Page numbers referenced within this brochure apply only to the printed brochure

Independent Health Association, Inc.

www.independenthealth.com
Customer Service 716-631-8701 or 800-501-3439

2021


IMPORTANT:
  • Rates
  • Changes for 2021
  • Summary of Benefits
  • Accreditations
Health Maintenance Organization (High and Standard Option) with a Point of Service Product and a High Deductible Health Plan Option (iDirect)

This plan’s health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. See page 9 for details.  This plan is accredited.  See page 14 for details.

Serving:  Western New York

Enrollment in this plan is limited. You must live or work in our geographic service area to enroll. See page 17 for requirements.

Enrollment codes for this Plan:
QA1 High Option - Self Only
QA3 High Option - Self Plus One
QA2 High Option - Self and Family 

C54 Standard Option - Self Only
C56 Standard Option - Self Plus One
C55 Standard Option - Self and Family

QA4 High Deductible Health Plan (HDHP) - Self Only
QA6 High Deductible Health Plan (HDHP) - Self Plus One
QA5 High Deductible Health Plan (HDHP) - Self and Family

FEHB LogoOPM Logo
RI73-103








Important Notice

Important Notice from Independent Health About
Our Prescription Drug Coverage and Medicare

The Office of Personnel Management (OPM) has determined that Independent Health's HMO prescription drug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all plan participants and is considered Creditable Coverage. This means you do not need to enroll in Medicare Part D and pay extra for prescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as long as you keep your FEHB coverage.

However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate   benefits with Medicare.

Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program.

Please be advised

If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that is at least as good as Medicare’s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1 percent per month for every month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug coverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the next Annual Coordinated Election Period (October 15 through December 7) to enroll in Medicare Part D.

Medicare’s Low Income Benefits

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA) online at www.socialsecurity.gov, or call the SSA at 800-772-1213, (TTY:  800-325-0778). 

You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places:

  • Visit www.medicare.gov for personalized help.
  • Call 800-MEDICARE 800-633-4227, TTY 877-486-2048.



Table of Contents

(Page numbers solely appear in the printed brochure)

Table of Content



Introduction

This brochure describes the benefits of Independent Health under contract (CS 1933) with the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. Customer Service may be reached at 716-631-8701 or 800-501-3439 or through our website: www.independenthealth.com. The address for Independent Health’s administrative offices is:

Independent Health Association, Inc.
511 Farber Lakes Drive
Buffalo, NY 14221

This brochure is the official statement of benefits. No verbal statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure.  If you are enrolled in Self Plus One or Self and Family coverage, each eligible family member is also entitled to these benefits.  You do not have a right to benefits that were available before January 1, 2021, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2021, and changes are summarized on page 18. Rates are shown at the end of this brochure.




Plain Language

All FEHB brochures are written in plain language to make them easy to understand. Here are some examples,

  • Except for necessary technical terms, we use common words. For instance, “you” means the enrollee and each covered family member, “we” means Independent Health Association Inc. (referred to as Independent Health).
  • We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States Office of Personnel Management. If we use others, we tell you what they mean.
  • Our brochure and other FEHB plans’ brochures have the same format and similar descriptions to help you compare plans.



Stop Health Care Fraud!

Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits Program premium.

OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud - Here are some things that you can do to prevent fraud:

  • Do not give your plan identification (ID) number over the phone or to people you do not know, except for your health care providers, authorized health benefits plan, or OPM representative.
  • Let only the appropriate medical professionals review your medical record or recommend services.
  • Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
  • Carefully review explanations of benefits (EOBs) statements that you receive from us.
  • Periodically review your claim history for accuracy to ensure we have not been billed for services you did not receive.
  • Do not ask your doctor to make false entries on certificates, bills, or records in order to get us to pay for an item or service.
  • If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:

        - Call the provider and ask for an explanation. There may be an error.

        - If the provider does not resolve the matter, call us at 716-631-8701 or 800-501-3439 and explain the situation.

        - If we do not resolve the issue:

CALL --THE HEALTH CARE FRAUD HOTLINE

877-499-7295

OR go to www.opm.gov/our-inspector-general/hotline-to-report-fraud-waste-or-abuse/complaint-form/

The online reporting form is the desired method of reporting fraud in order to ensure accuracy, and a quicker response time.

You can also write to:

United States Office of Personnel Management

Office of the Inspector General Fraud Hotline

1900 E Street NW Room 6400

Washington, DC 20415-1100

  • Do not maintain as a family member on your policy:
    • Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise)
    • Your child age 26 or over (unless he/she is disabled and incapable of self-support prior to age 26)

A carrier may request than an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

  • If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary Continuation of Coverage (TCC).
  • Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud and your agency may take action against you. Examples of fraud include, falsifying a claim to obtain FEHB benefits, trying to or obtaining services or coverage for yourself or for someone if you are not eligible for coverage, or enrolling in the Plan when you are no longer eligible.
  • 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 by your provider for services received. 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 is no longer eligible to use your health insurance coverage.



Discrimination is Against the Law

Independent Health complies with all applicable Federal civil rights laws, including Title VII of the Civil Rights Act of 1964. 

If a carrier is a covered entity, its members may file a 1557 complaint with HHS Office of Civil Rights, OPM, or FEHB Program carriers. For purposes of filing a complaint with OPM, covered carriers should use the following:

You can also file a civil rights complaint with the Office of Personnel Management by mail:

Office of Personnel Management

Healthcare and Insurance

Federal Employee Insurance Operations

Attention: Assistant Director, FEIO

1900 E Street NW, Suite 3400-S

Washington, D.C. 20415-3610

 




Preventing Medical Mistakes

Medical mistakes continue to be a significant cause of preventable deaths within the United States. While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments. Medical mistakes and their consequences also add significantly to the overall cost of healthcare.  Hospitals and healthcare providers are being held accountable for the quality of care and reduction in medical mistakes by their accrediting bodies.  You can also improve the quality and safety of your own health care and that of your family members by learning more about and understanding your risks.
Take these simple steps:

1. Ask questions if you have doubts or concerns.

  • Ask questions and make sure you understand the answers.
  • Choose a doctor with whom you feel comfortable talking.
  • Take a relative or friend with you to help you take notes, ask questions and understand answers.

2. Keep and bring a list of all the medications you take.

  • Bring the actual medication or give your doctor and pharmacist a list of all the medications and dosage that you take, including non-prescription (over-the-counter) medications and nutritional supplements.
  • Tell your doctor and pharmacist about any drug, food, and other allergies you have, such as to latex.
  • Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your doctor or pharmacist says.
  • Make sure your medication is what the doctor ordered. Ask your pharmacist about the medication if it looks different than you expected.
  • Read the label and patient package insert when you get your medication, including all warnings and instructions
  • Know how to use your medication. Especially note the times and conditions when your medication should and should not be taken.
  • Contact your doctor or pharmacist if you have any questions.
  • Understand both the generic and brand names of your medication. This helps ensure you do not receive double dosing from taking both a generic and a brand. It also helps prevent you from taking a medication to which you are allergic.

3. Get the results of any test or procedure.

  • Ask when and how you will get the results of tests or procedures.  Will it be in person, by phone, mail, through the Plan or Provider portal?
  • Don’t assume the results are fine if you do not get them when expected. Contact your health care provider and ask for results. 
  • Ask what the results mean for your care.

4. Talk to your doctor about which hospital or clinic is best for your health needs.

  • Ask your doctor about which hospital or clinic has the best care and results for your condition if you have more than one hospital or clinic to choose from to get the health care you need.
  • Be sure you understand the instructions you get about follow-up care when you leave the hospital or clinic.

5.   Make sure you understand what will happen if you need surgery.

  • Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.
  • Ask your doctor, “Who will manage my care when I am in the hospital?”
  • Ask your surgeon:
    • "Exactly what will you be doing?"
    • "About how long will it take?"
    • "What will happen after surgery?"
    • "How can I expect to feel during recovery?"
  • Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reactions to anesthesia, and any medications or nutritional supplements you are taking.

Patient Safety Links

For more information on patient safety, please visit:

  • www.jointcommission.org/speakup.aspx.  The Joint Commission’s Speak Up™ patient safety program.
  • www.jointcommission.org/topics/patient_safety.aspx.  The Joint Commission helps health care organizations to improve the quality and safety of the care they deliver.
  • www.ahrq.gov/patients-consumers/.  The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality health care providers and improve the quality of care you receive.
  • www.bemedwise.org.  The National Council on Patient Information and Education is dedicated to improving communication about the safe, appropriate use of medication.
  • www.leapfroggroup.org.  The Leapfrog Group is active in promoting safe practices in hospital care.
  • www.ahqa.org.  The American Health Quality Association represents organizations and health care professionals working to improve patient safety.

Preventable Healthcare Acquired Conditions (“Never Events”)

When you enter the hospital for treatment of one medical problem, you do not expect to leave with additional injuries, infections, or other serious conditions that occur during the course of your stay. Although some of these complications may not be avoidable, patients do suffer from injuries or illnesses that could have been prevented if doctors or the hospital had taken proper precautions. Errors in medical care that are clearly identifiable, preventable and serious in their consequences for patients, can indicate a significant problem in the safety and credibility of a health care facility.  These conditions and errors are sometimes called “Never Events” or “Serious Reportable Events.”

We have a benefit payment policy that encourages hospitals to reduce the likelihood of hospital-acquired conditions such as certain infections, severe bedsores, and fractures, and to reduce medical errors that should never happen.  When such an event occurs, neither you nor your FEHB plan will incur costs to correct the medical error. 




FEHB Facts

Coverage information




TermDefinition
  • No pre-existing condition limitation

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

  • Minimum essential coverage (MEC)

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

  • Minimum value standard

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

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

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

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

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

  • Types of coverage available for you and your family

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

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event.  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.

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.

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 QLE's, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events  If you need assistance, please contact your employing agency, Tribal Benefits Office, personnel/payroll office, or retirement office.  

  • Family member coverage

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

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

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

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

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

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

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

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

  • Children’s Equity Act

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

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

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

  • When benefits and premiums start

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

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

  • When you retire

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




When you lose benefits




TermDefinition
  • When FEHB coverage ends

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

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

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

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC), or a conversion policy (a non-FEHB individual policy.)

  • Upon divorce

If you are divorced from a Federal employee, Tribal employee, or an annuitant, you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices. You an 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.

  • Temporary Continuation of Coverage (TCC)

If you leave Federal service, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). The Patient Protection and Affordable Care Act (ACA) did not eliminate TCC or change the TCC rates. 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, if you are a covered dependent 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 new kind of tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premiums, 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.

  • Converting to individual 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 or 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 716-631-8701 or visit our website at www.independenthealth.com.

  • Health Insurance Marketplace

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.




Section 1. How This Plan Works

This Plan is a health maintenance organization (HMO).  OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. Independent Health holds the following accreditation: 

  • National Committee for Quality Assurance

To learn more about this plan's accreditation, please visit the following website: www.ncqa.org

We offer three types of coverage. You may enroll in our High or Standard Health Maintenance Organization (HMO) coverage with a Point of Service (POS) or you may enroll in our High Deductible Health Plan (HDHP) with a health savings account/health reimbursement arrangement.

General features of our High and Standard Options

The enrollment codes for our High Option HMO with POS coverage are QA1 (Self Only), QA3 (Self Plus One) and QA2 (Self and Family). The enrollment codes for our Standard Option HMO with POS coverage are C54 (Self Only), C56 (Self Plus One) and C55 (Self and Family). For the highest level of coverage (In-Network benefits), we require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services.  Contact us for a copy of our most recent provider directory.

HMO coverage emphasizes preventive care such as physical exams, well-baby care, and immunizations. In-Network preventive care services are covered in full. Please refer to Section 5(a) for a list of In-Network preventive care services. Our providers follow generally accepted medical practice when prescribing any course of treatment.

For the High & Standard Options, there is no annual In-Network deductible.  Your annual In-Network Out-of-Pocket expenses for covered In-Network medical and prescription drug services, including deductibles, co-payments, and coinsurance, cannot exceed $8,550 for Self Only enrollment, or $17,100 for Self Plus One or Self and Family enrollment. Member liability for routine vision services and routine dental do not apply to the Out-of-Pocket maximum. See below for information on out-of-network Point of Service (POS) benefits.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the co-payments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may have to submit claim forms.

