the form of coaching phone calls (up to five per quit attempt)
• Printed educational material mailed to your home

For more information on UMR's Tobacco Cessation Program, or to enroll, call 800-207-7680.

Telehealth

We provide coverage for telehealth services through Doctor On Demand. Doctor On Demand allows you to see a doctor face-to-face by using your mobile device or computer equipped with a camera. The board-certified physician who performs your visit is able to diagnose, treat and even prescribe medications if necessary. Members are able to utilize Doctor On Demand, 24 hours a day, 7 days a week.

Doctor On Demand physicians treat hundreds of conditions, in addition to providing mental health counseling and medication management. These physicians are board-certified doctors, psychiatrists and psychologists trained and based in the United States.

Plan members, including those with Medicare, are able to take advantage of this program. You pay nothing (no deductible) at the time of your visit. To ensure that you receive coverage under the Plan, use these instructions:

Download the Doctor On Demand app from your smartphone or tablet's app store. You may also text Compass to 68398. Once downloaded, open the app and follow the prompts. If you are using a computer, visit www.compassrosebenefits.com/DrNow. When setting up your account, be sure to select UMR as your insurance. Plan members with Medicare B, select Medicare as your insurance.

You may choose to receive telehealth services from your regular UnitedHealthcare Choice Plus network provider, or non-PPO provider. See section 5(a) for the amounts you must pay.

If you have any questions regarding the Doctor On Demand benefit, you can contact Doctor On Demand's Customer Support by emailing support@doctorondemand.com or calling 800-997-6196.

Maternity Management 

The Plan is pleased to support its members who are considering having a baby or who are already expecting with a free program provided through UMR. UMR Maternity Management can teach you how to reduce your risk of complications and prepare you to have a successful, full-term pregnancy and a healthy baby. To enroll, please call UMR at 888-438-8105. Once enrolled, you will receive one-on-one calls with a nurse and no-cost educational materials including your choice of one out of six top-selling pregnancy books.

Wellness Rewards Program

The Plan has a Wellness Rewards Program for members and covered spouses. Each member and their covered spouse can earn a maximum of $350 per calendar year by completing specific activities and screenings. Rewards earned by November 30th of the plan year will be available for use the following calendar year. The reward will be applied to the deductible for members who do not have Medicare B as their primary insurance. Members who have Medicare B as their primary insurance will receive their reward in a health reimbursement account that can be used for qualified medical expenses. Please note unused rewards earned do not roll over to the following calendar year. Additionally, rewards earned do not carry over to the Compass Rose UnitedHealthcare Medicare Advantage Plan. You must opt-in to the Wellness Rewards Program every year in order to begin earning rewards. For more information, visit www.compassrosebenefits.com/rewards or call UMR at 888-438-9135. 

To obtain claim forms, claims filing advice or answers about our benefits, contact (888) 438-9135, or at our website at www.compassrosebenefits.com/Forms

In most cases, providers and facilities file claims for you. Your provider must file on the form CMS-1500 or a claim form. Your facility will file on the UB-04 form. For claims questions and assistance, call 888-438-9135.

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. Itemized bills and receipts should be sent to UMR, P.O. Box 8095, Wausau, WI 54402-8095. For prescriptions, itemized bills and receipts should be sent to Express Scripts, ATTN: Commercial Claims, PO Box 14711, Lexington, KY 40512-4711.

• Patient’s name, date of birth, address, phone number and relationship to enrollee
• Patient’s Plan identification number
• Name and address of person or company providing the service or supply
• Dates that services or supplies were furnished
• Diagnosis
• Type of each service or supply
• Charge for each service or supply

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

In addition:

• If another health plan is your primary payor, you must send a copy of the explanation of benefits (EOB) form you received from your primary payor (such as the Medicare Summary Notice (MSN)) with your claim.
• Bills for home nursing care must show that the nurse is a registered or licensed practical nurse.
• If your claim is for the rental or purchase of durable medical equipment; private duty nursing; and physical therapy, occupational therapy, or speech therapy, you must provide a written statement from the provider specifying the medical necessity for the service or supply and the length of time needed.
• Claims for prescription drugs and supplies must include receipts that show the prescription number, name of drug or supply, prescribing provider name, date, and charge.
• We will provide translation and currency conversion services for claims for overseas (foreign) services.

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.

You will be reimbursed the amount approved, not necessarily the amount submitted. 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. 

