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

See www.opm.gov/healthcare-insurance 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, you must also contact your employing or retirement office.

Once enrolled in your FEHB Program Plan, you should contact your carrier directly for address 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 family member when there is already family Coverage.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

If you are divorced from a Federal employee, or annuitant, you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get information about your coverage choices. You can also visit OPM’s website at www.opm.gov/healthcare-insurance/healthcare/plan-information. 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, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, or if you are a covered child and you turn 26.

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

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

Alternatively, you can buy coverage through the 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 FEHB Program coverage.

You may convert to a non-FEHB individual policy if:

• Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);

• You decided 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.

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

Your benefits and rates will differ from those under the FEHB program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions. When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act's Health Insurance Marketplace in your state.  For assistance in finding coverage, please contact us at 844-440-1900 or visit our website at www.healthpartners.com/fehb.

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 letter (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 844-440-1900  (TTY: 952-883-5127) or write to us at Member Services, P.O. Box 1309, Minneapolis, MN 55440-1309. You may also request replacement cards through our website at www.healthpartners.com/fehb.

In Network: You get care from "Plan providers" and "Plan facilities." You will pay copayments, deductibles, and/or coinsurance. You can receive covered services from a participating provider without a referral from your primary care physician or another participating provider in the network.

Out of Network (Standard Option): You may choose to use your out-of-network benefits and receive care from any licensed provider. You may be billed for these services and may need to file a claim for reimbursement.

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

Plan providers are physicians and other healthcare professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards.

We list Plan providers in the HealthPartners Open Access Network provider directory, which we update periodically. For information that is updated weekly, visit www.healthpartners.com/fehb.

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 952-883-5469 or 800-871-9243 for assistance.

This Plan lets you receive care from more than 850,000 providers in the Open Access Network. Referrals are not required and you do not need to choose a primary care clinic. Any time you or a member in your family needs care, you may choose to see any provider in this network.

High Option: With limited exceptions, if you seek care from a provider who does not participate in the Open Access Network, your care is considered out of network and may not be covered.

Standard Option: With limited exceptions, if you seek care from a provider who does not participate in the Open Access Network, your care is considered out of network and the lower out-of-network benefits apply.

Plan facilities are hospitals and other facilities that we contract with to provide covered services to our members. We list these in the Open Access Network provider directory, which we update periodically. The list is on our website: www.healthpartners.com/fehb.

High Option: With limited exceptions, if you seek care from a facility that does not participate in the Open Access Network, your care is considered out of network and may not be covered.

Standard Option: With limited exceptions, if you seek care from a facility that does not participate in the Open Access Network, your care is considered out of network and the lower out-of network benefits apply.

High Option: Any time you or a member in your family needs care, you should choose to see any provider in the Open Access Network. With limited exceptions, if you seek care from a provider who does not participate in the Network your care is considered out of network and may not be covered.

Standard Option: Any time you or a member in your family needs care, you should choose to see any provider in the Open Access Network. You may choose to use your out-of-network benefit and receive care from any licensed provider. You may be billed for these services and may need to file a claim for reimbursement.

Members are not required to pick a primary clinic. However, we encourage members to work with personal physicians who will get to know them. Primary care providers are providers in the following categories: family and general practice, internal medicine, pediatrics, adolescent medicine, adult medicine and geriatrics. Your primary care physician will provide most of your healthcare or suggest that you see a specialist. You can see any specialist without a referral.

If you want to change your primary care physician or if your primary care physician leaves the Plan, simply choose another provider from the Open Access Network directory for in-network benefits. For the most up-to-date network provider information, visit www.healthpartners.com/fehb, where information is updated weekly.

Specialty care providers are providers who are not in the following categories: family and general practice, internal medicine, pediatrics, adolescent medicine, adult medicine and geriatrics.

You have direct access to any specialist in the Open Access Network without a referral.

If you are seeing a specialist when you enroll in our Plan and your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, you may be able to continue seeing your provider for a period of time, please see Continuity of care for more information.

If you are seeing a provider when you enroll in our Plan and your current provider does not participate with us, you must receive treatment from a provider who does. Generally, we will not pay for you to see a provider who does not participate with our Plan. However, in the event you must change your current primary care provider, specialty care provider or general hospital provider because that provider leaves the Open Access Network, HealthPartners drops out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB plan; or HealthPartners reduces our Service Area and you enroll in another FEHB plan, you may be able to continue seeing your provider for a period of time. Some services provided by out of network providers may be considered a covered benefit for up to 120 days under this Plan if you qualify for continuity of care benefits under state or federal law.

Conditions that qualify for this benefit are:

• an acute condition;
• a life-threatening mental or physical illness;
• pregnancy for which you have begun care;
• a physical or mental disability defined as an inability to engage in one or more major life activities, provided that the disability has lasted or can be expected to last for at least one year, or can be expected to result in death; or
• a disabling or chronic condition that is in an acute phase.

You may also request continuity of care benefits for culturally appropriate services or when we do not have a provider who can communicate with you directly or through an interpreter.

Terminally ill patients are also eligible for continuity of care benefits. Continuity of care may continue for the rest of the enrollee's life if a physician, advanced practice registered nurse, or physician assistant certifies that the enrollee has an expected lifetime of 180 days or less.

Continuity of care benefits will not be available or may be discontinued if the provider is terminated from the network for misconduct.

Call Member Services for further information regarding continuity of care benefits, or if we drop out of the Program, contact your new plan.

You may be required to see a designated provider for transplants and bariatric surgery. A designated provider is a healthcare provider, group or association of healthcare providers designated by us to provide services, supplies or drugs for specified transplants or bariatric surgery.

Your primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

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 HealthPartners Member Services immediately at 844-440-1900 (TTY: 952-883-5127). If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

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

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

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program 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.

We cover eligible services only when medically necessary for the proper treatment of a member. Our medical or dental directors, or their designees, make coverage determinations of medical necessity, restrictions on access and appropriateness of treatment, and they make final authorization for covered services. Coverage determinations are based on established medical policies, which are subject to periodic review and modification by the medical or dental directors. Coverage determinations for prescription drugs are based on requirements established by the HealthPartners Pharmacy and Therapeutics Committee, and are subject to periodic review and modification.

Since your primary care physician arranges most referrals to specialists and inpatient hospitalization, the pre-service claim approval process only applies to care shown under Other services.

You must get prior approval for certain services.

Prior-authorization is the process by which --  prior to your inpatient hospital admission -- we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition.

Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain prior approval from us. Before giving approval, we consider if the service is covered, medically necessary and follows generally accepted medical practice.

We call this review and approval process prior authorization. Your physician must obtain prior authorization for services such as:

• Reconstructive surgery
• Promising therapies/new technologies
• Transplants
• Medically necessary dental care, such as orthognathic surgery
• Durable medical equipment and prosthetics
• Home health care
• Skilled nursing care
• Hospice care
• Habilitative therapy
• Bariatric surgery
• Growth hormone therapy (GHT)
• Gender affirming (confirmation) surgery

The complete list, along with the criteria we use to review authorization requests, is available on
www.healthpartners.com/fehb or by calling HealthPartners Member Services at 844-440-1900 (TTY: 952-883-5127). Your physician is responsible for obtaining prior authorization. 

First your physician, your hospital, you, or your representative, must call us at 952-883-6333 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
• Number of days requested for hospital stay

For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the pre-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

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

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

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

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

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM.  Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 844-440-1900 (TTY: 952-883-5127). You may also call OPM's FEHB 2 at 202-606-3818 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at 844-440-1900 (TTY: 952-883-5127). If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

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

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

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

Inpatient delivery does not require precertification or prior authorization from us. You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery.  We will extend your inpatient stay if medically necessary.

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 72 hours after we receive the claim.

If you have a pre-service claim and you do not agree with our decision regarding prior approval of other services, you may request a review in accord with the procedures detailed below. If your claim is in reference to a contraceptive, call 844-440-1900.

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.

Example: With High Option, when you see your primary care physician, you pay a copayment of $30 per office visit.

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count toward any deductible.

Any amounts paid or reimbursed by a third party, including but not limited to: point of service rebates, manufacturer coupons, debit cards or other forms of direct reimbursement to an enrollee for a product or service, will not apply toward your deductible.

High Option:  There is no calendar year deductible for medical care.  

Standard Option: 
For Network Expenses: The calendar year deductible is $750 for persons enrolled for Self Only coverage, $1,500 for persons enrolled for Self Plus One coverage and $1,500 for families enrolled for Self and Family coverage. 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 $750. Under a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable to you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $1,500. 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 $1,500.

For Out-of-Network Expenses: The calendar year deductible is $2,000 for persons enrolled for Self Only coverage $4,000 for persons enrolled for Self Plus One coverage and $4,000 for families enrolled for Self and Family coverage. 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 $2,000. Under a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable to you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $4,000. 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 $4,000.

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

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

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

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.

Any amounts paid or reimbursed by a third party, including but not limited to: point of service rebates, manufacturer coupons, debit cards or other forms of direct reimbursement to an enrollee for a product or service, will not apply to your catastrophic protection out-of-pocket maximum.

High Option:  If you are enrolled for Self Only coverage, when your copayments and/or coinsurance total $6,500 in a calendar year, you do not have to pay any more for covered services for the remainder of that calendar year.