Your decision to join an HMO should be because you prefer the plan’s benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will be available and/or remain under contract with us.

We have Point of Service (POS) benefits

Our HMO options offer POS benefits. This means you can receive covered services from a non-participating provider. However, out-of-network benefits may have higher Out-of-Pocket costs than In-Network benefits. For more information regarding this benefit, see HMO Benefits Section 5(i) Point of Service Benefits.

How we pay providers

We contract with individual physicians, other health care providers, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles and non-covered services and supplies).

Under our POS, you will be subject to an annual deductible and coinsurance. You will owe all balances for covered services in excess of our plan allowance. For more information regarding this benefit, see HMO Benefits Section 5(i) Point of Service Benefits.

General features of our High Deductible Health Plan (HDHP)

The enrollment codes for our HDHP are QA4 (Self Only), QA6 (Self Plus One) and QA5 (Self and Family). We call our HDHP coverage, iDirect. Our HDHP is a consumer driven health plan with separate medical and dental funds that help you pay for covered medical and dental expenses. This health plan product combines HDHP health care coverage with a tax-advantaged program to help you build savings for future medical needs. You may seek covered services from the iDirect network of participating providers or you may use non-participating or out-of-network providers at a higher member liability.

For the High Deductible Option your annual In-Network Out-of-Pocket expenses for covered In-Network services, including deductibles, co-payments, and coinsurance, cannot exceed $6,950 for Self Only enrollment, or $13,900 for Self Plus One or Self and Family enrollment. Your annual Out-of-Pocket expenses for covered out-of-network services, including deductibles, co-payments, and coinsurance, cannot exceed $10,000 for Self Only enrollment, or $20,000 for Self Plus One or Self and Family enrollment. Member liability for routine vision services, routine dental, and penalties for failure to preauthorize do not apply to the Out-of-Pocket maximum.

Preventive care services

A complete list of the preventive services is available on our website at www.independenthealth.com, or will be mailed to you upon request. You may also request the list by calling the Member Services number on your identification card.

Annual deductible

For the High Deductible Option, the annual In-Network deductible is $2,000 for Self Only or $4,000 for Self Plus One or Self and Family.  The annual deductible must be met before Plan benefits are paid for care other than preventive care services.

HDHP Funds

Two different funds are available to offset Out-of-Pocket medical costs under the HDHP Plan – a Health Savings Account (HSA) or a Health Reimbursement Account (HRA). The Plan will contribute funds once you have verified your HSA/HRA eligibility. The funds are passed from FEHB to the plan, who in turn, will pass the funds directly into your HSA or HRA depending on your qualifications; this process is referred to as a premium pass-through. Forms will be provided to you to complete for this verification and must be returned to us for contributions to begin.

  • Annual Self Only pass-through contribution: $999.96
  • Annual Self Plus One pass-through contribution: $1,999.92
  • Annual Family fund pass-through contribution: $1,999.92

You may use the money in your HSA or HRA to pay all or a portion of the annual deductible, copayments, coinsurance, or other Out-of-Pocket costs that meet the IRS definition of a qualified medical expense.

Health Savings Account (HSA)

You are eligible for an HSA if you are enrolled in an HDHP, not covered by any other health plan that is not an HDHP (including a spouse’s health plan, excluding specific injury insurance and accident, disability, dental care, vision care, or long-term coverage), not enrolled in Medicare, not have received VA (except for veterans with a service-connected disability) or Indian Health Service (IHS) benefits within the last three months, not covered by your own or your spouse's flexible spending account (FSA), and are not claimed as a dependent on someone else’s tax return.

  • You may use the money in your HSA to pay all or a portion of the annual deductible, copayments, coinsurance, or other Out-of-Pocket costs that meet the IRS definition of a qualified medical expense.
  • Distributions from your HSA are tax-free for qualified medical expenses for you, your spouse, and your dependents, even if they are not covered by a HDHP.
  • You may withdraw money from your HSA for items other than qualified medical expenses, but it will be subject to income tax and, if you are under 65 years old, an additional 20% penalty tax on the amount withdrawn.
  • For each month that you are enrolled in an HDHP and eligible for an HSA, the HDHP will pass through (contribute) a portion of the health plan premium to your HSA.  In addition, you (the account holder) may contribute your own money to your HSA up to an allowable amount determined by IRS rules.  Your HSA dollars earn tax-free interest.
  • You may allow the contributions in your HSA to grow over time, like a savings account. The HSA is portable – you may take the HSA with you if you leave the Federal government or switch to another plan.

Health Reimbursement Arrangement (HRA)

If you are not eligible for an HSA, or become ineligible to continue an HSA, you are eligible for a Health Reimbursement Arrangement (HRA). Although an HRA is similar to an HSA, there are major differences.

  • An HRA does not earn interest.
  • An HRA is not portable if you leave the Federal government or switch to another plan.

Catastrophic protection

We protect you against catastrophic Out-of-Pocket expenses for covered services.  The IRS limits annual Out-of-Pocket expenses for covered services, including deductibles and copayments, to no more than $7,000 for Self Only enrollment, and $14,000 for a Self Plus One or Self and Family.  The Out-of-Pocket limit for this Plan may differ from the IRS limit, but cannot exceed that amount.

Health Education Resources and Accounts Management Tools

Key additional features of iDirect are the tools we provide to help you manage your health, monitor your claims and manage your money. Our decision support programs provide the information you need to take greater control of your healthcare cost management.

The Health Management programs include:

  • Health risk appraisal
  • Health wellness programs
  • Healthcare options and alternatives
  • Health coaching
  • In-depth health information and advice
  • The latest news from Independent Health that impacts your health
  • Calculators to measure personal statistics
  • Tools to help manage your costs for medical and pharmacy
  • Information on network providers
  • Information on hospital quality
  • Information on approximate cost of specific health care services in your area

An HDHP with an HSA or HRA is designed to give greater flexibility and discretion over how you use your health care benefits. You decide how to utilize your plan coverage and you decide how to spend the dollars in your HSA or HRA.

Your rights and responsibilities

OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, our providers and our facilities. OPM’s FEHB website (www.opm.gov/healthcare-insurance) lists the specific types of information that we must make available to you. Some of the required information is listed below.

  • Independent Health Association Inc., incorporated in March 1977, is a not-for-profit health maintenance organization licensed under Article 44 of the New York Public Health Law.
  • Independent Health Association Inc’s wholly owned subsidiary, Independent Health Benefit Corporation was incorporated in June 1995 and is licensed under Article 43 of the New York State Insurance Law.
  • Independent Health Association Inc. and its subsidiaries and affiliates are in compliance with all applicable state and federal laws.
  • We also have accreditation from the National Committee for Quality Assurance (NCQA).

You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan.  You can view the complete list of these rights and responsibilities by visiting our website at www.independenthealth.com.   You can also contact us to request that we mail a copy to you.

If you would like more information, call Independent Health at 716-631-5392 or 800-453-1910, or write to Independent Health, Sales Department, 511 Farber Lakes Drive, Buffalo, NY 14221. You may also visit our website at www.independenthealth.com.

By law, you have the right to access your protected health information (PHI).  For more information regarding access to PHI, visit our website at  www.independenthealth.com to obtain our Notice of Privacy Practices. You can also contact us to request that we mail you a copy of that Notice.

Your medical and claims records are confidential

We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.

Service Area

To enroll in this Plan, you must live in or work in our service area. This is where our providers practice. Our service area includes the following counties: Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans and Wyoming.

Under the HMO benefits, you must get your care from providers who contract with us. If you or a covered family member moves outside our service area, you can enroll in another plan. You do not have to wait until Open Season to change plans. Contact your employing or retirement office. If you receive care outside our service area, we will pay only for emergency or urgent care benefits, as described on page 61. We will not pay for any other health care services out of our service area unless it is an emergency, urgent care service or services which have prior plan approval.

Under the POS benefits you may receive care from a non-Plan provider and we will provide benefits for covered services as described in Section 5(i).

Under the HDHP benefit you may receive care from Plan and non-Plan providers as described in Section 5 HDHP. If you or a covered family member moves outside our service area, you can enroll in another plan.




Section 2. Changes for 2021

Do not rely only on these change descriptions; this Section is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change benefits.

Changes to our High, Standard and HDHP Options 

Changes to preauthorization requirements (See pages 23-25) :

Preauthorization is now required on the following:

CAR-T-Cell Therapy
Cochlear implants
Hyperbaric Oxygen Therapy (Systemic and Topical)
Lutathera
Uvulopalatopharyngoplasty (UPPP)
Total Artificial Heart
Transcatheter Aortic Valve Replacement (TAVR)
Varicose Vein Procedures
Wireless Capsule Endoscopy (WCE)
Continuous glucose monitoring devices, short term-long term CGM now done in pharmacy
Total electric Hospital Beds
Substance use inpatient admission except for Independent Health participating providers which are New York State Office of Addiction Services and Support credentialed facilities
Residential Treatment except inpatient substance use admissions to Independent Health contracted, New York State Office of Addiction Services and Support credentialed facilities

Preauthorization is no longer required on the following:

Cardiac Arrhythmia Monitoring
Hearing Aids
Light Boxes
Medical Supplies excluding ostomy
Continuous glucose monitoring devices, short term-long
Hospital beds
Substance use inpatient admission except for Independent Health participating providers which are New York State Office of Alcoholism and Substance Abuse Services credentialed facilities
Residential Treatment except inpatient substance use admissions to Independent Health contracted, New York State Office of Alcoholism and Substance Abuse Services credentialed facilities

Prescription Drugs:

  • Split Fill Program - To be more cost effective and reduce waste, we are adding a split fill dispensing program for prescription drugs. The therapeutic drug classes or prescription drugs included in this program are mental/neurological disorders and oncology. (See pages 65 and 115 for complete details)
  • Substance Use Disorder prescriptions - We are removing the "5-day emergency supply" requirement on Substance Use Disorder prescriptions to allow for a full 30-day supply.
  • Contraceptives - We are removing the first fill requirement of a 3-month supply of contraceptives before allowing a 12-month supply to now allow for a 12-month supply at the first fill. 
  • HIV PrEP medications - HIV PrEP medications will now be considered preventive and no member cost share will apply.  The deductible will still apply on the HDHP option.  Previously, there was a 35% coinsurance applied per 30-day supply (subject to the deductible for the HDHP option).  (See pages 67 and 118)
  • Half Tablet Program - In alignment with FDA recommendations that splitting most tablets is not efficacious, we are removing the Half Tablet Program.