Keep a separate record of the medical expenses of each covered family member as deductibles and maximum allowances apply separately to each person. Save copies of all medical bills, including those you accumulate to satisfy a deductible. In most instances they will serve as evidence of your claim. We will not provide duplicate or year-end statements.

Send us all the documents for your claim as soon as possible. You must submit the claim by December 31 of the following year after you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible. If we return a claim or part of a claim for additional information, you must resubmit it within 90 days, or before the timely filing period expires, whichever is later. Once we pay benefits, there is a three-year limitation on the re-issuance of uncashed checks.

For covered services you receive by providers and hospitals outside the United States and Puerto Rico, send a completed Claim Form and the itemized bills to: UMR, P.O. Box 8095, Wausau, WI 54402-8095, or fax to 855-405-2189. Obtain Claim Forms from: www.compassrosebenefits.com/ClaimForm. If you have questions about the processing of overseas claims, contact 888-438-9135.

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

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

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

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

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

1. Write to us within 6 months from the date of our decision; and

2. Send your request to us at: UMR-CRBG Appeals, P.O. Box 8080, Wausau, WI 54402-8080.

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

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

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

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

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

a) Pay the claim or  

b) Write to you and maintain our denial or

c) Ask you or your provider for more information. 

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

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

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

You must write to OPM within:

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

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal 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 file a lawsuit. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

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

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

Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call 888-438-9135. We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal. You may call OPM’s FEHB 2 at 202-606-3818 between 8 a.m. and 5 p.m. Eastern Time.

Please remember that we do not make decisions about Plan eligibility issues. For example, we do not determine whether you or a family member is covered under this Plan. You must raise eligibility issues with your Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant or the Office of Workers' Compensation Programs if you are receiving Workers' Compensation Benefits.

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 payer. 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.compassrosebenefits.com/NAIC.

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.

Coordination of benefits verification may be requested annually.

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

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

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

We do not cover services that:

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

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

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

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

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

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

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

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

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

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

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 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 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 test, X-rays and scans, and hospitalizations related to treating the patient's cancer, whether the patient is in a clinical trial or is receiving standard therapy.
• Extra care costs - costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient's routine care.
• 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.

For more detailed information on "What is Medicare?" and "Should I Enroll in Medicare?" please contact Medicare at 1-800-MEDICARE (1-800-633-4227), (TTY 1-877-486-4028) or at www.medicare.gov. 

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

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

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

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 claims 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 claims, call 888-438-9135, or email us at askcrbg@compassrosebenefits.com.

We waive some costs when the Original Medicare Plan is your primary payor. We will waive some out-of-pocket costs, as follows:

• If you are enrolled in Medicare Part B, we may waive calendar year deductible, copayments and coinsurance for medical services and supplies provided by physicians and other healthcare professionals. We will also waive deductibles and coinsurance for extended dental treatment for accidental dental injuries.
• If you are enrolled in Medicare Part A, we will waive hospital copayments, deductible and coinsurance.

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

Benefit Description: Deductible 

High Option You pay without Medicare in-network: $350

High Option you pay without Medicare out-of-network: $400

High Option you pay with Medicare Part B in-network: $0

High Option you pay with Medicare Part B out-of-network: $0

Benefit Description: Catastrophic Protection Out-of-Pocket Maximum

High Option You pay without Medicare in-network: $5,000 Self Only/$7,000 Self Plus One or Self and Family

High Option you pay without Medicare out-of-network: $7,000 Self Only/$9,000 for Self Plus One or Self and Family

High Option you pay with Medicare Part B in-network: $0

High Option you pay with Medicare Part B out-of-network: $0

Benefit Description: Part B Premium Reimbursement Offered

High Option You pay without Medicare in-network: N/A

High Option you pay without Medicare out-of-network: N/A

High Option you pay with Medicare Part B in-network: N/A

High Option you pay with Medicare Part B out-of-network: N/A

Benefit Description: Primary Care Physician

High Option You pay without Medicare in-network: $15 copayment

High Option you pay without Medicare out-of-network: 30% Plan allowance and difference between Plan allowance and billed amount

High Option you pay with Medicare Part B in-network: $0

High Option you pay with Medicare Part B out-of-network: $0

Benefit Description: Specialist

High Option You pay without Medicare in-network: $25 copayment

High Option you pay without Medicare out-of-network: 30% Plan allowance and difference between Plan allowance and billed amount