If you are enrolled for Self Plus One coverage, when you and your dependent's copayments and/or coinsurance total $13,000 in  a calendar year, you and your dependent do not have to pay any more for covered services for the remainder of that calendar year. However, each enrollee will not pay more than $9,100 in a calendar year.

If you are enrolled for Self and Family coverage, when your family’s copayments and/or coinsurance total $13,000 in a calendar year, you and your dependents do not have to pay any more for covered services for the remainder of that calendar year. However, each enrollee will not pay more than $9,100 in a calendar year.

Standard Option:  In Network:  If you are enrolled for Self Only coverage, when your deductible, copayments and/or coinsurance total $7,000 in a calendar year, you do not have to pay any more for covered services for the remainder of that calendar year.

If you are enrolled for Self Plus One coverage, when you and your dependent's, deductible, copayments and/or coinsurance total $14,000 in a calendar year, you and your dependent do not have to pay any more for covered services for the remainder of that calendar year. However, each enrollee will not pay more than $9,100 in a calendar year.

If you are enrolled for Self and Family coverage, when your family’s deductible, copayments and/or coinsurance total $14,000 in a calendar year, you and your dependents do not have to pay any more for covered services for the remainder of that calendar year. However, each enrollee will not pay more than $9,100 in a calendar year.

 Out of Network:  There is no limit on your out-of-pocket expenses.

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

Note: If you change options in this Plan due to a qualifying life event (QLE) during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your prior option to the catastrophic protection limit of your new option.

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 healthcare provider, facility, or air ambulance service for healthcare. Surprise bills can happen when you receive emergency care – when you have little or no say in the facility or provider from whom you receive care. They can also happen when you receive non-emergency services at participating facilities, but you receive some care from 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.

In addition, your health plan adopts and complies with any state surprise billing laws, as may be applicable, in Minnesota, Wisconsin, Iowa, North Dakota, South Dakota.

Provisions of the No Surprises Act do not apply to out-of-network claims from providers that are outside of the US or US territories. Coverage level for services received outside of these areas is the same as corresponding out-of-network Benefits (if available), depending on the type of service provided.

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.healthpartners.com/fehb or contact the health plan at 844-440-1900 (TTY: 952-883-5127).

• 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, your tax dependents, and your 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.

We cover professional services of physicians:

• In an office
• Office medical consultations
• Scheduled telephone visits
• Second surgical opinion
• Testing and treatment of sexually transmitted diseases and testing for HIV and HIV-related conditions provided by a Plan or non-Plan provider

Note: List of qualifying clinics is available at
www.healthpartners.com/fehb.

$30 per office visit

In Network:  $0 for the first 5 office, convenience clinic, telephone, urgent care visits and evisits combined in a calendar year (deductible does not apply), then 20% of charges, subject to the in-network deductible. Physician’s services, laboratory and radiology performed in conjunction with the same visit and on the same date of service are included; however, charges for day treatment services, group visits, office procedures and other ancillary services are not included and will be subject to your deductible and coinsurance.

Out of Network:  40% of charges after out-of-network deductible

• At a convenience clinic

Note: For a list of convenience clinics, see your provider directory, call Member Services or visit our website at www.healthpartners.com/fehb.

In Network: $0 for the first 5 office, convenience clinic, telephone, urgent care visits and evisits combined in a calendar year (deductible does not apply), then 20% of charges, subject to the in-network deductible. Physician’s services, laboratory and radiology performed in conjunction with the same visit and on the same date of service are included; however, charges for day treatment services, group visits, office procedures and other ancillary services are not included and will be subject to your deductible and coinsurance.

Out of Network: 40% of charges after out-of-network deductible

• E-visit or chat based visits

We cover asynchronous online or mobile app encounters to discuss a patient’s personal health information, vital signs, and other physiologic data or diagnostic images. The healthcare provider reviews and delivers a consultation, diagnosis, prescription or treatment plan after reviewing the patient’s visit information

$10 per visit.

In Network: $0 for the first 5 office, convenience clinic, telephone, urgent care visits and evisits combined in a calendar year (deductible does not apply), then 20% of charges, subject to the in-network deductible.

Physician’s services, laboratory and radiology performed in conjunction with the same visit and on the same date of service are included; however, charges for day treatment services, group visits, office procedures and other ancillary services are not included and will be subject to your deductible and coinsurance.

Out of Network: 40% of charges after out-of-network deductible

• Video Visits

We cover live, synchronous interactive encounters using secure web-based video between a patient and a healthcare provider.

$30 per office visit

$500 annual copayment for inpatient and outpatient hospital services combined, then 20% of inpatient hospital charges

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

• Through Virtuwell^®, our online benefits program at www.Virtuwell.com

Nothing.

Nothing.

• In an urgent care center

$30 per office visit

In or Out of Network:  $0 for the first 5 office, convenience clinic, telephone, urgent care visits and evisits combined in a calendar year (deductible does not apply), then 20% of charges, subject to the in-network deductible. Physician’s services, laboratory and radiology performed in conjunction with the same visit and on the same date of service are included; however, charges for day treatment services, group visits, office procedures and other ancillary services are not included and will be subject to your deductible and coinsurance.

• Specialty drugs administered in an office

We cover specialty drugs 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. We require prior authorization for certain drugs and the site where the drug will be administered.

In Network: 40% of charges, after deductible

Out of Network: All charges

• During a hospital stay
• In a skilled nursing facility

$500 annual copayment for inpatient and outpatient hospital services combined, then 20% of inpatient hospital charges

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

• At home physical therapy, occupational therapy, speech therapy, respiratory therapy and home health aide services

$30 per visit

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

Injections administered in an office (other than specialty drugs described above)

$2 per date of service

In Network: 20% of charges after in-network deductible 

Out of Network: 40% of charges after out-of-network deductible

We cover tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap test
• Pathology
• Routine prostate specific antigen (PSA) testing for individuals 40 years of age or over who are symptomatic or in a high-risk category and for all individuals 50 years of age or older

Nothing

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

• X-ray
• Non-routine mammogram
• CT/CAT Scan
• MRI
• Ultrasound
• Electrocardiogram and EEG
• MRI/CT scans

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

Routine physicals

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 www.cdc.gov/vaccines/schedules/
• Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at 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, all FDA approved 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 www.healthcare.gov/preventive-care-women/
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder

Nothing

In Network:  Nothing

Out of Network:  40% of charges after out-of-network deductible

• Routine hearing and eye exams

Nothing

In Network:  Nothing

Out of Network:  40% of charges after out-of-network deductible

•  Routine 2D and 3D mammogram

Nothing

In Network:  Nothing

Out of Network:  40% of charges after out-of-network deductible

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

Nothing

In Network:  Nothing

Out of Network:  40% of charges after out-of-network deductible

• Tobacco use screening and interventions

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

Nothing

In Network:  Nothing

Out of Network:  40% of charges after out-of-network deductible

$250 incentive, in the form of a HealthPartners Wellness Account debit card to be used towards most qualified medical expenses, for each adult employee or covered spouse who registers for online services and completes an online health assessment and an eligible online health improvement program (Limit one incentive per adult employee or covered spouse per calendar year). 

Total maximum incentive amount is $250 Self and $500 Family. 

Additional information is available at
www.healthpartners.com/fehb

$250 incentive, in the form of a HealthPartners Wellness Account debit card to be used towards most qualified medical expenses, for each adult employee or covered spouse who registers for online services and completes an online health assessment and an eligible online health improvement program (Limit one incentive per adult employee or covered spouse per calendar year). 

Total maximum incentive amount is $250 Self and $500 Family. 

Additional information is available at
www.healthpartners.com/fehb

Not covered:

Any health services, certifications or examinations required by a third party when not otherwise medically necessary or eligible preventive care. This includes, but is not limited to, services:

• To get or keep a job, including vocational assessments
• Required under a labor agreement or other contract
• Needed for legal proceedings. This includes, but is not limited to, services related to custody evaluations, parenting assessments, adoption studies, reports to the court, risk assessments for sexual offenses, educational classes for Driving Under the Influence (DUI)/Driving While Intoxicated (DWI) competency evaluations
• For purposes of insurance
• To get or keep a license

All charges

All charges

• Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to
  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
  www.cdc.gov/vaccines/schedules/index.html
• You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at
  www.uspreventiveservicestaskforce.org

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

In Network:  Nothing

Out of Network:  40% of charges after out-of-network deductible

We cover complete maternity (obstetrical) care, such as:

• Prenatal care
• Screening for gestational diabetes for pregnant individuals
• Postnatal care

Nothing for routine prenatal care, the first postpartum care visit or routine gestational diabetes screening. $30 per office visit for postpartum care visits thereafter.

In Network:  Nothing.

Out of Network:  40% of charges after out-of-network deductible

• Delivery

 Note: Here are some things to keep in mind:

• You do not need to prior authorize your vaginal delivery. 
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.
• We cover routine nursery care of the newborn child and other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• We pay non-routine prenatal and postnatal care the same as for illness and injury.

Note: When a newborn requires non-routine 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.