Telemedicine (Teladoc) - We are adding a copayment for telemedicine (Teladoc) visits as follows:

  • High - Medical or Behavioral Health: $25 copayment (See page 33)
  • Standard - Medical or Behavioral Health: $30 copayment (See page 33) 
  • HDHP (subject to the deductible) - Medical visit: $20 copayment. Behavioral Health visit: No change, remains a $0 copayment (See page 91)

Physical, Occupational and Speech Therapy (Autism Spectrum Disorder) - We will no longer count visit limits for Physical, Occupational and Speech Therapy when autism is the primary diagnosis. (See pages 41-42 and 95-96)  

Changes to our High Option Plan Only

In-Network Out-of-Pocket Maximums  are increasing as follows:

  • High Option - $8,550 (Self Only), $17,100 (Self Plus One and Self and Family). (See pages 14, 28, 145-146)

Radiology (Routine and Advanced) - The copayment for radiology procedures will increase as follows: Routine Radiology - $40 copayment per visit (plus applicable office visit copayment) for procedures such as routine X-rays and ultrasounds.  Advanced Radiology - $75 copayment per visit (plus applicable office visit copayment) (with a $750 maximum per calendar year) for procedures such as CT scans, MRI/MRA, PET scans and myocardial perfusion imaging. (See pages 33-34)

Autism Spectrum Disorder (Applied Behavioral Analysis office visits & Assistive Communication Devices) - Your copayment will now match the outpatient behavioral health copayment of $25 copayment per office visit. (See page 41-42)

Usual, Customary and Reasonable Rate (UCR) - The allowed amount for non-participating providers will now match the Fair Health Rate of 80th percentile.  (See pages 26 and 72)

Changes to our Standard Option Plan Only

In-Network Out-of-Pocket Maximums are increasing as follows:

  • Standard Option - $8,550 (Self Only), $17,100 (Self Plus One and Self and Family). (See pages 14, 28 and 147)

Autism Spectrum Disorder (Applied Behavioral Analysis office visits & Assistive Communication Devices) - Your copayment will now match the outpatient behavioral health copayment of $30 copayment per office visit. (See page 41-42)

Changes to our HDHP Option Plan Only

In-Network Out-of-Pocket Maximums are increasing as follows:

  • HDHP Option - $6,950 (Self Only), $13,900 (Self Plus One and Self and Family). (See pages 15, 29, 88 and 147) 

Prescription Drugs:  

  • Preventive medications - We are removing the deductible from the following drug categories: ACE inhibitors, Anti-resorptive therapy medications, Beta-blockers, Oral agents, Selective Serotonin Reuptake Inhibitors (SSRI's) and Statins (for those under age 40 and over age 75). (See page 116)

Inpatient Facility - The copayment for inpatient facility will be increasing to $1,000 copayment per admission (subject to the deductible).  (See page 107, 113, 135 and 146) 

Autism Spectrum Disorder (Applied Behavioral Analysis office visits & Assistive Communication Devices) - Your copayment will now match the outpatient behavioral health copayment of $0 copayment per office visit (subject to the deductible). (See page 95-96)

Usual, Customary and Reasonable Rate (UCR) -  The allowed amount for non-participating providers will now match the Fair Health Rate of 80th percentile. (See page 26)

Premium Pass-through - We are increasing the Self Plus One premium pass-through to $166.66, to double the Self Only benefit ($83.33) and match the Self and Family pass through benefit.  (See pages 79-82) 

Health Savings Account Administrative Fee - We are removing the $2.00 per month health maintenance fee charged by the fiduciary.   (See page 79)




Section 3. How You Get Care

TermDefinition

Identification cards

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 our Member Services Department at 716-631-8701 or 800-501-3439, or visit our website at www.independenthealth.com.

The address for Independent Health's administrative offices is:

Independent Health Association, Inc.

511 Farber Lakes Drive

Buffalo, NY 14221

Where you get covered care

You get care from “Plan providers” and “Plan facilities”. If you enroll in an HMO option and use the POS program or enroll in the HDHP program, you can also get care from non-Plan providers.

Plan providers

Plan providers are physicians and other health care 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 provider directory, which we update periodically. The list is also on our website.

Plan facilities

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The list is also on our website.

What you must do to get covered care

It depends on the type of plan in which you are enrolled. Our provider directory lists primary care and specialty care physicians with their locations and phone numbers. We update the directories on a regular basis. You may request one by calling our Member Services Department at 716-631-8701 or 800-501-3439 or view on our website at www.independenthealth.com.

Primary care

HMO (High, Standard and HDHP Options)

You are required to select a primary care physician.  You may add or change your PCP by calling Independent Health at the telephone number listed on your ID card or on our website at www.independenthealth.com.  This can be done at any time.

Your primary care physician can be any physician designated by the Plan to be a primary care physician, i.e., general practitioner, internist, family practitioner, etc. Your primary care physician is responsible for coordinating all of your health care as well as helping you maintain good health through preventive care.

Specialty care

Independent Health offers a wide choice of participating specialists. Your primary care physician will refer you when you need to see a specialist. However, a referral is not required. All you need to do is contact the specialist's office to schedule an appointment.

If you have started treatment with a specialist and wish to change to another specialist, you should contact your primary care physician to keep him or her aware of this change in medical care.

Here are some other things you should know about specialty care: 

  • If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a treatment plan and recommend a specialist. Your primary care physician will use our criteria when creating your treatment plan (the physician may have to get our authorization or approval beforehand).
  • If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he or she recommends that you see a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you may use your POS benefit.
  • If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else, up to a maximum of 90 days.
  • If you have a chronic and disabling condition and lose access to your specialist because we:
    • terminate our contract with your specialist for other than cause;  
    • drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program plan; or 
    • reduce our Service Area and you enroll in another FEHB plan;

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

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

Hospital care

High, Standard and HDHP Options - Your Plan 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. It is your responsibility to preauthorize any Out-of-Network inpatient admissions except for maternity admissions and medical emergencies.

If you are hospitalized when your enrollment begins

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our Member Services Department immediately at 716-631-8701, or 800-501-3439. 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.

You need prior Plan approval for certain services

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

You must get prior approval for certain services. Failure to do so will result in a minimum 50% penalty of our allowed amount up to a maximum of $500 for the High, Standard and HDHP Options.

Inpatient Hospital Admissions

You must obtain preauthorization from us for all Out-of-Network inpatient services (except maternity admissions and medical emergencies) and certain Out-of-Network outpatient services listed below under Procedures that Require Member preauthorization that you receive from a facility. Your physician will make necessary hospital arrangement and supervise your care. You must contact our Member Services Department at 716-631-8701 or 800-501-3439 to obtain preauthorization from us before the service is rendered.

Other Services

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

We are committed to working with your doctor to ensure you receive the best possible medical care in the most appropriate medical setting. Because some medical conditions can be treated in a variety of ways, our Medical Director has developed a list of procedures that we must approve before they are performed. Your doctor will work with us to obtain our prior approval and you do not have to do anything.

Note: Member preauthorization is applicable for Out-of-Network services listed below.

  • Procedures that require member preauthorization 

You are ultimately responsible for obtaining our prior approval before obtaining certain out-of-network services. If you do not obtain preauthorization from us, we will apply a penalty to the covered charges or we may not cover the service at all in the event that we determine it is not medically necessary. You must obtain preauthorization from us for the following out-of-network services:

  • Applied Behavior Analysis (ABA) for Diagnosis and Treatment of Autism Spectrum Disorder
  • Assistive Communication Devices (ACD) for Autism Spectrum Disorder
  • CAR-T-Cell Therapy
  • Clinical Trials
  • Continuous glucose monitoring devices, short term-long term CGM now done in pharmacy
  • Cochlear Implants
  • Durable Medical Equipment
    • Customized items/equipment
    • Electrical Stimulators
    • Total Electric Hospital Beds
    • Jaw Motion Rehabilitation system and accessories
    • Lift equipment/devices
    • Negative Pressure Wound Therapy (Wound Vac)
    • Non-standard wheel chair accessories
    • Oral appliances for sleep apnea
    • Wearable Defibrillator Vests
  • Elective hospital/facility admissions to include but not limited to:
    • Admissions for transplants
    • Inpatient rehabilitation and habilitation admissions (Physical, Speech and Occupational Therapy)
    • Mental Health admissions except for members under age 18 at Independent Health participating hospitals licensed by the Office of Mental Health (OMH)
    • Medical admissions 
    • Skilled nursing facility admission
    • Substance Use Inpatient Admission - except for Independent Health Participating Providers which are New York State Office of Addiction Services and Supports Credentialed Facilities
  • Extracorporeal Shock Wave Therapy (ECSWT) for Chronic Plantar Fasciitis
  • Genetic Testing 
  • Gender Dysphoria-Surgical Treatment
  • Home Births
  • Home Health Care Services including Home Infusion Nursing Visits
  • Hyperbaric Oxygen Therapy (Systemic and Topical)
  • Lutathera
  • Non-Emergent Ambulance, Planned Transfer
  • Partial Hospitalization for Mental Health Services
  • Partial Hospitalization for Substance Use Disorder
  • Prosthetic Devices External
  • Electronic Artificial Limbs
  • Custom Orthopedic Braces
  • Residential Treatment except inpatient substance use admissions to Independent Health contracted, New York State Office of Addiction Services and Supports credentialed facilities
  • Surgical Procedures:
    • Back and Neck Surgery
    • Bariatric Surgery (weight loss surgery)
    • Breast Surgery:   Implant Removal, Non Cancer Diagnosis Breast Reduction, Breast Reduction Mammoplasty (male and female)
    • Cosmetic Procedures (medically necessary)
    • Oral Surgeries
    • Reconstructive Procedures
    • Septorhinoplasty & Rhinoplasty
    • Temporomandibular (TMJ) Joint Disorder
    • Uvulopalatopharyngoplasty (UPPP)
  • Total Artificial Heart
  • Transcatheter Aortic Valve Replacement (TAVR)
  • Transcranial Magnetic Stimulation
  • Transplant Procedures
  • Varicose Vein Procedures
  • Wireless Capsule Endoscopy (WCE)
How to preauthorize an admission or other services

First, you, or your representative, must call us at 716-631-8701 or 800-501-3439 before admission or services requiring preauthorization are rendered. Your provider may call on your behalf.

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 services or surgery;
  • name and phone number of admitting physician;
  • name of provider; and
  • number of days requested for hospital stay (if applicable)
  • Non-urgent care claims

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

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

  • Urgent care claims

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

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

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

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 800-501-3439. You may also call OPM's Health Insurance 3 at 202 606-0755 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 800-501-3439. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

  • Concurrent care claims

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

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

  • The Federal Flexible Spending Account Program - FSAFEDS
  • Health Care FSA (HCFSA) - Reimburses you for eligible Out-of-Pocket health care expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you and your tax dependents, including adult children (through the end of the calendar year in which they turn 26).
  • FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans.  This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible Out-of-Pocket expenses based on the claim information it receives from your plan.
  • Emergency inpatient admission
If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must telephone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital.
  • Maternity care

Complete Maternity (obstetric) care is covered for In-Network prenatal delivery and postnatal care.  

  • If your treatment needs to be extended

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

What happens when you do not follow the preauthorization rules when using non-network providers 

You are ultimately responsible for requesting preauthorization from us for certain out-of-network covered services. Failure to obtain preauthorization will result in a drastic reduction of benefits or a complete denial of coverage. You will be responsible for 50% of our allowed amount as a penalty up to a maximum of $500 on the High, Standard and HDHP Options. We will reduce our allowance by 50% before calculating our payment. Under High, Standard and HDHP Options, we base our allowance on the lesser of the provider’s or facility’s charges, the negotiated rate, or the usual, customary and reasonable (UCR) charge at the 80th percentile.  The additional 50% that you must pay is a penalty. It is not reduced by the POS or HDHP coinsurance, Out-of-Pocket Maximum, or annual deductible. You must pay the balance after our payment up to the facility’s charges.

After receiving your request for preauthorization, our Medical Director will make the determination as to whether a service is medically necessary within three (3) business days from the date we receive the preauthorization request and all necessary documentation for review. We strongly recommend that you contact us to confirm whether or not a service is covered and requires preauthorization before you have the service.

Circumstances beyond our control

Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care.

If you disagree with our pre-service claim decision

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

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

  • To reconsider a non-urgent care claim

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

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

1. Preauthorize your hospital stay or, if applicable, arrange for the health care provider to give you the care or grant your request for prior approval for a service, drug, or supply; or

2. Ask you or your provider for more information.

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

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

3. Write to you and maintain our denial.

  • To reconsider an urgent care claim

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

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

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



Section 4. Your Cost for Covered Services

This is what you will pay Out-of-Pocket for covered care:




TermDefinition

Cost-sharing

Cost-sharing is the general term used to refer to your Out-of-Pocket costs (e.g., deductible, coinsurance, and copayments) for the covered care you receive.

Copayments

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

Example: Under our High Option benefits, you pay a copayment of $25 per office visit when you see a primary care physician who is part of our network.

Deductible

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.  You do not have an In-Network deductible on the High or Standard options. Annual deductibles apply to POS benefits (see HMO Section 5(i) Point of Service Benefits). If you are enrolled in the HDHP option, an annual combined deductible is applicable:

  •  Under our HDHP coverage, the annual combined deductible is $2,000 under Self Only and $4,000 under Self Plus One or Self and Family enrollment. The deductible must be satisfied in full by one or more family members before we will begin paying benefits. 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 for 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 prior plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.