High Option you pay with Medicare Part B in-network: $0

High Option you pay with Medicare Part B out-of-network: $0

Benefit Description: Inpatient Hospital

High Option You pay without Medicare in-network: $200 copayment per stay

High Option you pay without Medicare out-of-network: $400 copayment per stay and 30% Plan allowance and difference between Plan allowance and billed amount

High Option you pay with Medicare Part B in-network: $0

High Option you pay with Medicare Part B out-of-network: $0

Benefit Description: Outpatient Hospital

High Option You pay without Medicare in-network: 10% of Plan allowance

High Option you pay without Medicare out-of-network: 30% Plan allowance and difference between Plan allowance and billed amount

High Option you pay with Medicare Part B in-network: $0

High Option you pay with Medicare Part B out-of-network: $0

Benefit Description: Incentives Offered

High Option You pay without Medicare in-network: N/A

High Option you pay without Medicare out-of-network: N/A

High Option you pay with Medicare Part B in-network: Up to $2,400 coverage for hearing aids every 3 years, receive discount on non-specialty prescriptions 

High Option you pay with Medicare Part B out-of-network: Up to $2,400 coverage for hearing aids every 3 years, receive discount on non-specialty prescriptions 

You can find more information about how our Plan coordinates benefits with Medicare at www.compassrosebenefits.com/MedicareCoverage.

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

If you are enrolled in Medicare Part B, a physician may ask you to sign a private contract agreeing that you can be billed directly for services ordinarily covered by Original Medicare. 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 (1-800-633-4227), (TTY 1-877-486-2048) or at www.medicare.gov.

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

This Plan and our Medicare Advantage Plan: You may enroll in our Enhanced Benefit Opportunity through UnitedHealthcare Medicare Advantage PPO plan and also remain enrolled in our FEHB plan. For more information on our Enhanced Benefit Opportunity through UnitedHealthcare Medicare Advantage (PPO), please contact 844-279-9286, TTY 711, or go to retiree.uhc.com/compassrose. Enrollment in the Enhanced Benefit Opportunity through UnitedHealthcare Medicare Advantage (PPO) for Compass Rose Health Plan is voluntary.  Members must complete an application for enrollment.  Eligible enrollees voluntarily opt into the Enhanced Benefit Opportunity through UnitedHealthcare Medicare Advantage (PPO) for Compass Rose Health Plan and may opt out at any time. You may enroll in the Enhanced Benefit Opportunity through UnitedHealthcare Medicare Advantage (PPO) for Compass Rose Health Plan, if:

• You are a retiree or annuitant enrolled in Compass Rose Health Plan and have both Medicare Part A and Part B.
• You are a United States citizen or are lawfully present in the United States.
• You do NOT have End-Stage Renal Disease (ESRD). Enrollees who have ESRD cannot enroll until after the 30-month grace period has expired. Members diagnosed with ESRD while enrolled in the Enhanced Benefit Opportunity for UnitedHealthcare Medicare Advantage (PPO) for Compass Rose Health Plan may remain enrolled and ESRD services will be covered.
• You complete an application for enrollment in the Enhanced Benefit Opportunity for UnitedHealthcare Medicare Advantage (PPO) for Compass Rose Health Plan.

When you are enrolled in the Compass Rose Benefit Plan under the FEHB Program and the Enhanced Benefit Opportunity through UnitedHealthcare Medicare Advantage (PPO) you receive additional benefits that include the following:

• No deductibles, copays, or coinsurance for covered care other than for prescription drugs
• A four-tier prescription drug formulary ($1/$25/$75/$25%-$100 max per 30-day supply)
• 100 days for Skilled Nursing Facility
• Post-Discharge Transportation and Meal Delivery Program after inpatient hospitalization
• $125 credit toward Medicare Part B premium
• Renew Active™ helping the population maintain functional mobility and cognitive health
• Nationwide network of providers

To learn more about the Enhanced Benefits Opportunity through UnitedHealthcare Medicare Advantage (PPO) for the Compass Rose Health Plan and how to enroll, call us at 844-279-9286, 8 a.m. to 8 p.m., local time, 7 days a week, or go to retiree.uhc.com/compassrose. For TTY for the deaf, hard of hearing, or speech impaired, call 711. We will send you additional information and an application for enrollment.