$500 annual copayment for inpatient and outpatient hospital services combined, then Nothing for inpatient hospital maternity charges

In Network: $1,500 copayment for inpatient hospital maternity services, then Nothing for inpatient hospital charges

Out of Network: 40% of charges after out-of-network deductible

• Breastfeeding support, supplies and counseling for each birth

In Network: Nothing

Out of Network: 40% of charges after out-of-network deductible

Contraceptive counseling

In Network: Nothing

Out of Network: 40% of the charges after out-of-network deductible

We cover a range of voluntary family planning services, such as:

• Family planning services provided by a Plan provider or non-Plan provider

In Network:  Nothing

Out of Network:  40% of charges after out-of-network deductible

All FDA approved contraceptive methods for females, including:

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

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

In Network: Nothing

Out of Network: 40% of charges after out-of-network deductible

• Voluntary sterilization for males (See Surgical Procedures Section 5 (b)

$30 per office visit

$500 annual copayment for inpatient and outpatient hospital services combined, then 20% of charges

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

Not covered:

• Reversal of voluntary surgical sterilization

We cover advance care planning in an office

Nothing

In Network: 20% of charges after in-network deductible.

Out of Network: 40% of charges after out-of-network deductible

If you meet our criteria for coverage, you may qualify for our Medication Therapy Disease Management Program. The program covers consultations with a designated pharmacist.

Nothing

In Network: Nothing

Out of Network: All charges

In or Out of Network: 20% of charges

In or Out of Network: 20% of charges after in-network deductible

We cover fertility treatment including:

• Artificial insemination (AI)
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)

20% of charges and all charges beyond the lifetime limit

In Network: 20% of charges after in-network deductible and all charges beyond the lifetime limit (combined for In Network and Out of Network)

Out of Network: 40% of charges after out-of-network deductible and all charges beyond the lifetime limit (combined for In Network and Out of Network)

We cover fertility drugs (including but not limited to products listed on the Formulary)

20% of charges and all charges beyond the lifetime limit

In Network: 20% of charges after in-network deductible, and all charges beyond the lifetime limit

Out of Network: All charges

We cover therapeutic preservation fertility services:

These preservation services are for members that may become infertile due to chemotherapy, pelvic radiotherapy, other gonadotoxic therapies, or ovary or testicle removal for treatment of disease. This includes fertility services associated with gender affirming care.

• Cryopreservation of sperm, oocyte, and embryo
• Sperm, oocyte and embryo storage for up to one year
• Thawing of preserved sperm, oocyte, and embryo

20% of charges and all charges beyond the lifetime limit

In Network: 20% of charges after in-network deductible, and all charges beyond the lifetime limit

Out of Network: All charges

Maximum Benefit per Lifetime

Fertility treatment, fertility drugs and therapeutic preservation fertility services are limited to a combined $10,000 maximum benefit per lifetime

Fertility treatment, fertility drugs and therapeutic preservation fertility services are limited to a combined $10,000 maximum benefit per lifetime

Not covered: 

• Assisted reproductive technology (ART) procedures,
  such as:
  • In vitro fertilization (IVF)
  • Embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote
    intra-fallopian transfer (ZIFT)
• Services and supplies related to ART procedures
• Cost of donor sperm or egg 
• Cost of storage of donor sperm, ova or embryo, except for therapeutic preservation services
• Fertility treatment after reversal of sterilization
• Artificial insemination for surrogate pregnancy

We cover:

• Testing and treatment
•  Allergy injections and serum

$30 per office visit

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

Not covered:

• Provocative food testing
• Sublingual allergy desensitization

We cover:

• Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants beginning on page (Applies to printed brochure only).

• Respiratory and inhalation therapy

Note: Cardiac rehabilitation following a qualifying event/condition is covered under Physical and occupational therapies on page (Applies to printed brochure only).

• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion therapy (other than specialty drugs described below)

For services received in an office or outpatient hospital: $30 per visit

Inpatient hospital services: $500 annual copayment for inpatient and outpatient hospital services combined, then 20% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

• Blood and blood plasma (unless replaced) and blood derivatives for the treatment of blood disorders

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

We cover Applied Behavior Therapy (ABA) and Intensive Early Intervention Behavioral Therapy (IEIBT) for the treatment of Autism Spectrum Disorder for children age 17 or younger.

$30 per visit

In Network: 20% of charges after in-network deductible

Out of Network: All charges

• Specialty drugs

We cover specialty drugs 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. We require prior authorization for certain drugs and the site where the drug will be administered.

In Network: 40% of charges, after deductible

Out of Network: All charges

Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit. See Services requiring our prior approval in Section 3.

Note: We only cover GHT when we preauthorize the treatment. 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 and related services and supplies 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).

20% of charges

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

Not covered: Growth hormones which are not for growth hormone deficiency or chronic renal insufficiency

We cover gene therapy treatment that meets our current medical coverage criteria. Gene therapy must be provided by a designated provider. Specific types of gene therapy are limited to therapies and conditions specified in our medical coverage criteria.

For services received in an office: $30 per visit 

For services received in a hospital: $500 annual copayment for inpatient and outpatient hospital services combined, then 20% of charges 

For services received in the home: 20% of the charges incurred

In Network: 20% of charges after in-network deductible 

Out of Network: All charges

We cover:

• Rehabilitative therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury. You must achieve significant functional improvement, within a predictable period of time (generally within a period of two months), toward your maximum potential ability to perform functional daily living activities.
• Habilitative care rendered for congenital, developmental or medical conditions which have significantly limited the successful initiation of normal speech and motor development.

Note: To be considered habilitative, significant functional improvement and measurable progress must be made toward achieving functional goals and your maximum potential ability, within a predictable period of time. Our Plan Medical Director will determine whether measurable progress has been made based on objective documentation.

For services received in an office or outpatient hospital: $30 per visit

Inpatient hospital services: $500 annual copayment for inpatient and outpatient hospital services combined, then 20% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

• Cardiac rehabilitation following a qualifying event/condition is provided for Phase I and Phase II if it is medically necessary. Phase III and IV are not covered.

$30 per office visit

Nothing for inpatient or outpatient hospital

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

Not covered:

• Long-term rehabilitative therapy (maintenance care)
• Health club memberships, exercise programs and use or purchase of exercise equipment

We cover:

• Speech therapy for congenital, developmental or medical conditions which have significantly limited the successful initiation of normal speech development.
• Usually 60 visits or two months per condition per year

For services received in an office or outpatient hospital: $30 per visit

Inpatient hospital services: $500 annual copayment for inpatient and outpatient hospital services combined, then 20% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

Not covered: Long term rehabilitative therapy (maintenance care)

We cover:

• 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.

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

• External hearing aids for members age 18 or younger who have hearing loss that is not correctable by other covered procedures. Coverage is limited to one basic, standard hearing aid for each ear every three years. A basic hearing aid is defined as a hearing device that consists of a microphone, amplifier, volume control, battery and receiver. It does not include upgrades above and beyond the functionality of a basic hearing aid, including but not limited to hearing improvements for group settings, background noise, Bluetooth/remote control functionality, or extended warranties.
• Implanted hearing related devices, such as bone- anchored hearing aids (BAHA) and cochlear implants based on our criteria.

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

Not covered:

• Charges for upgrades above the cost of a basic, standard hearing aid
• Hearing aids, testing and examinations for them, unless noted above

All charges

All charges

• Hearing Aids

The plan covers up to two TruHearing-branded hearing aids every year (one per ear per year). This benefit is limited to TruHearing Advanced and Premium hearing aids, which come in various styles and colors. Premium hearing aids are available in rechargeable style options for an additional $75 per aid. You must see a TruHearing provider to use this benefit. TruHearing offers a national network of providers. Call 833-718-5803 to schedule an appointment (for TTY, dial 711).

Hearing aid purchase includes:

• 3 provider visits within the first year of hearing aid purchase
• 45-day trial period
• 3-year extended warranty
• 48 batteries per aid for non-rechargeable models

This benefit does not include or cover any of the following:

• Additional cost for optional hearing aid rechargeability
• Ear molds
• Hearing aid accessories
• Additional provider visits
• Additional batteries or batteries when a rechargeable hearing aid is purchased
• Hearing aids that are not TruHearing-branded hearing aids
• Costs associated with loss and damage warranty claims

Costs associated with excluded items are the responsibility of the enrollee and not covered by the plan.

$699 copayment per aid for Advanced Aids*

$999 copayment per aid for Premium Aids*

A rechargeable battery option is available on some Premium hearing aids for an additional $75 per aid.

*Please note that this service does not apply to your maximum out-of-pocket amount for medical services.

All charges

We cover:

• Eye exams to determine the need for vision correction
• Annual eye refractions

Note: See Preventive care, adult; Preventive care, children

In Network: Nothing

Out of Network: 40% of charges after out-of-network deductible

• Diagnosis and treatment of illness and injury to the eye

$30 per office visit

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

Initial evaluation, lenses and fitting for contact or eyeglass lenses if medically necessary for the post surgical treatment of cataracts or for the treatment of aphakia, acute or chronic corneal pathology, or keratoconus

$30 per office visit

All charges for lens replacement beyond the initial pair

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

All charges for lens replacement beyond the initial pair

Not covered:

• Eyeglasses or contact lenses and their fitting, measurement and adjustment, except as shown above
• Eyewear options, including, but not limited to, ultraviolet absorbing properties, scratch resistant protective coating, sunglasses in addition to other lenses, anti-reflective coating, edge treatment, fashion tints or polarized lenses, frames, contact lens cleaning solution or normal saline for contact lenses, progressive lenses or invisible bifocals, low vision aids or oversize lenses
• Eye exercises and orthoptics
• Vision correction (refractive) surgeries in otherwise healthy eyes to replace eyeglasses or contact lenses. Examples include, but are not limited to, LASIK, radial keratotomy, laser and other refractive eye surgery

All charges

All charges

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

$30 per office visit

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

Not covered:

• Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

We cover:

• Artificial limbs and eyes
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy
• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
• Orthopedic and corrective shoes when approved by this Plan based on our criteria
• Hearing aids and implantable hearing-related devices as described under Hearing Services on page (Applies to printed brochure only).