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

Coinsurance

Coinsurance is the percentage of our negotiated fee that you must pay for certain types of care. Under the POS benefits and the HDHP plan, coinsurance does not begin until you have met your calendar year deductible.

Differences between our Plan allowances and the bill

For out-of-network services, you pay the difference between the non-Plan provider’s charges and the amount that we pay for a covered service in addition to the deductible amount applied, copayment, coinsurance, and/or any non-covered service.  Additional expenses may also result from charges that exceed a benefit maximum.  To protect you from surprise billing, non-Plan provider services when rendered at a Plan participating hospital or ambulatory surgical center, will be treated as an In-Network benefit.

Your catastrophic protection Out-of-Pocket Maximum

For the High and Standard Options, after your In-Network Out-of-Pocket expenses, (including any applicable deductibles, copayments and coinsurance) total $8,550 for Self Only, or $17,100 for a Self Plus One or Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. 

For Self Plus One or Self and Family, the family must collectively meet $17,100 in total Out-of-Pocket costs but no one individual in the family may exceed $8,550.

However, copayments and coinsurance, if applicable for the following services do not count toward your catastrophic In-Network protection Out-of-Pocket Maximum, and you must continue to pay copayments and coinsurance for these services:

• Dental Discount services 

• Eyeglasses or contact lenses

• Expenses for services and supplies that exceed the stated maximum dollar or day limit

• Expenses from utilizing Out-of-Network providers

For the High Deductible Health Plan (HDHP) Option, after your In-Network Out-of-Pocket expenses (including any applicable deductibles, copayments and coinsurance) total $6,950 for Self Only, or $13,900 for a Self Plus One or Self and Family enrollment in any calendar year, you do not have to pay any more for covered services.  Reference section 5 High Deductible Health Plan Benefits Overview for details.

For Self Plus One or Self and Family, the Out-of-Pocket Maximum of $13,900 must be satisfied in full by one or more family members before you do not have to pay any more for covered services.

Carryover

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

Note:  If you change options in this Plan during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic Out-of-Pocket limit of your old option to the catastrophic protection limit of your new option (if applicable).

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



Section 5. HMO (High and Standard Option) Benefits (HMO (High and Standard Option))

See page 18 for how our benefits changed this year. This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection.




(Page numbers solely appear in the printed brochure)

Table of Content



Section 5(a). Medical Services and Supplies Provided by Physicians and Other Health Care Professionals (High and Standard Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Plan physicians must provide or arrange your care.
  • A facility copayment applies to services that appear in this section but are performed in an ambulatory surgical center or the outpatient department of a hospital.
  • We do not have a calendar year deductible for services that you receive under the HMO benefits.
  • Please see Section 5(i) for information regarding POS benefits for Out-of-Network services. An annual deductible and coinsurance will apply to covered POS benefits.
  • Your physician must obtain preauthorization for certain services.  You must obtain preauthorization for certain Out-of-Network services.  Please see pages 23-25 for details.
  • If preventive routine screenings are billed with an office visit, the applicable primary copayment or specialist copayment will apply.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.



Benefit Description : Diagnostic and treatment servicesHigh Option (You pay)Standard Option (You pay)

Professional services of physicians

  • In physician's office
  • Office medical consultations
  • Second surgical opinion
  • At home

Primary: $25 copayment per office visit

Specialist: $40 copayment per office visit

Primary: $30 copayment per office visit

Specialist: $50 copayment per office visit

  • In an urgent care center
  • During a hospital stay
  • In a covered skilled nursing facility
  • Advance care planning 
NothingNothing
Benefit Description : Telehealth servicesHigh Option (You pay)Standard Option (You pay)

Telehealth - the use of electronic and communication technologies by a provider to deliver covered services when the member's location is different than the provider's location. 

Note: You may inquire with a provider to see if he/she offers telehealth or contact Member Services at 716-631-8701.

Primary: $25 copayment per office visit

Specialist: $40 copayment per office visit

Primary: $30 copayment per office visit

Specialist: $50 copayment per office visit

Telemedicine program - The telemedicine program is an online video or phone consultation service administered by a unique network of U.S. board-certified physicians who participate in our telemedicine program.   Teladoc physicians use electronic health records to diagnose and treat conditions, including writing prescriptions. The service is intended to provide a solution for non-emergency medical situations and should not be used if you are experiencing a medical emergency. Telemedicine offers you an alternative option to an urgent care facility or when you are unable to obtain services from your primary care physician for many common medical issues including but not limited to cold and flu symptoms, allergies, pink eye, urinary tract infection and respiratory infection.  

Additionally, Teladoc services are available for behavioral health services (i.e. mental health and substance use).

Note: To utilize the telemedicine program visit teladoc.com or call 800-TELADOC (800-835-2362). This service is available 24/7 and may be accessed if traveling throughout most of the United States.

General Medicine: $25 copayment per consultation

Behavioral Health: $25 copayment per consultation

General Medicine: $30 copayment per consultation

Behavioral Health: $30 copayment per consultation

Benefit Description : Lab, X-ray and other diagnostic testsHigh Option (You pay)Standard Option (You pay)

Tests, such as:

  • Blood tests
  • Urinalysis
  • Non-routine pap tests
  • Pathology

NothingNothing

Preventive radiology procedures - for the detection of breast cancer:

  • Ultrasound 
  • MRI
  • Diagnostic mammograms 

Nothing

Nothing

Radiology procedures such as:

  • Routine X-rays
  • Ultrasound

$40 copayment per visit for radiology procedures in addition to any copayment for office services

$40 copayment per visit for radiology procedures in addition to any copayment for office services

Advanced Radiology such as:

  • CT scans
  • MRI/MRA
  • PET scans
  • Myocardial perfusion imaging

Subject to a $750 advanced radiology copayment maximum per calendar year.

$75 copayment per visit for advanced radiology services in addition to any copayment for office services.  

Note: If a member has a routine radiology service and an advanced radiology service on the same day by the same provider, the member will be responsible for a routine radiology copayment and an advanced radiology copayment.

$75 copayment per visit for advanced radiology services an addition to any copayment for office services.

Note: If a member has a routine radiology service and an advanced radiology service on the same day by the same provider, the member will be responsible for a routine radiology copayment and an advanced radiology copayment.

Diagnostic tests, such as:

  • Electrocardiogram and EEG

Primary: $25 copayment per office visit

Specialist: $40 copayment per office visit

Primary: $30 copayment per office visit

Specialist: $50 copayment per office visit

Benefit Description : Preventive care, adultHigh Option (You pay)Standard Option (You pay)

Routine physical examination

  • Once every plan year

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

  • Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV).  For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/
  • Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening.  For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org
  • Individual counseling on prevention and reducing health risks
  • Well woman care such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening to interpersonal and domestic violence.  For a complete list of Well Women preventive care services please visit the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/

Nothing       

Nothing


Routine Prostate Specific Antigen (PSA) test - one annually for men age 50 and older

Nothing for laboratory services

Nothing for laboratory services

Routine well-woman examination

  • Two OB/GYN visits annually

Nothing

Nothing

Routine mammogram - covered for women

NothingNothing

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

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

Nothing

Nothing

Not covered: 

  • Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
  •  Immunizations, boosters, and medications for travel or work-related exposure.
All chargesAll charges
Benefit Description : Preventive care, biometric screeningHigh Option (You pay)Standard Option (You pay)
  • Body mass index
  • Total cholesterol
  • Blood pressure screening
  • Glucose screening

Nothing

Nothing

Benefit Description : Preventive care, childrenHigh Option (You pay)Standard Option (You pay)
  • Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics.  For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
  • Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella.  For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html
  • You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org

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

NothingNothing
Benefit Description : Preventive care, adults and childrenHigh Option (You pay)Standard Option (You pay)

The following additional preventive services are covered in full when rendered by a participating provider:

  • Chlamydia Screening
  • General Health Panel with Basic Metabolic Panel
  • Hemoglobin and Hematocrit
  • HIV Screening
  • HPV Screening
  • Lead Screen in childhood and pregnancy
  • Lipid Panel
  • Periodic Routine Health Examination
  • Rh Screen
  • Rubella Screen

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

Nothing

Nothing

Benefit Description : Maternity careHigh Option (You pay)Standard Option (You pay)

Preventive maternity care limited to:

  • Routine prenatal office visits

Note: The preventive care benefits will not apply to complications of pregnancy.  See Section 5(c) for information on hospitalization.

Complete maternity (obstetrical) care, such as:

  • Prenatal care (excluding diagnostic testing)
  • Screening for gestational diabetes for pregnant women 
  • Delivery
  • Postnatal care
  • Screening for diabetes mellitus after pregnancy

Note: Here are some things to keep in mind:

  • You do not need to preauthorize your vaginal delivery; see pages 36-37 for other circumstances, such as extended stays for your baby.
  • You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.
  • We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment 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. 
  • Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

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

NothingNothing 

Breastfeeding support, supplies and counseling for each birth

Nothing

Nothing

Sonograms

$40 copayment per visit

$40 copayment per visit

Benefit Description : Family planning High Option (You pay)Standard Option (You pay)

Contraceptive counseling on an annual basis

NothingNothing

A range of family planning services, limited to:

  • Voluntary sterilization for women limited to tubal ligation
  • Surgically implanted contraceptives (See Surgical procedures Section 5 (b))
  • Injectable contraceptive drugs (such as Depo Provera)  (see Surgical procedures Section 5(b))
  • Intrauterine devices (IUDs)
  • Diaphragms
  • Genetic testing

Note: Genetic testing is covered based on medical necessity

Note: We cover oral contraceptives and certain contraceptive devices under the prescription drug benefit.

Nothing                Nothing

Voluntary sterilization for men limited to:

  • Vasectomy

Primary: $25 copayment per office visit

Specialist: $40 copayment per office visit

 $75 copayment for surgical services provided at an outpatient hospital

 $50 copayment per visit for surgical services provided at an ambulatory surgical center

 

 

 

Primary: $30 copayment per office visit

Specialist: $50 copayment per office visit

$100 copayment for surgical services provided at an outpatient hospital

$75 copayment per visit for surgical services provided at an ambulatory surgical center

Not covered:

  • Reversal of voluntary surgical sterilization
All chargesAll charges
Benefit Description : Infertility servicesHigh Option (You pay)Standard Option (You pay)

Diagnosis and treatment of infertility such as:

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

Covered diagnostic tests and procedures including but not limited to the following procedures:

  • Hysterosalpingogram
  • Hysteroscopy
  • Endometrial biopsy
  • Laparoscopy
  • Sonohysterogram
  • Post Coital tests
  • Testis biopsy
  • Semen analysis
  • Blood tests
  • Ultrasound
  • Sperm washing
  • Electroejaculation
  • Fertility drugs

Note: We cover self injectable and oral fertility drugs under the prescription drug benefit.

Note: On the High and Standard Options, advanced radiology is subject to a $750 copayment maximum per calendar year.

Note:  We will cover medical or surgical procedures which are medically necessary to diagnose or correct a malformation, disease, or dysfunction, resulting in infertility, and diagnostic tests and procedures that are necessary to determine infertility.

We limit infertility coverage to correctable medical conditions that have resulted in infertility. Your applicable office visit copayment or outpatient facility coinsurance (inpatient is covered in full) will depend on the type and location of treatment or services (See Section 5(a), 5(b) and 5(c)). Correctable medical conditions include: endometriosis, uterine fibroids, adhesive disease, congenital septate uterus, recurrent spontaneous abortions, and varicocele.

In order to be eligible for Infertility services, you must:

  • be at least 21 years of age and no older than 44; except for diagnosis and treatment for a correctable medical condition which incidentally results in infertility
  • have a treatment plan submitted in advance to us by a physician who has the appropriate training, experience and meets other standards for diagnosis and treatment of infertility as promulgated by New York State
  • have a treatment plan that is in accordance with standards and guidelines established and adopted by the American College of Obstetricians and Gynecologists, the American Society for Reproductive Medicine, and the American Hospital Formulary Service
  • the number of allowable artificial insemination procedures is based on accepted medical practices.