Medicare B Premium Reimbursement: If you are enrolled in the Compass Rose Benefit Plan and enroll in the Enhanced Benefit Opportunity through UnitedHealthcare Medicare Advantage (PPO) for Compass Rose Health Plan, you will receive a credit of $125 toward your Medicare Part B monthly premium. This will be sent from Centers for Medicare & Medicare Services (CMS).

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

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

If you enroll in the Compass Rose Medicare Advantage plan you must retain your FEHB coverage. Do not suspend your FEHB coverage as this will make you ineligible for the Compass Rose Medicare Advantage plan.

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

• 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 A (Hospital insurance) and Medicare 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 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.

Your authorization for the Plan to issue payment of benefits directly to the provider. We reserve the right to pay the member directly for all covered services.

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

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition, and is either Federally-funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration (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 as part of the patient’s routine care.
• Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes are generally covered by the clinical trials. This Plan does not cover these costs.

See Section 4 page (Applies to printed brochure only).

A condition existing at or from birth that is a significant deviation from the common form or anomaly norm. For purposes of this Plan, congenital includes protruding ear deformities, cleft lips, cleft palates, webbed fingers or toes, and other conditions that we may determine to be congenital anomalies. In no event will the term congenital anomaly include conditions relating to teeth or intra-oral structures supporting the teeth.

See Section 4 page (Applies to printed brochure only).

See Section 4 page (Applies to printed brochure only). 

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

1) personal care such as help in: walking; getting in or out of bed; bathing; eating by spoon, tube or gastrostomy; exercising; dressing;

2) homemaking, such as preparing meals or special diets;

3) moving the patient;

4) acting as a companion or sitter;

5) supervising medication that can usually be self administered; or

6) treatment services such as recording temperature, pulse, and respirations, or administration and monitoring of feeding systems.

See Section 4 page (Applies to printed brochure only). 

Impairment in the performance of tasks or the meeting of milestones that a child should achieve by a specific chronological age.

A doula is trained professional who provides continuous physical, emotional and informational support to a mother before, during and shortly after childbirth to help her achieve the healthiest, most satisfying experience possible. 

The date the benefits described in this brochure are effective:

1. January 1 for continuing enrollments and for all annuitant enrollments;
2. the first day of the first full pay period of the new year for enrollees who change plans or options or elect FEHB coverage during Open Season for the first time; or
3. for new enrollees during the calendar year, but not during Open Season, the effective date of enrollment as determined by your employing office or retirement system.

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

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

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

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

A disorder characterized by the following criteria:

1. A strong and persistent cross gender identification (not merely a desire for any perceived cultural advantages of being the other sex).
2. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.
3. The disturbance is not concurrent with a physical intersex condition.
4. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
5. The transsexual identity has been present persistently for at least two years.
6. The disorder is not a symptom of another mental disorder or chromosomal abnormality.

Healthcare coverage that you are eligible for because of employment, membership in, or connection with, a particular organization or group that provides payment for hospital, medical or other healthcare service or supplies, or that pays a specific amount for each day or period hospitalization.

Healthcare services that help you keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

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

A public or private agency or organization appropriately licensed, qualified and operated under the law of the state in which it is located.

A written plan, approved in writing by a physician, for continued care and treatment for a Plan member who is under the care of a physician and who would need a continued stay in a hospital or skilled nursing facility with the home healthcare.

An inpatient admission as a registered bed patient using and being charged for room and board in a hospital for 24 hours or more. A person is not an inpatient on any day on which he or she is on leave or otherwise gone from the hospital, whether or not a room and board charge is made.

A disease defined by the failure to achieve a successful pregnancy after 12 months or more of appropriate, timed unprotected intercourse or therapeutic donor insemination. Earlier evaluation and treatment may be justified based on medical history and physical findings and is warranted after 6 months for individuals over age 35 years. Disease is defined as "any deviation from or interruption of the normal structure or function of any part, organ or system of the body as manifested by characteristic symptoms and signs; the etiology, pathology and prognosis may be known or unknown" (American Society for Reproductive Medicine, 2013d)

A program that offers time-limited services that are coordinated, structured, and intensively therapeutic. Such programs are designed to treat a variety of individuals with moderate to marked impairment in at least one area of daily life resulting from psychiatric or addictive disorders. At a minimum, IOPs offer three to four hours of active treatment per day at least two to three days per week.