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

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.

• Wigs required due to hair loss caused by alopecia areata

20% of charges, and all charges beyond one wig per calendar year limit

In Network:  20% of charges after in-network deductible, and all charges beyond one wig per calendar year limit

Out of Network:  40% of charges after out-of-network deductible, and all charges beyond one wig per calendar year limit

Not covered:

• Over-the-counter foot orthotics
• Non-custom orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
• Replacement or repair of any covered items if they are damaged or destroyed by member misuse, abuse or carelessness; lost; or stolen
• Duplicate or similar items, including replacement or repair of duplicate or similar items
• Items which are primarily educational in nature or for hygiene, vocation, comfort, convenience, recreation or safety
• Other equipment and supplies, including but not limited to assistive devices, that we determine are not eligible for coverage

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment, when prescribed by your Plan physician. Covered items include:

• Oxygen
• Dialysis equipment
• Hospital beds
• Wheelchairs
• Crutches
• Walkers
• Blood glucose monitors
• Insulin pumps
• Diabetic supplies
• Disposable needles and syringes needed for the administration of covered medications
• Compression garments

Note: Covered items may be subject to limitations or require prior authorization. We reserve the right to determine if an item will be approved for rental vs. purchase. 

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

In Network: 20% of charges

Out of Network: 40% of charges after out-of-network deductible

Not covered:

• Replacement or repair of any covered items if they are damaged or destroyed by member misuse, abuse or carelessness; lost; or stolen
• Duplicate or similar items
• Items which are primarily educational in nature or for hygiene, vocation, comfort, convenience or recreation
• Household equipment, such as exercise cycles, air purifiers, water purifiers, air conditioners, non-allergenic pillows, mattresses or water beds
• Household fixtures, such as escalators or elevators, ramps, swimming pools or saunas
• Modifications to the home, such as wiring, plumbing or charges to install equipment
• Vehicle, car or van modifications, such as hand brakes, hydraulic lifts and car carriers
• Rental of medically necessary durable medical equipment while your own equipment is being repaired, that is beyond one month rental
• Other equipment and supplies, including but not limited to assistive devices, that we determine are not eligible for coverage 
• We require that certain diabetic supplies and equipment be purchased at a pharmacy

We cover home healthcare ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), or home health aide, as shown below. You need to be homebound (i.e., unable to leave home without considerable effort due to a medical condition) to receive home health services. You do not need to be homebound to receive total parenteral nutrition/intravenous ("TPN/IV") therapy. 

Note: We waive the requirement that you be homebound if you have a life-threatening, non-curable condition which has a prognosis of survival of two years or less.

• At home physical therapy, occupational therapy, speech therapy, respiratory therapy and home health aide services

$30 per visit

• TPN/intravenous therapy (other than specialty drugs described below), skilled nursing services, nonroutine prenatal and postnatal services, and phototherapy

• Specialty drugs administered in home
  
  We cover specialty drugs 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. We require prior authorization for certain drugs and the site where the drug will be administered.

In Network: 40% of charges, after deductible

Out of Network: All charges

• Palliative care

Palliative care includes symptom management, education and establishing goals of care.

If you are eligible to receive palliative care in the home and you are not homebound, there is a maximum of 12 visits per calendar year. Additional palliative care visits are eligible under the home health services benefit if you are homebound and meet all other requirements defined in this section.

$30 per visit

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

• Routine prenatal and postnatal services and child health services

In Network: Nothing

Out of Network: 40% of charges after out-of-network deductible

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

We cover chiropractic services for rehabilitative care, provided to diagnose and treat acute neuromusculo-skeletal conditions, limited to:

• Manipulation of the spine
• Adjunctive procedures such as massage therapy, ultrasound, electrical muscle stimulation, and vibratory therapy,  when they are performed in conjunction with other treatment by a chiropractor, are part of a prescribed treatment plan and are not billed separately

$30 per office visit

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

Not covered:

• Massage therapy as a standalone treatment
• Naturopathic services
• Hypnotherapy

All charges

All charges

We cover:

• Acupuncture – by a certified Plan acupuncturist for:
  • anesthesia
  • pain relief
  • headaches
  • nausea
• Biofeedback for:
  • incontinence
  • headaches
  • musculo-skeletal spasms which do not respond to other treatments
  • mental/nervous disorders

$30 per office visit

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

Not covered:

• Naturopathic services
• Hypnotherapy

We cover:

• Education for preventive services
• Tobacco cessation programs, including individual, group, phone counseling, and physician prescribed over-the-counter (OTC) and prescription drugs approved by the FDA to treat nicotine dependence. Includes up to two quit attempts and up to four counseling sessions
• Physician prescribed over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence whether or not one is enrolled in a smoking cessation program
• Education for the management of chronic health problems (such as diabetes)
• Childhood obesity screening programs and interventions

In Network: Nothing

Out of Network: 40% of charges after out-of-network deductible

We cover a comprehensive range of services, such as:

• Operative procedures, including normal pre- and post-operative care by the surgeon
• Treatment of fractures, including casting
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Vasectomy
• Treatment of burns
• Gender confirmation surgery that meets medical coverage criteria
• Insertion of internal prosthetic devices.
  See 5(a) -- Orthopedic and prosthetic devices for device coverage information

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.

$30 per office visit

$500 annual copayment for inpatient and outpatient hospital services combined, then 20% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

Surgical treatment of morbid obesity (bariatric surgery)

See Services requiring our prior approval on page (Applies to printed brochure only). See bariatric surgery criteria on www.healthpartners.com/fehb

$30 per office visit

$500 annual copayment for inpatient and outpatient hospital services combined, then 20% of charges.

In Network: 20% of charges after in-network deductible

Out of Network: All charges

Not covered:

• Reversal of voluntary sterilization
  

We cover:

• 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 congenital anomalies are: protruding ear deformities, cleft lip, cleft palate, birth marks, port wine stains, webbed fingers and webbed toes.

Note: Port wine stains do not have to result in a functional defect to be covered.

• 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)

$30 per office visit

$500 annual copayment for inpatient and outpatient hospital services combined, then 20% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

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.

• Gender affirming (confirmation) surgery that meets medical coverage criteria, including breast augmentation, mastectomy, reduction mammoplasty, orchidectomy, penectomy, urethroplasty, vaginoplasty, labiaplasty, clitoroplasty, hysterectomy, salpingectomy, oophorectomy, vaginectomy and phalloplasty or metoidioplasty, scrotoplasty, and placement of a testicular prosthesis and erectile prosthesis. Prior authorization is required.

Not covered:

• Surgery, services, treatments or drugs that improve or enhance the shape or appearance of the body for purposes other than treating an illness or injury. These types of services are considered cosmetic and are not covered whether or not they also impact your psychological/emotional well-being or self-esteem. Examples include but are not limited to enhancement procedures, reduction procedures and scar revision surgery. This exclusion does not apply to services for port wine stain removal, reconstructive surgery, gender confirmation services and emergency care required due to complications of Cosmetic Surgery.

We cover oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones
• Surgical correction of cleft lip, cleft palate
• Removal of stones from salivary ducts
• Excision of leukoplakia or malignancies
• Excision of cysts and incision of abscesses when done as independent procedures
• Other surgical procedures that do not involve the teeth or their supporting structures, including non-dental treatment of temporomandibular joint dysfunction (TMJ)

$30 per office visit

$500 annual copayment for inpatient and outpatient hospital services combined, then 20% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

We cover orthognathic surgery for the treatment of a skeletal malocclusion when a functional occlusion cannot be achieved through non-surgical treatment alone and a demonstrable functional impairment exists.

25% of charges

In Network:  25% of charges after in-network deductible

Out of Network:  50% of charges after out-of-network deductible

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva and alveolar bone)
• Orthodontic services (pre or post operative) associated with orthognathic surgery

These solid organ transplants are subject to medical necessity and experimental investigational review by the Plan. See Other services in Section 3 for prior authorization procedures. Solid organ transplants are limited to:

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

$500 annual copayment for inpatient and outpatient hospital services combined, then 20% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

These tandem blood or marrow stem cell transplants for covered transplants are not 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)
  • Recurrent germ cell tumors (including testicular cancer)

$500 annual copayment for inpatient and outpatient hospital services combined, then 20% of charges

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

These blood or marrow stem cell transplants are not subject to medical necessity and experimental investigational review by the Plan. Refer to Other services in Section 3 for prior authorization procedures.

Physicians consider many features to determine how diseases will respond to different types of treatment. Some of the features measured are the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and how fast the tumor cells grow.  By analyzing these and other characteristics, physicians can determine which diseases will respond to treatment without transplant and which diseases may respond to transplant. 