 

Primary: $25 copayment per visit for services performed at an office

Specialist: $40 copayment per visit for services performed at an office

$75 copayment per visit for surgical services provided at an outpatient hospital

$50 copayment per visit for surgical services provided at an ambulatory surgical center

Nothing for inpatient and laboratory services

$40 copayment per visit for routine radiology

$75 copayment per visit for advanced radiology services

Primary: $30 copayment per visit for services performed at an office

Specialist: $50 copayment per visit for services performed at an office

$100 copayment per visit for surgical services provided at an outpatient hospital

$75 copayment per visit for surgical services provided at an ambulatory surgical center

Nothing for inpatient and laboratory services

$40 copayment per visit for routine radiology services

$75 copayment for advanced radiology services

Not covered:

  • Services for an infertility diagnosis as a result of current or previous sterilization procedures(s) and/or procedures(s) for reversal of sterilization.
  • 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 donor egg and all related services
  • Over-the-counter medications, devices or kits, such as ovulation kits
  • Cloning or any services incident to cloning
All chargesAll charges
Benefit Description : Allergy careHigh Option (You pay)Standard Option (You pay)
  • Testing and treatment
  • Allergy injections

Primary: $25 copayment per office visit

Specialist: $40 copayment per office visit

Primary: $30 copayment per office visit

Specialist: $50 copayment per office visit

Allergy serum

NothingNothing
Not covered: 
  • Provocative food testing
  • Sublingual allergy desensitization
All chargesAll charges
Benefit Description : Treatment therapiesHigh Option (You pay)Standard Option (You pay)
  • Radiation therapy
  • Respiratory and inhalation therapy
  • Cardiac rehabilitation following qualifying event/condition is provided for up to 36 sessions
  • Dialysis – hemodialysis and peritoneal dialysis
  • Growth hormone therapy (GHT) 
  • Injections administered in a physician’s office (for example, B-12 and steroid injections)
  • Hormonal therapies

Note: Growth hormone is covered under the prescription drug benefits. We only cover GHT when we preauthorize treatment. You or your doctor must submit information that establishes that the GHT is medically necessary and 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.

$40 copayment per office visit

$50 copayment per office visit

  • Applied Behavior Analysis (ABA) – Children with autism spectrum disorder

$25 copayment per office visit

$30 copayment per office visit

  • Chemotherapy

Note: High dose chemotherapy in association with autogolous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on pages 50-55.

Primary: $25 copayment per office visit

Specialist: $40 copayment per office visit

Primary: $30 copayment per office visit

Specialist: $50 copayment per office visit

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

Nothing

Nothing

Benefit Description : Physical and occupational therapies – Rehabilitative and HabilitativeHigh Option (You pay)Standard Option (You pay)

High Option: Up to 60 visits combined per calendar year.  When autism is the primary diagnosis, no visit limitation applies.

Standard Option: Up to 20 visits combined per calendar year.  When autism is the primary diagnosis, no visit limitation applies.

  • Qualified physical therapists
  • Occupational therapists

Note: The visit limits apply to any combination of physical, occupational, and/or speech therapy.

Note:  We only cover therapy when a physician:

  • orders the care
  • identifies the specific professional skills the patient requires and the medical necessity for skilled services; and
  • indicates the length of time the services are needed.

$25 copayment per outpatient visit 

Nothing per visit during covered inpatient admission

$30 copayment per outpatient visit 

Nothing per visit during covered inpatient admission

Not covered:

  • Long-term rehabilitative therapy
  • Exercise programs
All chargesAll charges
Benefit Description : Speech therapy – Rehabilitative and HabilitativeHigh Option (You pay)Standard Option (You pay)

High Option: Up to 60 visits combined per calendar year.  When autism is the primary diagnosis, no visit limitation applies.

Standard Option: Up to 20 visits combined per calendar year.  When autism is the primary diagnosis, no visit limitation applies.

Note: The visit limits apply to any combination of physical, occupational, and/or speech therapy.

$25 copayment per outpatient visit

Nothing per visit during covered inpatient admission

$30 copayment per outpatient visit

Nothing per visit during covered inpatient admission

Assistive communication devices for the diagnosis of Autism Spectrum Disorder

$25 copayment per item

$30 copayment per item

Benefit Description : Hearing services (testing, treatment, and supplies)High Option (You pay)Standard Option (You pay)
  • For hearing 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.

Primary: $25 copayment per office visit

Specialist: $40 copayment per office visit

Primary: $30 copayment per office visit

Specialist: $50 copayment per office visit

  • Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants. 

Note: See 5(b) for coverage of the surgery to insert the device.

Nothing

Nothing

Not covered:

  • Hearing services that are not shown as covered
  • Hearing aids, supplies, examinations and fitting
All chargesAll charges
Benefit Description : Vision services (testing, treatment, and supplies)High Option (You pay)Standard Option (You pay)
  • One pair of eyeglasses to correct an impairment directly caused by accidental ocular injury or intraocular surgery. 
  • Contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts).  
  • Eye examinations for medical conditions such as glaucoma, retinitis pigmentosa, and macular degeneration

Note: See Preventive care, children for eye example for children

Note: Benefits are limited to one pair of replacement lenses, or contact lenses per incident prescribed within one year of injury

$40 copayment per office visit

$50 copayment per office visit






Not covered:

  • Eye exercises and orthoptics
  • Radial keratotomy and other refractive surgery
  • Eyeglasses or contact lenses, except as shown above

All chargesAll charges
Benefit Description : Foot careHigh Option (You pay)Standard Option (You pay)

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

Note: See Section 5(a) Orthopedic and prosthetic devices for information on podiatric shoe inserts.

Primary: $25 copayment per office visit

Specialist: $40 copayment per office visit

Primary: $30 copayment per office visit

Specialist: $50 copayment per office visit

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)
All chargesAll charges
Benefit Description : Orthopedic and prosthetic devices High Option (You pay)Standard Option (You pay)
  • Artificial limbs*
  • Artificial eyes
  • Prosthetic sleeve or sock
  • Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
  • Compression stockings** 

*Note: One prosthetic device per limb, per lifetime.  Replacement limbs may be considered based on medical necessity

**Note: Compression stockings, including below the knee and thigh, are limited to a total of 12 units (6 pair) per year with a compression type of 30-40 mmHg and 40-50 mmHg

50% coinsurance per device/supply50% coinsurance per device/supply
  • Implanted hearing-related devices, such as bone-anchored hearing aids (BAHA) and cochlear implants. 
  • 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. 
  • Ostomy supplies 

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

NothingNothing

Not covered:

  • Hearing aids
  • Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups 
  • Lumbosacral supports
  • Corsets, trusses, and other supportive devices
  • Compression stockings with a compression of less than 30 mmHg 
  • Wigs and hair prosthesis

All chargesAll charges
Benefit Description : Durable medical equipment (DME)High Option (You pay)Standard Option (You pay)

We cover rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician. Under this benefit, we cover:

  • Oxygen and oxygen equipment
  • Dialysis equipment
  • Hospital beds
  • Wheelchairs
  • Crutches
  • Walkers

Note:  Call us at 716-631-8701 as soon as your Plan physician prescribes this equipment.  We will arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

50% coinsurance per device

50% coinsurance per device

Diabetic equipment such as:

  • Insulin pumps
  • Blood glucose monitors
  • Diabetic shoes and inserts

Note:  Call us at 716-631-8701 as soon as your Plan physician prescribes this equipment.  We will arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

$25 copayment per item

$30 copayment per item

Not covered:

  • Personal convenience items
  • Humidifiers, air conditioners
  • Athletic or exercise equipment
  • Computer assisted communication devices (except for the diagnosis of Autism Spectrum Disorder)

All chargesAll charges
Benefit Description : Home health servicesHigh Option (You pay)Standard Option (You pay)
  • Home health care ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide.  
  • Service include oxygen therapy, intravenous therapy and medications.
    • High Option: Unlimited visits per year as long as medically necessary
    • Standard Option: Up to 40 visits per year as long as medically necessary

$25 copayment per visit

Note: Nothing for oxygen therapy, intravenous therapy and medications.

$30 copayment per visit

Note: Nothing for oxygen therapy, intravenous therapy and medications.

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
  • Private duty nursing
All chargesAll charges
Benefit Description : ChiropracticHigh Option (You pay)Standard Option (You pay)

Manipulation of the spine and extremities

Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

Note: Chiropractic care must be provided in connection with the detection and correction by manual or mechanical means, of any structural imbalance, distortion or subluxation in the human body.

$25 copayment per office visit

$30 copayment per office visit

Benefit Description : Alternative treatmentsHigh Option (You pay)Standard Option (You pay)

No benefit.

All chargesAll charges
Benefit Description : Educational classes and programsHigh Option (You pay)Standard Option (You pay)

Coverage is provided for:

  • Tobacco Cessation programs, including individual/group/telephone counseling, over the counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence.

Nothing for counseling for up to two quit attempts per year.

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

Nothing for counseling for up to two quit attempts per year.

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

  • Diabetes self-management
  • Nutritional counseling
  • Childhood obesity education

Nothing

Nothing




Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Health Care Professionals (High and Standard Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Plan physicians must provide or arrange your care.
  • We do not have a calendar year deductible for services that you receive under the HMO benefits.
  • Please see Section 5(i) for information regarding POS benefits for Out-of-Network services. An annual deductible and coinsurance will apply to covered POS benefits.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • The services listed below are for the charges billed by a physician or other health care professionals for your surgical care. See Section 5(c) for charges associated with the facility (i.e. hospital, surgical center, etc.).
  • YOUR PHYSICIAN MUST GET PREAUTHORIZATION FOR SOME SURGICAL PROCEDURES. Please refer to the preauthorization information shown in Section 3 to be sure which services require preauthorization and identify which surgeries require preauthorization.



Benefit Description : Surgical proceduresHigh Option (You pay)Standard Option (You pay)

A comprehensive range of services, such as:

  • Operative procedures
  • Treatment of fractures, including casting
  • Normal pre- and post-operative care by the surgeon
  • Correction of amblyopia and strabismus
  • Endoscopy procedures
  • Biopsy procedures
  • Removal of tumors and cysts
  • Correction of congenital anomalies (see Reconstructive surgery)
  • Voluntary sterilization for men (vasectomy) 
  • Surgical treatment of morbid obesity (bariatric surgery)
  • Insertion of internal prosthetic devices. See 5(a) – Orthopedic and prosthetic devices for device coverage information
  • Treatment of burns

Note:  Reference www.independenthealth.com for medical policy criteria for bariatric surgery.

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.

Primary: $25 copayment per office visit

Specialist: $40 copayment per office visit

Nothing for outpatient surgery or inpatient services

Primary: $30 copayment per office visit

Specialist: $50 copayment per office visit

Nothing for outpatient surgery or inpatient services

  • Abortions
  • Voluntary sterilization for women (tubal ligation)

Note: Services, drugs or supplies covered at no member liability only when the life of the mother would be endangered if the fetus were carried to full term or when the pregnancy is a result of rape or incest.

Nothing

Nothing

Not covered:

  • Reversal of voluntary sterilization
  • Routine treatment of conditions of the foot; (see Foot care)
  • Abortions, except those stated above
All chargesAll charges
Benefit Description : Reconstructive surgery High Option (You pay)Standard Option (You pay)

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: severe protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes.

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

  • Surgery to produce a symmetrical appearance of breasts;
  • Treatment of any physical complications, such as lymphedemas;
  • Breast prostheses and surgical bras and replacements
    (see Prosthetic devices)

Surgical treatment for gender reassignment considered medically necessary for procedures including but not limited to:

  • Complete hysterectomy
  • Orchiectomy
  • Penectomy
  • Vaginoplasty
  • Vaginectomy
  • Clitoroplasty
  • Labiaplasty
  • Salpingo-oophorectomy
  • Scrotoplasty
  • Urethroplasty
  • Phalloplasty

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.