The term medical food, as defined in section 5(b) of the Orphan Drug Act (21 U.S.C. 360ee (b) (3)) is a food which is formulated to be consumed or administered enterally under the supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation.

 In general, to be considered a medical food, a product must, at a minimum, meet the following criteria: the product must be a food for oral or tube feeding; the product must be labeled for the dietary management of a specific medical disorder, disease, or condition for which there are distinctive nutritional requirements; and the product must be intended to be used under medical supervision. Modified grocery item foods, even if categorized as medical foods by the manufacturer, are not considered a covered benefit.

Healthcare services provided for the purpose of preventing, evaluating, diagnosing or treating an Illness, Injury, mental illness, substance use disorder, condition, disease or its symptoms, that are all of the following as determined by us or our designee, within our sole discretion:

• In accordance with Generally Accepted Standards of Medical Practice; and
• Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for Your Illness, Injury, mental illness, substance use disorder, disease or its symptoms; and
• Not mainly for Your convenience or that of Your doctor or other healthcare provider; and
• Not more costly than an alternative drug, service(s) or supply that is at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of your Illness, Injury, disease or symptoms.

A disorder that is a clinically significant psychological syndrome associated with distress, dysfunction or Illness. The syndrome must represent a dysfunctional response to a situation or event that exposes the Covered Person to an increased risk of pain, suffering, conflict, illness, or death.

An individual who has been diagnosed to have a psychiatric or behavior disorder that severely limits the individual's ability to function without daily supervision or assistance.

Services, supplies, treatment, facilities or equipment which the Plan determines are not Medically Necessary. Furthermore, this Plan excludes services, supplies, treatment, facilities or equipment which reliable scientific evidence has shown does not cure the condition, slow the degeneration/deterioration or harm attributable to the condition, alleviate the symptoms of the condition, or maintain the current health status of the Covered Person.

Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as a hospital inpatient or if they are able to be discharged from the hospital. Observation status is commonly assigned to patients who present to the emergency department and who then require a significant period of treatment or monitoring before a decision is made concerning their admission or discharge.

A time-limited, ambulatory, active treatment program that offers therapeutically intensive, coordinated, and structured clinical services with a stable therapeutic environment. It provides 20 hours of scheduled programming, extended over a minimum of five days per week, by a licensed or Joint Commission accredited facility

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

PPO Providers - Our Plan allowance is a negotiated amount between the Plan and the provider. The Plan allowance must be considered reasonable, and we base our coinsurance on this negotiated amount. The PPO benefit also applies to providers used outside the 50 United States. Please note you will not be responsible for any amount above the providers’ negotiated rate.

Non-PPO Providers - Our Plan allowance is the lesser of: (1) the providers' billed charge; or (2) the Plan's out-of-network (OON) fee schedule amount.

When you receive care from a Non-PPO provider, our allowance is determined as follows:

• Rule One: When a Non-PPO provider has agreed to discount their charges, our allowance is the amount that the provider has negotiated and agreed to accept for the services or supplies. You are not responsible for the difference between the allowance and the provider’s billed charges. If the provider has not agreed to discount their charges, we will access Rule Two.

• Rule Two: An amount equal to 200% of the current Medicare rate for professional and facility expenses. You may be responsible for the difference between the allowance and the provider’s billed charges. If there is no Medicare rate for the service(s) billed, we will access Rule Three.

• Rule Three: We will utilize outside sources, such as Fair Health, Inc., to determine the allowance for certain services and supplies in a specific geographic area. You may be responsible for the difference between the allowance and the provider’s billed charges.

For certain services, exceptions may exist to the use of the OON fee schedule to determine the Plan's allowance for non-PPO 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 payor to Medicare (Medicare COB situations), the Plan allowance is the Medicare allowable charge.

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

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

Any claims that are not pre-service claims. In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits.

Health care services that help you keep, get back, or improve skills and functioning for daily living that have been lost or impaired because you were sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.

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.

Provides temporary relief to the family or other caregivers in the case of an emergency or to provide temporary relief from the daily demands of caring for a terminally ill person.

Health care services you receive from a covered provider without any apparent signs or symptoms of an illness, injury or disease.

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.

Disorders listed in the International Classification of Diseases (ICD) requiring treatment for abuse of or dependence upon substances such as alcohol, narcotics, or hallucinogens.

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 UMR, P.O. Box 8095 Wausau, WI 54402-8095, or call (888) 438-9135. 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.