The Plan extends coverage for the diagnosis as indicated below.

Allogeneic transplants for

• Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
• Acute myeloid leukemia 
• Advanced Hodgkin’s lymphoma with recurrence (relapsed)
• Advanced Myeloproliferative Disorders (MPDs)
• Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
• Amyloidosis
• Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
• Hemoglobinopathy
• Hurler’s syndrome, Maroteaux-Lamy syndrome
• Infantile malignant osteopetrosis
• Kostmann’s syndrome
• Leukocyte adhesion deficiencies
• Marrow failure and related disorders (i.e., Fanconi's, Paroxysmal Nocturnal Hemoglobinuria, pure red cell aplasia)
• Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
• Myelodysplasia/myelodysplastic syndromes 
• Paroxysmal nocturnal hemoglobinuria
• Phagocytic/hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
• Severe combined immunodeficiency
• Severe or very severe aplastic anemia
• Sickle cell anemia
• X-linked lymphoproliferative syndrome

Autologous transplants for

• Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
• Advanced Hodgkin’s lymphoma with recurrence (relapsed) 
• Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
• AL Amyloidosis
• Breast Cancer
• Epithelial ovarian cancer 
• Multiple myeloma 
• Neuroblastoma
• Recurrent germ cell tumors (including testicular, mediastinal, retroperitoneal)

$500 annual copayment for inpatient and outpatient hospital services combined, then 20% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

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

Autologous transplants for

• Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
• Advanced Hodgkin’s lymphoma with recurrence (relapsed)
• Advanced non-Hodgkin’s lymphoma with recurrence (relapsed
• Amyloidosis
• Neuroblastoma

$500 annual copayment for inpatient and outpatient hospital services combined, then 20% of charges

In Network: 20% of charges after  in-network deductible

Out of Network: 40% of charges after out-of-network deductible

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

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

$500 annual copayment for inpatient and outpatient hospital services combined, then 20% of charges.

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

Allogeneic transplants for

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

Autologous transplants for

• Advanced childhood kidney cancers
• Advanced Ewing sarcoma
• Childhood rhabdomyosarcoma
• Mantle cell (Non-Hodgkin lymphoma)

$500 annual copayment for inpatient and outpatient hospital services combined, then 20% of charges    

In Network: 20% of charges after in-network deductible

Out of network: 40% of charges after out-of-network deductible

HealthPartners Designated Transplant Providers and HealthPartners Centers of Excellence - These are local and national Designated Transplant Centers based upon their experience, clinical outcomes, service, access, cost, coordination of care, research and education. For a list of participating programs visit
www.healthpartners.com/fehb.

$500 annual copayment for inpatient and outpatient hospital services combined, then 20% of charges

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

Not covered:

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

We cover professional services provided in –

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

$500 annual copayment for inpatient and outpatient hospital services combined, then 20% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

$30 per office visit

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

We may provide travel and lodging when an enrollee needs a transplant or CAR-T therapy and a designated transplant center or CAR-T treatment center is greater than 100 miles from the enrollee’s primary address.

This benefit is subject to our medical policies (medical coverage criteria).

To receive reimbursement for eligible travel and lodging expenses, the Insured will need to submit itemized receipts of services. In addition, include a letter explaining that the receipts are in conjunction with an authorized organ or bone marrow transplant or CAR-T therapy, and include the recipient’s full name, date of birth, HealthPartners ID number, dates of services, names of vendors, service type (airfare, lodging), and mileage (submit actual miles driven with route and destination addresses). Receipts and the letter should be sent to: Claims Department, HealthPartners, P.O. Box 1289, Minneapolis, MN 55440-1289.

20% of charges

Expenses for travel, and lodging for the enrollee (the recipient) and one adult companion, or up to two companions for a recipient that is a minor dependent, may be covered, up to a maximum of $10,000 per transplant or CAR-T therapy. Lodging coverage is limited to $100 per day

20% of charges

Expenses for travel, and lodging for the enrollee (the recipient) and one adult companion, or up to two companions for a recipient that is a minor dependent, may be covered, up to a maximum of $10,000 per transplant or CAR-T therapy. Lodging coverage is limited to $100 per day

Out of Network: All Charges

We cover room and board, such as

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

For Maternity Care see page (Applies to printed brochure only).

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

$500 annual copayment for inpatient and outpatient hospital services combined, then 20% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible 

We cover other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Administration of blood and blood products
• Blood or blood plasma (unless replaced) and blood derivatives
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment and any covered items billed by a hospital for use at home
• MRI / CT scans

$500 annual copayment for inpatient and outpatient hospital services combined, then 20% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

Not covered:

• Custodial care
• Non-covered facilities, such as nursing homes, extended care facilities, schools
• Personal comfort items, such as phone, television, barber services, guest meals and beds
• Private nursing care

We cover:

• Operating, recovery and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests, X-rays and pathology services
• Administration of blood, blood plasma and other biologicals
• Pre-surgical testing
• Dressings, casts and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

$500 annual copayment for inpatient and outpatient hospital services combined, then 20% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

• MRI / CT scans
• Blood and blood plasma (unless replaced) and blood derivatives

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

• Specialty drugs

We cover specialty drugs 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. We require prior authorization for certain drugs and the site where the drug will be administered.

In Network: 40% of charges, after in-network deductible

 Out of Network: All charges

We cover a comprehensive range of benefits for up to 120 days per calendar year when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by your Plan doctor and prior authorized by this Plan. All necessary services are covered, including:

• Bed, board and general nursing care
• Drugs, biologicals, services and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by your Plan doctor.

$500 annual copayment for inpatient and outpatient hospital services combined, then 20% of charges

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

   Not covered: Custodial care

We cover supportive and palliative care in your home or a hospice if you are terminally ill. We cover the following services:

• Outpatient care, family counseling and continuous care
• Inpatient care, when medically necessary 
• Respite care
• End of life care

Note: Respite care is limited to 5 days per episode, and respite care and continuous care combined are limited to 30 days. 

Note: Inpatient hospital care:  designed for those patients who require an acute hospital admission for pain or symptom control related to the terminal illness. Free-standing hospice: a hospice inpatient unit set up as a geographically distinct building.  Residential hospices/hospice houses:  goal is to provide longer-term care, in homelike settings, for patients who cannot be cared for in their own homes. Staffing and intensity of services are comparable to a board-and-care home or other types of licensed residential facility. A residential hospice program may be operated by a home care hospice or by an independent agency that contracts with a community hospice for professional services. Payment for residential room and board is made privately.

In Network:  20% of charges after in-network deductible

Out of Network:  40% of charges after out-of-network deductible

Not covered:

• Independent nursing, homemaker services
• Room and board expenses in a residential hospice facility, free standing hospice or skilled nursing facility 

Ambulance and medical transportation for medical emergencies described in Section 5(d) and non-emergency medical transportation when medically appropriate.

The amount you pay for these services will be determined based on the requirements of the No Surprises Act and its implementing regulations.

In or Out of Network: 20% of charges

In or Out of Network:  20% of charges after in-network deductible 

Note: Fixed Wing Air Ambulance transport requires prior authorization from HealthPartners. Fixed Wing Air Ambulance is an aircraft such as an airplane, jet, or turbo prop plan that is able to travel longer distances than its counterpart, the Rotary Wing Air Ambulance (i.e. the helicopter). Under the No Surprises Act, Non-Network air ambulance providers may not bill patients for more than their cost-sharing responsibility for the corresponding Network service.

We cover:

• Emergency and urgently needed services at a doctor’s office
• Emergency and urgently needed services at an urgent care clinic

The amount you pay for these services will be determined based on the requirements of the No Surprises Act and its implementing regulations.

$30 per office visit 

$0 for the first 5 office, convenience clinic, telephone, urgent care visits and evisits combined in a calendar year (deductible does not apply), then 20% of charges, subject to the in-network deductible. Physician’s services, laboratory and radiology performed in conjunction with the same visit and on the same date of service are included; however, charges for day treatment services, group visits, office procedures and other ancillary services are not included and will be subject to your deductible and coinsurance.

• Emergency and urgently needed services as an outpatient in a hospital, including doctors' services

The amount you pay for these services will be determined based on the requirements of the No Surprises Act and its implementing regulations.

$150 per visit

The ER copayment is waived if you are admitted to the hospital

•  Emergency and urgently needed inpatient hospital services

The amount you pay for these services will be determined based on the requirements of the No Surprises Act and its implementing regulations.

$500 annual copayment for inpatient and outpatient hospital services combined, then 20% of charges

Ambulance and medical transportation for medical emergencies described in this section and non-emergency medical transportation when medically appropriate.

The amount you pay for these services will be determined based on the requirements of the No Surprises Act and its implementing regulations.

Under the No Surprises Act, out-of-network air ambulance providers may not bill patients for more than their cost-sharing responsibility for the corresponding in-network service.

In or Out of Network: 20% of charges

Note: Fixed Wing Air Ambulance transport requires prior authorization from HealthPartners.  Fixed Wing Air Ambulance is an aircraft such as an airplane, jet, or turbo prop plan that is able to travel longer distances than its counterpart, the Rotary Wing Air Ambulance (i.e. the helicopter). Under the No Surprises Act, Non-Network air ambulance providers may not bill patients for more than their cost-sharing responsibility for the corresponding Network service.