Primary: $25 copayment per office visit

Specialist: $40 copayment per office visit

Nothing for outpatient surgery or inpatient services

Primary: $30 copayment per office visit

Specialist: $50 copayment per office visit

Nothing for outpatient surgery or inpatient services

Not covered:

  • Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury
  • Surgeries related to gender reassignment that are not considered medically necessary (including but not limited to):
    • Breast augmentation other than when performed as part of the initial gender reassignment surgery
    • Blepharoplasty
    • Collagen injections
    • Rhinoplasty
    • Lip reduction/enhancement
    • Face or forehead lift
    • Chin implant
    • Nose implant
    • Trachea shave/reduction thyroid chondroplasty
    • Laryngoplasty or shortening of the vocal cords
    • Liposuction
    • Electrolysis
    • Jaw shortening
    • Facial bone reduction
    • Hair removal or transplantation
All chargesAll charges
Benefit Description : Oral and maxillofacial surgery High Option (You pay)Standard Option (You pay)

Oral surgical procedures, limited to:

  • Reduction of fractures of the jaws or facial bones;
  • Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
  • Removal of stones from salivary ducts;
  • Excision of leukoplakia or malignancies;
  • Excision of cysts and incision of abscesses when done as independent procedures; and
  • Other surgical procedures that do not involve the teeth or their supporting structures.

Primary: $25 copayment per office visit

Specialist: $40 copayment per office visit

Nothing for outpatient surgery or inpatient services

Primary: $30 copayment per office visit

Specialist: $50 copayment per office visit

Nothing for outpatient surgery or inpatient services

Not covered:

  • Oral implants and transplants
  • Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
All chargesAll charges
Benefit Description : Organ/tissue transplantsHigh Option (You pay)Standard Option (You pay)

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan.  Refer to other services in Section 3 for prior authorization procedures.

  • 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

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity for review by the Plan. Please refer to 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)

Nothing 

Nothing 

Blood or marrow stem cell transplants 

The Plan extends coverage for the diagnoses as indicated below.

Allogeneic transplants for:

  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced myeloproliferative disorders (MPDs)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Marrow Failure and related disorders (i.e. Fanconi's, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • 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 reccurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with reccurrence (relapsed)
  • Amyloidosis
  • Breast cancer
  • Epithelial ovarian cancer
  • Multiple myeloma
  • Neuroblastoma
  • Testicular, Mediastinal, Retroperitoneal, and ovarian germ cell tumors

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 Hodgkins'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
    • Marrow failure and related disorders (i.e., Fanconi's, PNH, Pure Red Cell Aplasia)
    • Myelodysplasia/Myelodysplastic syndromes
    • Paroxysmal Nocturnal Hemoglobinuria
    • Severe combined immunodeficiency
    • Severe or very sever 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

Nothing 

Nothing 

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 and if approved by the Plan’s medical director in accordance with the Plan’s protocols.

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

Allogeneic transplants for:

  • Advanced Hodgkins lymphoma
  • Advanced non-Hodgkins lymphoma
  • Beta Thalessemia Major
  • Chronic inflammatory demyelination polyneuropathy (CIDP)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Sickle cell anemia

Mini Transplants (Nonmyeloblative allogeneic transplants or Reduced intensity conditioning (RIC) for

  • Acute lymphocytic or non-lymphocytic (i.e., myelogeneous) leukemia
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Breast cancer
  • Chronic lymphocytic leukemia
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Colon cancer
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Myeloproliferative disorders
  • Non-small cell lung cancer
  • Ovarian cancer
  • Prostate cancer
  • Renal cell carcinoma
  • Sarcomas
  • Sickle cell disease

Autologous transplants for

  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced childhood kidney cancers
  • Advanced Ewing's sarcoma
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma 
  • Aggressive non-Hodgkin's lymphomas
  • Breast cancer
  • Childhood rhabdomyosarcoma
  • Chronic myelogenous leukemia
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Epithelial Ovarian Cancer
  • Mantle cell (Non-Hodgkin's lymphoma)
  • Small cell lung cancer
  • Systemic sclerosis

Note: You must obtain our preauthorization for all organ/tissue transplants. Contact us directly for information at 716-631-8701.

Note: We cover related medical and hospital expenses of the donor when we cover the recipient. We cover donor testing for the actual solid organ donor or up to four bone marrow/stem cell transplant donors in addition to the testing of family members.

Nothing 

Nothing 

Not covered:

  • Donor screening tests and donor search expenses, except as shown above
  • Implants of artificial organs
  • Transplants not listed as covered
All chargesAll charges
Benefit Description : AnesthesiaHigh Option (You pay)Standard Option (You pay)

Professional services provided in –

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



Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services (High Option and Standard Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • We do not have a calendar year deductible for services that you receive under the HMO benefits.
  • Please see Section 5(i) for information regarding POS benefits for Out-of-Network services. An annual deductible and coinsurance will apply to covered POS benefits.
  • Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions.
  • Be sure to read Section 4, Your costs for covered services for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are covered in Sections 5(a) or (b).
  • YOUR PHYSICIAN MUST GET PREAUTHORIZATION FOR HOSPITAL STAYS. Please refer to Section 3 to be sure which services require preauthorization.



Benefit Description : Inpatient hospitalHigh Option (You pay )Standard Option (You pay )

Room and board, such as

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

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

Note:  Copayment is waived if readmitted within 90 days from date of last discharge.

$500 copayment per admission

$750 copayment per admission

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, if not donated or replaced
  • Dressings, splints, casts, and sterile tray services
  • Medical supplies and equipment, including oxygen
  • Anesthetics, including nurse anesthetist services
  • Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home
NothingNothing

Not covered:

  • Custodial care
  • Non-covered facilities, such as nursing homes, schools
  • Personal comfort items, such as telephone, television, barber services, guest meals and beds
  • Private nursing care
All chargesAll charges
Benefit Description : Outpatient hospital or ambulatory surgical centerHigh Option (You pay )Standard Option (You pay )
  • 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
  • Blood and blood plasma, if not donated or replaced
  • 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.

$75 copayment per visit for surgical services provided at an outpatient hospital

$50 copayment per visit for surgical services provided at an ambulatory surgical center

$100 copayment per visit for surgical services provided at an outpatient hospital

$75 copayment per visit for surgical services provided at an ambulatory surgical center

Abortions

Note: Services, drugs or supplies related to abortions covered at no member liability only when the life of the mother would be endangered when the fetus were carried to term or when the pregnancy is a result of an act of rape or incest.

Nothing

Nothing

Not covered:

Abortions, except when noted above

All Charges

All Charges

Benefit Description : Extended care benefits/Skilled nursing care facility benefitsHigh Option (You pay )Standard Option (You pay )

Skilled nursing facility (SNF) and subacute facility: We provide a comprehensive range of benefits for up to 45 days per year under the High Option and 30 days per year under the Standard Option, when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by Plan.

All necessary services are covered, including:

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

Note: Copayment is not waived when discharged from a hospital/facility and admitted to a Skilled Nursing Facility.

$500 copayment per admission


$750 copayment per admission


Not covered:
  • Custodial care, maintenance care, respite care, or convenience care
All chargesAll charges
Benefit Description : Hospice careHigh Option (You pay )Standard Option (You pay )

We cover hospice services on an inpatient or outpatient basis (including medically necessary supplies and drugs) for a terminally ill member. Covered care is provided in the home or hospice facility under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six months or less. As a part of hospice care, we cover bereavement counseling for covered family.

Nothing

Nothing

Not covered:

  • Independent nursing
  • Homemaker services
All chargesAll charges
Benefit Description : End of life careHigh Option (You pay )Standard Option (You pay )

End of life care includes Advance Care Planning (ACP) prior to admittance to a hospice Plan program or facility. ACP means home visits from a program sponsored by a plan hospice provider to assist members in preparing for issues they face following a life threatening or terminal diagnosis. ACP is limited to a maximum of six (6) ACP visits per calendar year. This benefit is in addition to the hospice care benefit described above.

  • Advance care planning
Nothing

Nothing

Benefit Description : AmbulanceHigh Option (You pay )Standard Option (You pay )
  • Local professional ambulance service when medically appropriate. See 5(d) for emergency service.

$75 copayment per trip

$100 copayment per trip

Not covered:

  • Wheelchair van transportation
All chargesAll charges



Section 5(d). Emergency Services/Accidents (High and Standard Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • We do not have a calendar year deductible for services that you receive under the HMO benefits.
  • Please see Section 5(i) for information regarding POS benefits for Out-of-Network services. An annual deductible and coinsurance will apply to covered POS benefits.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.



What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick action.



What to do in case of emergency within the service area:

If you believe that you have an emergency, call 911 or go to the nearest emergency room. If you aren’t sure, call your primary care doctor as soon as you can. You may also contact Independent Health’s 24-hour Medical Help Line at 800-501-3439. A nurse will return your call and tell you what to do at home or to go to the primary care doctor’s office or the nearest emergency room.

What to do in case of emergency outside the service area:

Go to the nearest emergency room. Call Independent Health as soon as you can (within 48 hours if possible). For urgent care services, call Independent Health’s 24-hour Medical Help Line at 800-501-3439.  Please see Section 5(i) for information regarding the POS benefits.




Benefit Description : Emergency within our service areaHigh Option (You Pay )Standard Option (You Pay )
  • Emergency care at a doctor’s office

Primary: $25 copayment per office visit

Specialist: $40 copayment per office visit

Primary: $30 copayment per office visit

Specialist: $50 copayment per office visit

  • Emergency care at an urgent care center  

$50 copayment per visit

$75 copayment per visit

  • Emergency care as an outpatient at a hospital, including doctors’ services

Note: We waive the copayment if the emergency results in an inpatient admission to the hospital.

Note: Health care forensic examinations performed by trained medical personnel for gathering evidence of a sexual assault in a manner suitable for use in a court of law will not be subject to cost-sharing.

$150 copayment per visit

$150 copayment per visit

Not covered: 

  • Elective care or non-emergency care. 
All chargesAll charges
Benefit Description : Emergency outside our service areaHigh Option (You Pay )Standard Option (You Pay )
  • Emergency care at a doctor’s office
  • Emergency care at an urgent care center
  • Urgent care at a doctor’s office or urgent care center

$50 copayment per date of service 

$75 copayment per date of service

  • Emergency care as an outpatient at a hospital, including doctors’ services.

Note: We waive the copayment if the emergency results in an inpatient admission to the hospital.

$150 copayment per visit

$150 copayment per visit

Not covered:

  • Elective care or non-emergency care
  • Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

All chargesAll charges
Benefit Description : AmbulanceHigh Option (You Pay )Standard Option (You Pay )

Professional ambulance service for the prompt evaluation and treatment of a medical emergency and/or transportation to a hospital for the treatment of an emergency condition.

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

$75 copayment per trip

$100 copayment per trip

Not covered:

  • Wheelchair van transportation
All chargesAll charges



Section 5(e). Mental Health and Substance Use Disorder Benefits (High and Standard Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • We do not have a calendar year deductible for services that you receive under the HMO benefits.
  • Please see Section 5(i) for information regarding POS benefits for Out-of-Network services. An annual deductible and coinsurance will apply to covered POS benefits.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • YOU MUST GET PREAUTHORIZATION FOR CERTAIN SERVICES. Please see pages 23-25 for a list of procedures that require preauthorization.



Benefit Description : Professional servicesHigh Option (You Pay)Standard Option (You Pay)

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.

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

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 or group therapy visits)
  • Diagnosis and treatment of alcoholism and drug use, including detoxification, treatment and counseling
  • Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
  • Electroconvulsive therapy

$25 copayment per visit

$30 copayment per visit

Benefit Description : DiagnosticsHigh Option (You Pay)Standard Option (You Pay)
  • 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
  • Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
  • Inpatient diagnostic tests provided and billed by a hospital or other covered facility

Note: Advanced radiology is subject to a $750 advanced radiology copayment maximum per calendar year on the High and Standard Options.

Nothing for laboratory test;

Primary: $25 copayment per visit for diagnostic tests

Specialist: $40 copayment per visit for diagnostic tests

$40 copayment per visit for routine radiology services 

$75 copayment per visit for advanced radiology services 

Note: For routine and advanced radiology services, an additional office visit copayment may apply.