PPO: $15 copayment (No Deductible); $25 copayment for Specialist (No Deductible)

*Non-PPO: 30% of our Plan allowance

 $15 copayment (No Deductible) for providers used outside of the 50 United States; $15 copayment for Specialist (No Deductible) used outside the 50 United States

31

PPO: 10% of our allowance

*Non-PPO: 30% of our Plan allowance

10% of our allowance for providers used outside the 50 United States

48-59

PPO: $200 hospital stay (No Deductible)

Non-PPO: $400 hospital stay and 30% of our Plan allowance (No Deductible)

$200 hospital stay (No Deductible) for providers used outside the 50 United States

60-61

*PPO: 10% of our allowance

*Non-PPO: 30% of our Plan allowance

*10% of our allowance for providers used outside the 50 United States

61-62

PPO: Emergency Room $200 copayment per occurrence (No Deductible).

Non-PPO: $200 Emergency Room copayment per occurrence (No Deductible).

Emergency Room $200 copayment per occurrence (No Deductible) for providers outside the 50 United States.

PPO: Urgent Care $50 copayment per occurrence (No Deductible).

Non-PPO: Urgent Care 30% of the Plan Allowance and any difference between our allowance and the billed amount (No Deductible).

Urgent Care $50 copayment per occurrence (No Deductible) for providers outside the 50 United States.

65-67

PPO: Regular cost- sharing.

Non-PPO: Regular cost- sharing

Regular cost-sharing for providers used outside the 50 United States

68-71

Network Retail 30-day supply: Level 1 (Generics): $5 (No Deductible), Level 2 (Formulary / Preferred Brand Name): $45 (No Deductible), Level 3 (Non-Formulary / Non-Preferred Brand Name): 40% or $75, whichever is greater (No Deductible)

Network Home Delivery: Level 1 (Generics): $10 (No Deductible), Level 2 (Formulary / Preferred Brand Name): $90 (No Deductible), Level 3 (Non-Formulary / Non-Preferred Brand Name): 40% or $150, whichever is greater (No Deductible)

Voluntary Smart90: Level 1 (Generics): $10 (No Deductible), Level 2 (Formulary / Preferred Brand Name): $90 (No Deductible), Level 3 (Non-Formulary / Non-Preferred Brand Name): 40% of the Plan cost or $150, whichever is greater (No Deductible)

Network Retail 30-day supply when Medicare Part B is primary: Level 1 (Generics): $3 (No Deductible), Level 2 (Formulary / Preferred Brand Name): $25 (No Deductible), Level 3 (Non-Formulary / Non-Preferred Brand Name): 35% or $50, whichever is greater (No Deductible)

Voluntary Smart90 when Medicare Part B is primary: Level 1 (Generics): $6 (No Deductible), Level 2 (Formulary / Preferred Brand Name): $50 (No Deductible), Level 3 (Non-Formulary / Non-Preferred Brand Name): 35% of the Plan cost or $100, whichever is greater (No Deductible)

Network Home Delivery when Medicare Part B is primary: Level 1 (Generics): $6 (No Deductible), Level 2 (Formulary / Preferred Brand Name): $50 (No Deductible), Level 3 (Non-Formulary / Non-Preferred Brand Name): 35% or $100, whichever is greater (No Deductible)

Specialty Generics: 10% of the plan cost up to a maximum of $100 for up to 30-day supply (No Deductible)

Specialty Formulary / Preferred Brand Name: 25% of the Plan cost up to a maximum of $250 for up to 30-day supply (No Deductible)

Specialty Non-Formulary / Non-Preferred Brand Name: 35% of the Plan cost up to a maximum of $500 for up to 30-day supply (No Deductible)

Specialty Medications must be received through our Specialty Pharmacy Provider, Accredo to receive the benefit. There is no benefit if other providers are used. Please contact 800-803-2523 for more information.

Note: If there is no generic equivalent available, you will still have to pay the Level 2 copay or Level 3 copay.

72-80

Medical PPO and Pharmacy Network Providers: Nothing after $5,000 for Self Only and $7,000 for Self Plus One or Self and Family enrollment per year

Medical, Non-PPO: Nothing after $7,000 for Self Only and $9,000 for Self Plus One or Family enrollment per year

Medical and Pharmacy, Nothing after $5,000 for Self Only and $7,000 for Self Plus One or Family enrollment per year for providers used outside the 50 United States

26