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 marriage and family therapists.

We cover diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders.  Services include:

• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Medication evaluation and management (pharmacotherapy)
• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
• Treatment and counseling (including individual therapy visits)
• Diagnosis and treatment of substance use disorders, including detoxification, treatment and counseling
• Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
• Electroconvulsive therapy
• Gender affirming care for gender dysphoria

$30 per visit

In Network: $0 for the first 5 office, convenience clinic, telephone, urgent care visits and evisits combined in a calendar year (deductible does not apply), then 20% of charges, subject to the in-network deductible. Physician’s services, laboratory and radiology performed in conjunction with the same visit and on the same date of service are included; however, charges for day treatment services, group visits, office procedures and other ancillary services are not included and will be subject to your deductible and coinsurance.

Out of Network: 40% of charges after out-of-network deductible

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

We cover:

• Outpatient diagnostic tests 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
• Inpatient diagnostic tests provided and billed by a hospital or other covered facility

$30 per visit

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

We cover 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, residential treatment, and other hospital services

$500 annual copayment for inpatient and outpatient hospital services combined, then 20% of inpatient hospital charges

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

We cover outpatient services provided and billed by a hospital or other covered facility

• Services in approved treatment programs, such as partial hospitalization, half-way house, full-day hospitalization, or facility-based intensive outpatient treatment

$30 per visit

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

• Marriage or relationship counseling services
• Sex therapy
• Religious counseling
• Wilderness and outdoor programs even when the program is through a licensed facility
• Animal therapy, including hippotherapy and equine therapy
• Professional services associated with substance use disorder interventions. A “substance use disorder intervention” is a gathering of family and/or friends to encourage an Enrollee or family member to seek substance use disorder treatment.

We cover the following medications and supplies prescribed by a licensed provider and obtained from a Plan pharmacy or through our designated mail order program:

• Drugs and medications that by Federal law of the United States require a physician's prescription for their purchase, except those listed as Not covered.
• Insulin
• Gender affirming drugs

$5 for preferred low cost generic drugs

$25 for preferred high cost generic drugs

$55 for brand-name preferred drugs

$90 for non-preferred drugs

The copayment applies per 30-day supply, or portion thereof

In Network: 

$5 for preferred low cost generic drugs (deductible does not apply)

$25 for preferred high cost generic drugs (deductible does not apply)

$60 for brand-name preferred drugs after deductible

$150 for non-preferred drugs after deductible

The copayment applies per 30-day supply, or portion thereof  

Out of Network:  40% of charges after out-of-network deductible

We cover all FDA approved contraceptive methods as listed in the ACA/HRSA site, including contraceptive drugs, the morning after pill, injectable contraceptives or implantable contraceptive devices. 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. Your prescriber will obtain prior approval.

Notes:

• Coverage is limited to females (based on sex assigned at birth)

• This benefit applies whether the birth control drug or device is used for birth control or for a medically necessary purpose other than birth control.

• Over-the-counter contraceptive drugs and devices approved by the FDA require a written prescription by an approved provider. These may be purchased at a pharmacy counter.

Nothing for generic preferred drugs

All charges for non-preferred drugs

In Network: Nothing for generic preferred drugs; All charges for non-preferred drugs

Out of Network: 40% of charges after out-of-network deductible

We cover physician prescribed over-the-counter and prescription drugs for tobacco cessation, no limit

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

In Network: Nothing

Out of Network: 40% of charges after out-of-network deductible

Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a healthcare professional and filled by a network pharmacy. These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

In Network: Nothing

Out of Network: 40% of charges after out-of-network deductible

Diabetic supplies limited to

• disposable needles and syringes for the administration of covered medications
• blood glucose testing meters and strips
• other diabetes supplies such as lancets and pen needles or insulin syringes

20% of charges

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

Drugs for breast cancer prevention for individuals at high risk for breast cancer who have not yet been diagnosed with the disease

Nothing for preferred drugs

$90 for non-preferred drugs

In Network: Nothing for preferred drugs; $150 for non-preferred drugs after deductible

Out of Network: 40% of charges after out-of-network deductible

We cover specialty drugs.

Note: Specialty drugs 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. We require prior authorization for certain drugs and the site where the drug will be administered. Please refer to the drug plan formulary to determine if the drug you have been prescribed by your physician needs to be filled by one of the plan's Specialty Pharmacy providers.

• For safety, all mailing will be shipped based on temperature requirements and considerations.
• Specialty drugs cannot be obtained through the traditional 90-day mail order program.

20% coinsurance for specialty drugs

In Network: 40% coinsurance for specialty drugs, after in-network deductible

Out of Network: All charges

Not covered:

• Drugs and supplies for cosmetic purposes
• Nonprescription (over-the counter) drugs, including, but not limited to vitamins, nutrients, medical foods, food supplements and homeopathic remedies, even if a physician prescribes or administers them, except as specified in this brochure or on the Formulary and prescribed by a physician or legally authorized health care provider under applicable state and federal law.
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies (High Option only)
• Medical supplies such as dressings and antiseptics
• Drugs to enhance athletic performance
• Sexual dysfunction drugs
• Replacement of prescription drugs, equipment and supplies due to loss, damage or theft
• Medical cannabis
• Drugs that are newly approved by the FDA until they are reviewed and coverage is established by HealthPartners Pharmacy and Therapeutics Committee.
• Drugs on the Excluded Drug List. The Excluded Drug List includes select drugs within a therapy class that are not eligible for coverage. This includes drugs that may be excluded for certain indications. The Excluded Drug List is available at healthpartners.com/fehb

You may also get outpatient prescription drugs which can be self-administered through the designated mail order service. For information on how to obtain drugs through HealthPartners mail order service, please visit www.healthpartners.com/fehb.

This benefit does not apply to drugs listed under Limited Benefits below.

$10 for preferred low cost generic drugs

$50 for preferred high cost generic drugs

$110 for brand-name preferred drugs

$180 for non-preferred drugs

The copayment applies per 90-day supply, or portion thereof

In Network: 

$10 for preferred low cost generic drugs (deductible does not apply)

$50 for preferred high cost generic drugs (deductible does not apply)

$120 for brand-name preferred drugs after deductible

$300 for non-preferred drugs after deductible

The copayment applies per 90-day supply, or portion thereof

Out of Network:  all charges

In Network: 20% of charges after in-network deductible

Out of Network: 40% of charges after out-of-network deductible

Fertility drugs (including but not limited to products listed on the Formulary)

20% of charges and all charges beyond the lifetime limit

In Network: 20% of charges after in-network deductible, and all charges beyond the lifetime limit 

Out of Network: All charges

Maximum Benefit per Lifetime

Fertility treatment, fertility drugs and therapeutic preservation fertility services are limited to a combined $10,000 maximum benefit per lifetime

Fertility treatment, fertility drugs and therapeutic preservation fertility services are limited to a combined $10,000 maximum benefit per lifetime

We cover:

• Accidental dental services In Network: Restorative services and supplies provided by Plan dentists necessary to promptly repair or replace sound, natural, unrestored teeth, including the cost and installation of necessary prescription dental prosthetic items or devices. The need for these services must directly result from an accidental injury, not including injury from biting, chewing, clenching or grinding of teeth. Coverage is limited to the initial treatment (or course of treatment) and/or restoration. Only services provided within 24 months from the date of injury are covered.

• Emergency accidental dental services Out of Network: Emergency dental services for accidental injury, as described above, when they are provided by Out of Network dentists if the injuries require immediate treatment.

Our Behavioral Health Personalized Assistance Line (PAL) staff can match you with the network provider that best meets your behavioral health needs. We can identify providers based on:

• Specialty or subspecialty
• Specific diagnostic, language and cultural competence

And if you have an urgent need, we can link you to same day/next day psychiatric appointments. Call 952-883-5811 or 888-638-8787.

Nurse Navigators are experienced nurses who can help research treatment options, coordinate care and guide you through difficult decisions. Call 844-440-1900.

If you are deaf or hearing impaired, we have special phone lines which you may call for the following services:

Member Services: 952-883-5127

CareLine Service: 952-883-5474

As a Plan member, you have instant access to detailed, secured information and helpful services tailored to you. Depending on your coverage, you may be able to:

• View your personal health record
• See your claims information
• View your benefits
• View your medical and dental provider networks
• Find health and wellness information 
• Order new ID cards
• Make appointments at HealthPartners Clinics 
• Refill a mail order prescription or a prescription at a HealthPartners Clinic
• Determine the retail and mail order costs of specific drugs
• See all the medications on the HealthPartners preferred list of covered drugs
• Estimate your annual cost of medical care

Virtuwell is an online clinic that treats everyday illnesses so you- or your kids-can get better.

• Quickly and conveniently get care for over 40 common conditions
• get a diagnosis, treatment plan and prescription if needed- all in less than an hour
• you pay nothing. See section 5(a)
• 24/7, with nurse practitioners available

Download the HealthPartners app or visit the mobile site to find and manage your health plan on-the-go.

Use your smartphone to:

• Access your Member ID card
• Check your plan balances including your deductible
• Search for the closest care locations to you
• Get cost estimates
• View claims and Explanation of Benefits (EOBs)
• …and more

Download the app today in your app store or visit m.healthpartners.com to learn more about HealthPartners mobile offerings, visit www.healthpartners.com/gomobile.