Nothing for laboratory test;

Primary: $30 copayment per visit for diagnostic tests

Specialist: $50 copayment per visit for diagnostic tests

$40 copayment per visit for routine radiology services

$75 copayment per visit for advanced radiology services

Note: For routine and advanced radiology services, an additional office visit copayment may apply.

Benefit Description : Inpatient hospital or other covered facilityHigh Option (You Pay)Standard Option (You Pay)

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

  • Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services
  • Residential treatment for mental health and substance misuse

Note: Copayment is waived if readmitted within 90 days from date of last discharge

$500 copayment per admission

$750 copayment per admission

Benefit Description : Outpatient hospital or other covered facilityHigh Option (You Pay)Standard Option (You Pay)

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

$25 copayment per visit

$30 copayment per visit




Section 5(f). Prescription Drug Benefits (High and Standard Option)

Important things you should keep in mind about these benefits:

  • We cover prescribed drugs and medications, as described in the chart beginning on page 67.
  • Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • We do not have a calendar year deductible for services that you receive under the HMO benefits.
  • Prescription drugs are not covered under the POS benefits. You must use a Plan pharmacy to fill your prescription, including those within our National Pharmacy Network.
  • Some drugs require prior authorization, including non-formulary insulin and non-formulary diabetic supplies. Your prescribing Plan prescribers will request required prior authorization from us when the drug is medically necessary for your treatment. We review most prior authorization requests within 1 business day of receipt of all necessary information. If the prescribing provider is a non-Plan provider, the non-Plan provider must contact us for preauthorization or we will not cover the prescription.
  • Federal law prevents the pharmacy from accepting unused medications.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how
    cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.



There are important features you should be aware of. These include:

  • Who can write your prescription.  A licensed physician or dentist, and in states allowing it, licensed certified providers with prescriptive authority prescribing within their scope of practice must prescribe your medication.
  • Where you can obtain them.You must fill the prescription at a Plan pharmacy. In addition to the many local pharmacies that are available, our national pharmacy network provides access to more than 52,000 pharmacies across the country. To find a list of participating pharmacies, visit our website at www.independenthealth.com or contact our Member Services Department at 716-631-8701 or 800-501-3439.To take advantage of our National Pharmacy Network, simply present your member ID card at a participating pharmacy.
  • We use a formulary. We use a 5-tier prescription drug formulary. It is a list of drugs that we have approved to be dispensed through Plan pharmacies. Our formulary has more than 1,000 different medications and covers all classes of drugs prescribed for a variety of diseases. Tier 1 generally contains preferred generic and some over-the-counter drugs. Tier 2 contains preferred brand name drugs. Tier 3 contains non-preferred drugs. Tier 4 contains preferred specialty drugs. Tier 5 contains non-preferred specialty drugs.To obtain a copy of the formulary, visit our website at www.independenthealth.com or contact our Member Services Department at 716-631-8701 or 800-501-3439. Our Pharmacy and Therapeutics Committee, which consists of local doctors and pharmacists, meets quarterly to review the formulary. The committee's recommendations are forwarded to our Board Quality Review Oversight Committee who makes the final decision.
  • These are the dispensing limitations.   You may obtain up to a 30-day supply or up to a 90-day supply for maintenance medications.   For contraceptives you may obtain up to a 12-month supply of contraceptives.   For all opioids (excluding medication assisted treatment) issued for acute conditions there will be a 7-day initial fill (excluding oncology, hospice and sickle-cell) dispensed.  If an additional supply is required, your provider may issue a prescription for up to a 30-day supply.  Plan pharmacies fill prescriptions using FDA-approved generic equivalents if available. All other prescriptions are filled using FDA-approved brand name pharmaceuticals. Most antibiotics are limited to a 10-day supply with one refill within 15 days of the original fill. Prescriptions written by an emergency room physician are limited to a 10-day supply with no refills. If you are in the military and called to active duty, please contact us if you need assistance in filling a prescription before your departure.
  • A generic equivalent will be dispensed if it is available, unless your physician requires a name brand. If you receive a name brand drug when a Federally-approved generic drug is available, and your physician has not specified Dispense as Written for the name brand drug, you have to pay the difference in cost between the name brand drug and the generic.
  • Why use generic drugs? Generic drugs offer a safe and economic way to meet your prescription drug needs. Generic drugs contain the same active ingredients and are equivalent in strength and dosage to the original brand name product. The U.S. Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same standards for safety, purity, strength and equivalence as brand-name drugs. Generic drugs are generally less expensive than brand name drugs, in most instances, are the most cost effective therapy available, and may save you money.
  • Split Fill Program  The split fill dispensing program is designed to prevent wasted prescription drugs if your prescription drug or dose changes. The prescription drugs that are included under this program have been identified as requiring more frequent follow up to monitor response to treatment and reactions.  You will initially get up to a 15-day supply of your prescription order for certain drugs filled by a plan pharmacy instead of the full prescription order.  You pay no cost-share for the initial 15-day fill.  You pay the full copayment (30-day script) for the second half of the prescription.  The therapeutic classes of prescription drugs that are included in this program are: Mental/Neurologic Disorders and Oncology.  The Split Fill Program will not apply to all drugs in these categories, nor will it apply to any medications outside of these categories. As new drugs come to market, they will be reviewed for inclusion on the Split Fill Program medication list.  Medications that are reviewed for this list are costly, have a high discontinuation rate, and can be dispensed easily in 14-15-day supplies (e.g. oral tablets).  This program applies for the first 30 days when you start a new prescription drug. You or your provider may opt out by contacting us.

Maintenance Medications

  • Retail Pharmacy.  You may obtain a 90-day supply of your maintenance medications (following the issuance of a 30-day supply) at select participating pharmacies at a cost of 2.5 copayments for Tier 1 drugs or the full applicable coinsurance for all other Tiers. Please visit our website at www.independenthealth.com or contact our Member Services Department at 716-631-8701 or 800-501-3439 to obtain a list of the select participating pharmacies.
  • Mail Order Pharmacy.  In addition to Independent Health's pharmacy network, you may also obtain your maintenance medications through Wegmans or ProAct Pharmacy Services. When using mail order pharmacies, your medications are shipped to you by standard delivery at no additional cost to you (express shipping is available for an additional charge). Maintenance medications must be dispensed in 90-day supply quantities (2.5 copayments apply for Tier 1 drugs or the full applicable coinsurance for all other Tiers).  You must have received a 30-day supply before a 90-day supply can be requested.  Before using Wegmans or ProAct Pharmacy Services for the first time, you will have to register with the mail order pharmacy of your choice.

Here's how to register:

  • By mail: please contact our Member Services Department at 716-631-8701 or 800-501-3439 for a registration form for the pharmacy of your choice.
  • Online: www.wegmans.com/pharmacy or www.proactrx.com
  • By Phone:
    • Wegmans: 888-205-8573 (TTY/TDD: 877-409-8711)
    • ProAct Pharmacy Services: 888-425-3301 (TTY National 711 Relay Service)
  • To obtain your mail order pharmacy prescription
    • You will first need a new prescription written by your doctor. Please ask your doctor to write a new prescription for a 90-day supply for mail service plus refills for up to 1 year (as appropriate). Please check the Independent Health drug formulary for covered medications.
    • Please note: when placing your initial order, you should have at least a 14-day supply of that medication on hand to hold you over. If you do not have enough medication, you may need to ask your doctor for another prescription for a 30-day supply to be filled at your local retail network pharmacy.
  • To order refills:
    • You can easily refill your prescriptions online, by telephone or by mail. Have your Member ID ready and your prescription number for the medication available. If you choose to pay by credit card, please have that number available as well. To make sure you don't run out of medication, remember to re-order 14 days before your medication runs out.
  • When you do have to file a claim.  If you do not have access to a Plan pharmacy in an emergency situation and you paid for prescriptions filled at a non-Plan pharmacy, please send a copy of the paid receipt along with your member ID number and a Medical/Pharmacy General Claim form to: Independent Health, 511 Farber Lakes Drive, Buffalo, NY 14221 Attn: Pharmacy Department.  The Medical/Pharmacy General Claim form can be obtained on our website at www.independenthealth.com.



Benefit Description : Covered medications and suppliesHigh Option (You Pay)Standard Option (You Pay)

We cover the following medications and supplies prescribed by a licensed provider and obtained from a Plan pharmacy:

  • Drugs and medicines that by Federal law of the United States require a provider’s prescription for their purchase, except those listed as Not covered.
  • Growth hormones 
  • Contraceptives and contraceptive devices, including diaphragms
  • Nutritional supplements medically necessary for the treatment of phenylketonuria (PKU) and other related disorders 
  • Self-administered injectable drugs 
  • Fertility drugs when you meet specific criteria (See Section 5(a) Infertility Services)
  • Hormonal drugs
  • Sexual dysfunction drugs 

Note: Intravenous fluids and medication for home use, implantable drugs, and injectable or implantable contraceptives are covered under Medical and Surgical Benefits.

Note: For all opioids (excluding medication assisted treatment) issued for acute conditions there will be a 7-day initial fill (excluding oncology, hospice and sickle-cell) dispensed.  If an additional supply is required, your provider may issue a prescription for up to a 30-day supply.

Note: Some drugs require preauthorization.  See our Drug formulary at www.independenthealth.com.

Note: Some drugs have dispensing limitations.  Contact us for details.

Unless otherwise indicated,
Retail Pharmacy

  • $7 copayment per 30-day supply of a Tier 1 drug (preferred generics)

  • 35% per 30-day supply of a Tier 2 drug (preferred brand drugs)

  • 50% per 30-day supply of a Tier 3 drug (non-preferred brand drugs)

  • 35% per 30-day supply of Tier 4 drug (preferred specialty drugs)

  • 50% per 30-day supply of Tier 5 drug (non-preferred specialty drugs)

Maintenance Medications
Retail or Mail Order Pharmacy -

  • $17.50 copayment per 90-day supply of a Tier 1 drug (preferred generics)

  • 35% per 90-day supply of a Tier 2 drug (preferred brand drugs)

  • 50% per 90-day supply of a Tier 3 drug (non-preferred brand drugs)

  • 35% per 90-day supply of Tier 4 drug (preferred specialty drugs)

  • 50% per 90-day supply of Tier 5 drug (non-preferred specialty drugs)

Note: If there is no Tier 1 equivalent available, you will still have to pay the Tier 2 or Tier 3 member cost-share.

Unless otherwise indicated, 
Retail Pharmacy -

  • $7 copayment per 30-day supply of a Tier 1 drug (preferred generics)

  • 35% per 30-day supply of a Tier 2 drug (preferred brand drugs)

  • 50% per 30-day supply of a Tier 3 drug (non-preferred brand drugs)

  • 35% per 30-day supply of Tier 4 drug (preferred specialty drugs)

  • 50% per 30-day supply of Tier 5 drug (non-preferred specialty drugs)

Maintenance Medications 
Retail or Mail Order Pharmacy -

  • $17.50 copayment per 90-day supply of a Tier 1 drug (preferred generics)

  • 35% per 90-day supply of a Tier 2 drug (preferred brand drugs)

  • 50% per 90-day supply of a Tier 3 drug (non-preferred brand drugs)

  • 35% per 90-day supply of Tier 4 drug (preferred specialty drugs)

  • 50% per 90-day supply of Tier 5 drug (non-preferred specialty drugs)

Note: If there is no Tier 1 equivalent available, you will still have to pay the Tier 2 or Tier 3 member cost-share.

Oral chemotherapyNothing for up to a 30-day supplyNothing for up to a 30-day supply

Women's contraceptive drugs and devices

  • Tier 1 and Tier 2 oral contraceptive drugs and devices
  • Select Tier 3 oral contraceptive drugs and devices

Note: Over-the counter contraceptive drugs and devices approved by the FDA require a written prescription by an approved provider.

Note: For contraceptives you may obtain up to a 12-month supply of contraceptives.  