If you have a mobile phone that can get text messages, you can receive a variety of texts from HealthPartners. Either opt in to receive weekly texts or add a phone number in your myHealthPartners account to get text specific to you.

Text one of these commands to 77199:

• DED: For how much is remaining until you meet your deductible
• YUM: For better-for-you eating tips from yumPower
• FAMILY: For ideas to support your family's health
• QUITNOW: For tips to help you quit smoking

There’s no greater reward than living a healthy life. In case you need extra incentive, we've got one for you. When you complete your health assessment and register and complete an eligible online health improvement program, you are entitled to receive a contribution of $250 into your HealthPartners Wellness Account debit card to be used for most qualified medical expenses, prescriptions and IRS 213(d) vision expenses. For those with Self Plus One or Self and Family coverage, each adult employee or covered spouse, is eligible for the $250 contribution to the HealthPartners Wellness Account. We will send the policyholder two debit cards to access the account. Please keep your card for future use even if you use all of your health account dollars; you may be eligible for wellness incentives in subsequent benefit years. We do not send new cards to continuing participants until the card expires. The account funds must be used by December 31, 2024 or the account will be forfeited.

After completing the online health assessment, you may access online wellness courses to set personalized goals designed to improve your health through increased exercise, healthier nutrition habits, managing your weight, reduced stress, better emotional health, or goals that focus on managing a specific condition. You must complete the health assessment and complete an eligible online health improvement program no later than December 31, 2023 in order to receive these incentives.

Getting rewarded is simple.

• Log into your myHealthPartners account at www.healthpartners.com/fehb. If you don't have a username and password, click on “sign up for myHealthPartners”.

• Take your health assessment.

• Register for an eligible online health improvement program

• Complete the eligible online health improvement program.

• Don’t forget, this includes your covered spouse!

• One set of two debit cards will be sent to access the funds in your HealthPartners Wellness Account.

High option members enrolled in both Medicare Part A and Part B are eligible to be reimbursed up to $1,200 per calendar year for their Medicare Part B premium payments. Eligible members must notify HealthPartners of their Medicare enrollment status. For more information on how to get reimbursement for your paid Medicare Part B premiums, please call 844-440-1900 or visit healthpartners.com/fehb/medicare.

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

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

Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8).

You may be eligible for an eyewear discount at Plan optical centers, including HealthPartners Eye Care Centers and EyeMed retailers such as Target, LensCrafters, etc.  For more information on the program visit www.healthpartners.com/fehb or call member services at 844-440-1900.

HealthPartners retail savings program gives you discounts on tools and services from reputable organizations to help you be as healthy as you can be. Complete information and list of partner organizations can be found online at www.healthpartners.com/fehb or call member services at 844-440-1900

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, contact us at 844-440-1900 (TTY: 952-883-5127), or at our website at www.healthpartners.com/fehb. 

When you must file a claim – such as for services you received outside the Plan's Network– submit it on the CMS -1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:  

• Covered member’s name, date of birth, address, phone number and ID number
• Name and address of the provider or facility that provided the service or supply
• Dates you received the services or supplies
• Diagnosis
• Type of each service or supply
• The charge for each service or supply
• A copy of the explanation of benefits, payments, or denial from any primary payor – such as the Medicare Summary Notice (MSN)
• Receipts, if you paid for your services

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

Submit your claims to:
HealthPartners Claims
P.O. Box 1289
Minneapolis, MN 55440-1289

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

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

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

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, we will permit a healthcare professional with knowledge of your medical condition 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.

If you live in a county where at least 10% of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that 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.

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

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

b) Send your request to us at: Member Services, P.O. Box 1309, Minneapolis, MN 55440-1309; and

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

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

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

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

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

a) Pay the claim or  

b) Write to you and maintain our denial or

c) Ask you or your provider for more information

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

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

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

You must write to OPM within:

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

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

Send OPM the following information:

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

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

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

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

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

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

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

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

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

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

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. For example, we will generally only make up the difference between the primary payor’s benefits payment and 100% of the Plan allowance, subject to our applicable coinsurance or copayment amounts, except when Medicare is the primary payor (see page (Applies to printed brochure only)). Thus, it is possible that the combined payments from both plans may not equal the entire amount billed by the provider.

Note: When we pay secondary to primary coverage you have from a prepaid plan (HMO), we base our benefits on your out-of-pocket liability under the prepaid plan (generally, the prepaid plan’s copayments), subject to our coinsurance or copayment amounts.
In certain circumstances when we are secondary and there is no adverse effect
on you (that is, you do not pay any more), we may also take advantage of any provider discount arrangements your primary plan may have and only make up the difference between the primary plan’s payment and the amount the provider has agreed to accept as payment in full from the primary plan.

Note: Any visit limitations that apply to your care under this Plan are still in effect when we are the secondary payor. Remember: Even if you do not file a claim with your other plan, you must still tell us that you have double coverage, and you must also send us documents about your other coverage if we ask for them.

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

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

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

We do not cover services that:

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

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

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

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

Our 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 on BENEFEDS.com or by phone at 877-888-3337, (TTY 877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits.  Providing your FEHB information may reduce your out-of-pocket cost.

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

If you are a participant in a clinical trial, this health plan will 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.  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 800-MEDICARE (800-633-4227), (TTY 877-486-2048) or at www.medicare.gov.

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

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary. This is true whether or not they accept Medicare. When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

Claims process when you have the Original Medicare Plan – You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan. When we are the primary payor, we process the claim first. When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 844-440-1900.

To be eligible for full cost-share waiving, members must be enrolled in both Parts A and B of Original Medicare. For members enrolled in High and Standard Option and also enrolled in the Original Medicare Plan (Part A and B) as your primary payor – we will waive your out-of-pocket costs (applicable deductibles, copays and coinsurance) at in-network providers as follows:

• Inpatient hospital benefits: We waive applicable deductibles, copays and coinsurance.
• Medical and surgery benefits and mental health/substance use disorder care: We waive applicable deductibles, copays and coinsurance.
• Office visits: We waive the applicable deductibles, copays and coinsurance at In-Network Providers.
• Physical, speech and occupational therapy benefits: Applicable deductibles, copays and coinsurance is waived.
• Benefit limits and maximums still apply.
• There is no change to your prescription drug coverage. We do not waive deductibles, copays, or coinsurance.
• We do not waive cost-sharing on hearing aids through TruHearing.

You can find more information about how our Plan coordinates benefits with Medicare by calling our FEHB Member Services team at 844-440-1900 or visit healthpartners.com/fehb/medicare.

Cost sharing may not apply if the Original Medicare Plan is your primary payor

– For Medicare covered services we will coordinate benefits to potentially reduce your out-of-pocket costs as follows: 

When Medicare Part A is primary –

• You may experience a reduction in cost sharing for our in-network:

− Annual hospital copayments for Medicare covered services;

− Hospital coinsurance for Medicare covered services. 

Note: Once you have exhausted your Medicare Part A benefits, you must then pay the applicable copayment or coinsurance.

When Medicare Part B is primary –

• You may experience a reduction in cost sharing for our in-network:

− Coinsurance and copayments for inpatient and outpatient services and supplies provided by physicians and other covered healthcare professionals for Medicare covered services; and

− Coinsurance and/or copayment for outpatient facility services for Medicare covered services. 

Note: We do not waive benefit limitations, such as the 25-visit limit for home nursing visits. In addition, we do not waive any coinsurance or copayments for prescription drugs.

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.

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

Benefit Description: Deductible
High Option You Pay Without Medicare: $0
High Option You Pay With Medicare Part B: $0
Standard Option You Pay Without Medicare: In Network: $750/Self Only; $1,500/Self Plus One; $1,500/Family; Out of Network: $2,000/Self Only; $4,000/Self Plus One; $4,000/Family
Standard Option You Pay With Medicare: In Network: $0; Out of Network: $2,000/Self Only; $4,000/Self Plus One; $4,000/Family

Benefit Description: Out-of-Pocket Maximum
High Option You Pay Without Medicare: Self Only: Nothing after $6,500; Self Plus One: Nothing after $13,000, subject to a maximum of $9,100 per enrollee; Self and Family: Nothing after $13,000, subject to a maximum of $9,100 per enrollee
High Option You Pay With Medicare Part B: Self Only: Nothing after $6,500; Self Plus One: Nothing after $13,000, subject to a maximum of $9,100 per enrollee; Self and Family: Nothing after $13,000, subject to a maximum of $9,100 per enrollee
Standard Option You Pay Without Medicare: In Network: Self Only: Nothing after $7,000; Self Plus One: Nothing after $14,000, subject to a maximum of $9,100 per enrollee; Self and Family: Nothing after $14,000, subject to a maximum of $9,100 per enrollee; Out of Network: No maximum
Standard Option You Pay With Medicare: In Network: Self Only: Nothing after $7,000; Self Plus One: Nothing after $14,000, subject to a maximum of $9,100 per enrollee; Self and Family: Nothing after $14,000, subject to a maximum of $9,100 per enrollee; Out of Network: No maximum

Benefit Description: Part B Premium Reimbursement Offered
High Option You Pay Without Medicare: NA
High Option You Pay With Medicare Part B: Up to $1,200
Standard Option You Pay Without Medicare: NA
Standard Option You Pay With Medicare: None

Benefit Description: Primary Care Physician
High Option You Pay Without Medicare: $30
High Option You Pay With Medicare Part B: Nothing for most Medicare covered services and never more than $30
Standard Option You Pay Without Medicare: In Network: You pay $0 for 5 visits, then 20% after deductible; Out of Network: 40% after deductible
Standard Option You Pay With Medicare: In Network: Nothing for most Medicare covered services and never more than 20% after deductible; Out of Network: Nothing for most Medicare covered services and never more than 40% after deductible

Benefit Description: Specialist
High Option You Pay Without Medicare: $30
High Option You Pay With Medicare Part B: Nothing for most Medicare covered services and never more than $30
Standard Option You Pay Without Medicare: In Network: 20% after deductible; Out of Network: 40% after deductible
Standard Option You Pay With Medicare: In Network: Nothing for most Medicare covered services and never more than 20% after deductible; Out of Network: Nothing for most Medicare covered services and never more than 40% after deductible

Benefit Description: Inpatient Hospital
High Option You Pay Without Medicare: $500 annual copayment for inpatient & outpatient combined, then 20% of charges
High Option You Pay With Medicare Part B: Nothing for most Medicare covered services and never more than a $500 annual copayment for inpatient & outpatient combined, then 20% of charges
Standard Option You Pay Without Medicare: In Network: 20% after deductible; Out of Network: 40% after deductible
Standard Option You Pay With Medicare: In Network: Nothing for most Medicare covered services and never more than 20% after deductible; Out of Network: Nothing for most Medicare covered services and never more than 40% after deductible

Benefit Description: Outpatient Surgery - Hospital
High Option You Pay Without Medicare: $500 annual copayment for inpatient & outpatient combined, then 20% of charges
High Option You Pay With Medicare Part B: Nothing for most Medicare covered services and never more than a $500 annual copayment for inpatient & outpatient combined, then 20% of charges
Standard Option You Pay Without Medicare: In Network: 20% after deductible; Out of Network: 40% after deductible
Standard Option You Pay With Medicare: In Network: Nothing for most Medicare covered services and never more than 20% after deductible; Out of Network: Nothing for most Medicare covered services and never more than 40% after deductible

Benefit Description: Incentives Offered
High Option You Pay Without Medicare: N/A
High Option You Pay With Medicare Part B: Health assessment and wellness courses. For more information see page (Applies to printed brochure only)
Standard Option You Pay Without Medicare:
Standard Option You Pay With Medicare: Health assessment and wellness courses. For more information see page (Applies to printed brochure only)

You can find more information about how our plan coordinates benefits with Medicare by visiting www.healthpartners.com/fehb.

This health plan does not coordinate its prescription drug benefits with Medicare Part B.

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (800-633-4227) (TTY: 877-486-2048) or at www.medicare.gov or call us at 844-440-1900 (TTY: 952-883-5127) or see our website at www.healthpartners.com/fehb.

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

This Plan and another plan’s Medicare Advantage plan: You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (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.

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)

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 review by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.

• 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. These costs are generally covered by the clinical trials. This plan does not cover these costs.

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

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

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

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

As determined by us, a drug, device, medical, behavioral health or dental treatment is investigative if reliable evidence does not permit conclusions concerning its safety, effectiveness, or positive effect on health outcomes and will be considered investigative unless all of the following categories of reliable evidence are met:

• There is final approval from the appropriate government regulatory agency, if required. This includes whether a drug or device can be lawfully marketed for its proposed use by the United States Food and Drug Administration (FDA); and
• The drug or device or medical, behavioral health or dental treatment or procedure is not the subject of ongoing Phase I, II or III clinical trials; and
• The drug, device or medical, behavioral health or dental treatment or procedure is not under study and further studies are not needed (such as post-marketing clinical trial requirements) to determine maximum tolerated dose, toxicity, safety, effect on health outcomes or efficacy as compared to existing standard means of treatment or diagnosis; and
• There is conclusive evidence in major peer-reviewed medical journals demonstrating the safety, effectiveness and positive effect on health outcomes (the beneficial effects outweigh any harmful effects) of the service or treatment when compared to standard established service or treatment.  Each article must be of well-designed investigations, using generally acceptable scientific standards that have been produced by nonaffiliated, authoritative sources with measurable results.  Case reports do not satisfy this criterion.  This also includes consideration of whether a drug is included in one of the standard reference compendia or “Major Peer Reviewed Medical Literature” (defined below) for use in the determination of a medically necessary accepted indication of drugs and biologicals used off-label as appropriate for its proposed use.

Major Peer Reviewed Medical Literature. This means articles from major peer reviewed medical journals that have recognized the drug or combination of drugs' safety and effectiveness for treatment of the indication for which it has been prescribed. Each article shall meet the uniform requirements for manuscripts submitted to biomedical journals established by the International Committee of Medical Journal Editors or be published in a journal specified by the United States Secretary of Health and Human Services pursuant to United States Code, title 42, section 1395x, paragraph (t), clause (2), item (B), as amended, as acceptable peer review medical literature. Each article must use generally acceptable scientific standards and must not use case reports to satisfy this criterion.

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

This plan defines medically necessary care as care that is appropriate for the condition, including those related to mental health. It includes the kind and level of service. It includes the number of treatments. It also includes where you get the service and how long it continues. Medically necessary care must:

• Be the service that other providers would usually order
• Help you get better, or stay as well as you are
• Help stop the condition from getting worse
• Help prevent and find health problems

Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways.

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.

We determine our allowance as follows:

• For covered services delivered by Plan providers, Plan referral providers, or out-of-network providers that have a contract with us, our allowance is the provider’s contracted rate for a given medical/surgical service, procedure or item, which Plan providers have agreed to accept as payment in full.
• For covered services delivered by non-Plan providers that do not have a contract with us, our allowance is the provider’s charge for a given medical/surgical service, procedure or item, according to the usual and customary charge amount.
• The usual and customary charge is the maximum amount allowed that we consider in the calculation of the payment of charges incurred for certain covered services. You must pay for any charges above the usual and customary charge, and they do not apply to the deductible or catastrophic protection out-of-pocket maximum.
• The usual and customary charge is determined using one of the following options in the following order, depending on availability: 1) a percentage of the Medicare fee schedule; 2) a comparable schedule if the service is not on the Medicare fee schedule; or 3) a commercially reasonable rate for such service.

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

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

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 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. 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.

$10 per convenience clinic visit; $30 per office visit; $30 per urgent care visit; nothing for Virtuwell evisits 

(Applies to printed brochure only)

Nothing

(Applies to printed brochure only)

$500 annual copayment for inpatient & outpatient combined, then 20% of charges

(Applies to printed brochure only)

$150 per emergency room visit; $30 per office or urgent care center visit

(Applies to printed brochure only)

Regular cost sharing

(Applies to printed brochure only)

$5 for low cost generic preferred drugs; $25 for high cost generic preferred drugs; $55 for brand-name preferred drugs; $90 for non-preferred drugs; 20% for specialty drugs

(Applies to printed brochure only)

$10 for low cost generic preferred drugs; $50 for high cost generic preferred drugs; $110 for brand-name preferred drugs; $180 for non-preferred drugs

(Applies to printed brochure only)

20% of charges, if Plan dentist provides care

30% of charges when provided by Out of Network dentist if the injuries require immediate treatment.

(Applies to printed brochure only)

Nothing for preventive care

(Applies to printed brochure only)

Self Only: Nothing after $6,500; Self Plus One: Nothing after $13,000, subject to a maximum of $9,100 per enrollee; Self and Family: Nothing after $13,000, subject to a maximum of $9,100 per enrollee

(Applies to printed brochure only)

CareLine® service, Nurse Navigator, Behavioral Health Personalized Assistance Line, special phone lines for deaf and hearing impaired, personalized member page on website, health improvement programs

(Applies to printed brochure only)

In Network: $0 for 5 visits, then 20% after deductible
Out of Network: 40% after deductible

(Applies to printed brochure only)

Nothing

(Applies to printed brochure only)

In Network: 20% after deductible
Out of Network: 40% after deductible

(Applies to printed brochure only)

20% after in-network deductible

(Applies to printed brochure only)

Regular cost sharing

(Applies to printed brochure only)

(Applies to printed brochure only)

In Network copayments: $10 for low cost generic preferred drugs; $50 for high cost generic preferred drugs; $120 for brand name preferred drugs after deductible; $300 for non-preferred drugs after deductible. Out of Network: all charges.

(Applies to printed brochure only)

In Network: 20% after deductible. Out of Network: 30% after deductible.

(Applies to printed brochure only)

Nothing for preventive care

(Applies to printed brochure only)

In Network: Self Only: Nothing after $7,000; Self Plus One: Nothing after $14,000, subject to a maximum of $9,100 per enrollee; Self and Family: Nothing after $14,000, subject to a maximum of $9,100 per enrollee; Out of Network: no maximum

(Applies to printed brochure only)

CareLine® service, Nurse Navigator, Behavioral Health Personalized Assistance Line, special phone lines for deaf and hearing impaired, personalized member page on website, health improvement programs

(Applies to printed brochure only)