Nothing per 30-day supplyNothing per 30-day supply
  • Insulin and oral agents

$25 copayment or the applicable prescription member liability, whichever is less

$30 copayment or the applicable prescription member liability, whichever is less

  • Diabetic supplies such as test strips for glucose monitors and visual reading and urine testing strips, syringes, lancets and cartridges for the visually impaired
    • Disposable needles and syringes needed to inject insulin

Note: For non-insulin dependent members: 100 test strips limit for a 30-day supply and a 300 test strip limit for a 90-day supply.

For insulin dependent members: 300 test strip limit for a 30-day supply and a 900 test strip limit for a 90-day supply.

Needles and syringes necessary to inject covered medication

$25 copayment

$30 copayment

Benefit Description : Preventive medicationsHigh Option (You Pay)Standard Option (You Pay)

  • Aspirin ( 81 mg) for adults age 50-59 
  • Folic acid supplements for women of childbearing age 400 & 800 mcg
  • Liquid iron supplements for children age 6 months - 1 year
  • Prenatal vitamins for pregnant women
  • Fluoride tablets, solution ( not toothpaste, rinses) for children age 0-6
  • Statins used for the primary prevention of cardiovascular disease (CVD) for adults age 40-75 with no history of CVD, 1 or more CVD risk factors, and a calculated 10 year CVD event risk of 10% or greater
  • Naloxone-based agents
  • HIV PrEP medications

Note: Preventive medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a health care 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

Nothing

Nothing

Not covered:

  • Drugs and supplies for cosmetic purposes
  • Drugs to enhance athletic performance
  • Fertility drugs when you do not meet the New York State-mandated criteria for coverage or when related to non-covered infertility procedures
  • Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies
  • Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them, except as noted above
  • Medical supplies such as dressings and antiseptics
  • Prescription refills beyond one year from the original date written
  • Nonprescription medications 

Note: Over-the-counter and prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation program benefit (See page 46)

All charges

All charges




Section 5(g). Dental Benefits (High Option and Standard Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your FEHB Plan will be First/Primary payor of any Benefit payments and your FEDVIP Plan is secondary to your FEHB plan. See Section 9 Coordinating benefits with other coverage.
  • Plan dentists must provide or arrange your care.
  • We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. See Section 5(c) for inpatient hospital benefits. We do not cover the dental procedure unless it is described below.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.



Benefit Desription : Accidental injury benefitHigh Option (You Pay)Standard Option (You Pay)

We cover restorative services and supplies necessary to repair (but not replace) sound natural teeth within twelve months of the accident. The need for these services must result from an accidental injury.

Note: Please see specific benefit description for any additional services that may be rendered in an office setting for the amount you pay.

Member liability based on specific service rendered.Member liability based on specific service rendered.

Not covered:

  • Injury to the teeth caused by eating or chewing
All chargesAll charges
Benefit Desription : Dental benefitsHigh Option (You Pay)Standard Option (You Pay)
We cover treatment that is medically necessary due to a congenital disease or anomaly such as cleft lip/cleft palate. Member liability based on specific service rendered.Member liability based on specific service rendered.

Not covered:

  • Dental services listed above
All chargesAll charges



Section 5(h). Wellness and Other Special Features (High Option and Standard Option)

Feature : FeatureHigh Option & Standard Option (Description) (Description)
Flexible benefits option

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

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

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).

24-Hour Medical Help Line

Independent Health’s 24-Hour Medical Help Line is ideal for those times when you can’t reach your doctor right away and you have concerns and questions about an illness or you need to reach a medical resource management (MRM) case manager. Our registered nurses are on call to assist you 24 hours a day, 7 days a week, and can even coordinate a trip to the hospital in case of an emergency. Call 716-631-8701 or 800-501-3439 to get the help you need when you need it most.

Independent Health’s 24-Hour Medical Help Line is ideal for those times when you can’t reach your doctor right away and you have concerns and questions about an illness or you need to reach a medical resource management (MRM) case manager. Our registered nurses are on call to assist you 24 hours a day, 7 days a week, and can even coordinate a trip to the hospital in case of an emergency. Call 716-631-8701 or 800-501-3439 to get the help you need when you need it most.

Services for deaf and hearing impaired

TTY National 711 Relay Service

TTY National 711 Relay Service

Case ManagementThe purpose of case management is to identify high-risk members and coordinate care such that the member receives appropriate care in the appropriate setting. Members are referred from many sources. Those cases, which are referred to the Case Management team, will have an assessment and phone call to the member/family within 48 hour of the referral.

The purpose of case management is to identify high-risk members and coordinate care such that the member receives appropriate care in the appropriate setting. Members are referred from many sources. Those cases, which are referred to the Case Management team, will have an assessment and phone call to the member/family within 48 hour of the referral.

Travel benefit/services overseas

You have worldwide coverage for emergency care services. This does not include travel-related expenses. Contact us for details.

You have worldwide coverage for emergency care services. This does not include travel-related expenses. Contact us for details.

Facilities for transplants/heart surgery/etc.With preauthorization, you have access to certain facilities through Optum Health Care Solutions. Please contact us for any additional information.

With preauthorization, you have access to certain facilities through Optum Health Care Solutions. Please contact us for any additional information.

Well-being Assessment

FitWorks:

· Online tool that provides a Well-being Assessment allowing you to identify your strengths, opportunities to improve your health and well-being, and health risks.

· Provides targeted recommendations for improvement of physical and mental well-being.

· Allows you to take a more active role in your health by setting and tracking goals, as well as through engaging in challenges and social networking.

· Get started by creating your FitWorks account at www.ihfitworks.com

FitWorks:

· Online tool that provides a Well-being Assessment allowing you to identify your strengths, opportunities to improve your health and well-being, and health risks.

· Provides targeted recommendations for improvement of physical and mental well-being.

· Allows you to take a more active role in your health by setting and tracking goals, as well as through engaging in challenges and social networking.

· Get started by creating your FitWorks account at www.ihfitworks.com

Zipongo

Independent Health has partnered with Zipongo to offer members an easy new way to eat well. Zipongo is a free new app and website that gives you access to personalized healthy-eating tools. Get recipes, nutrition tips, weekly meal planning tools and money-saving discounts at your favorite grocery stores. Register for Zipongo now through your online member account at independenthealth.com/login.

Independent Health has partnered with Zipongo to offer members an easy new way to eat well. Zipongo is a free new app and website that gives you access to personalized healthy-eating tools. Get recipes, nutrition tips, weekly meal planning tools and money-saving discounts at your favorite grocery stores. Register for Zipongo now through your online member account at independenthealth.com/login.

Brook Health Companion

Brook Health Companion is a new way to access 24/7 support for general health and chronic conditions, such as diabetes and hypertension - all from the convenience of your smartphone.  Using an intuitive blend of technology, Brook provides personalized advice and chat-based coaching from health experts.  Learn more by visiting www.brook.health and get Brook now!

Brook Health Companion is a new way to access 24/7 support for general health and chronic conditions, such as diabetes and hypertension - all from the convenience of your smartphone.  Using an intuitive blend of technology, Brook provides personalized advice and chat-based coaching from health experts.  Learn more by visiting www.brook.health and get Brook now!




Section 5(i). Point of Service Benefits (High and Standard Option)

Facts about this Plan’s Point of Service (POS) option

Point of Service (POS) provides you flexibility in accessing covered care from non-Plan providers. When you receive medically necessary non-emergency covered Out-of-Network services, you are subject to the deductibles, coinsurance, and provider charges that exceed the Plan reimbursement and benefit limitations described below. Certain benefits are excluded from POS coverage and we list them in this section under “What is not covered”. The exclusions that appear on page 127 in Section 6 General exclusions - things we don’t cover, still apply to POS benefits.

High Option:

  • Under the POS benefit, your cost share for covered Out-of-Network services is higher than the HMO benefit. For Self Only POS coverage, you must satisfy a deductible of $500 per calendar year. Under Self Plus One or Self and Family enrollment, 2 family members must each satisfy a $500 annual deductible. After the annual deductible has been met, we reimburse 75% of our allowable charges for covered medical services. We reimburse 50% of the allowable charges for covered durable medical equipment and prosthetic devices. In addition to the annual deductible and coinsurance, you are also responsible for any amount that exceeds our allowance for covered services. Our allowance is based on the lesser of the non-Plan provider’s charges, the negotiated rate, or the 80th percentile of Usual, Customary or Reasonable (UCR).
  • The Out-of-Network Out-of-Pocket Maximum is $10,000 for Self Only and $20,000 for Self Plus One or Self and Family per calendar. Your POS deductible and coinsurance apply to the Out-of-Network Out-of-Pocket Maximum; In-Network member liability, prescription drugs, routine vision and dental services, and penalties for failure to preauthorize do not apply. Once you have satisfied the Out-of-Pocket Maximum, you will not pay coinsurance for covered POS benefits. However, you will still owe any amount of the provider’s charge that exceeds our allowance or any applied penalties.

Standard Option:

  • Under the POS benefit, your cost share for covered Out-of-Network services is higher than the HMO benefit. For Self Only POS coverage, you must satisfy a deductible of $1,000 per calendar year. Under Self Plus One or Self and Family a $2,000 annual deductible must be satisfied, but no individual family member will exceed a $1,000 deductible. After the annual deductible has been met, we reimburse 70% of our allowable charges for covered medical services. We reimburse 50% of the allowable charges for covered durable medical equipment and prosthetic devices. In addition to the annual deductible and coinsurance, you are also responsible for any amount that exceeds our allowance for covered services. Our allowance is based on the lesser of the non-Plan provider’s charges, the negotiated rate, or the 80th percentile of Usual, Customary or Reasonable (UCR).
  • The Out-of-Network Out-of-Pocket Maximum is $10,000 for Self Only and $20,000 for Self Plus One or Self and Family per calendar. Your POS deductible and coinsurance applies to the Out-of-Network Out-of-Pocket Maximum; In-Network member liability, prescription drugs, routine vision and dental services, and penalties for failure to preauthorize do not apply. Once you have satisfied the Out-of-Pocket Maximum, you will not pay coinsurance for covered POS benefits. However, you will still owe any amount of the provider’s charge that exceeds our allowance or any applied penalties.



Important things you should keep in mind about these benefits:

Limitations/Requirements

  • You must select a primary care physician (pcp) and notify us of the provider's name.
  • You or a provider must report services that you receive from a non-Plan provider or facility to your primary care physician no later than seventy-two (72) hours after receiving medical services.
  • You are responsible for filing a claim form with us for all services that you receive from a non-Plan provider or facility.  A claim form must be submitted in its entirety and submitted within one-hundred twenty (120) days after the date you receive medically necessary health care services.
  • Benefit limitations on health care services listed in this plan brochure will be applied to all such health care services, regardless of whether the health care services are rendered by Plan or non-Plan providers or facilities.




Section 5. High Deductible Health Plan Benefits (HDHP)

See page 18 for how our benefits changed this year. This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection.




(Page numbers solely appear in the printed brochure)

Table of Content



Section 5. High Deductible Health Plan Benefits Overview (HDHP)

This Plan offers a High Deductible Health Plan (HDHP). We call this plan iDirect. The HDHP benefit package is described in this section. Make sure that you review the benefits that are available under the benefit product in which you are enrolled.

HDHP Section 5, which describes the HDHP benefits, is divided into subsections. Please read Important things you should keep in mind at the beginning of each subsection. Also read the general exclusions in Section 6; they apply to benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about HDHP benefits, contact us at 716-631-8701 or 800-501-3439 or on our website at www.independenthealth.com.

Our HDHP option provides comprehensive coverage and a tax-advantaged way to help you build savings for future medical expenses. The Plan gives you greater control over how you use your health care benefits. You may seek covered care from our network of Plan providers (In-Network) or from non-Plan providers (Out-of-Network).

When you enroll in this HDHP, we establish either a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) for you. Once you have completed and returned the HSA/HRA Eligibility Form confirming your eligibility to be enrolled in an HSA or HRA, we will automatically fund a portion of the total health plan premium on a monthly basis, known as a pass-through.

Eligible preventive care services are covered in full. We apply the deductible and any other applicable member liability to all other medical and prescription care services before we will pay benefits. You can choose to use funds available in your HSA or HRA for qualified medical expenses or you can allow your savings to continue to grow.

This HDHP includes five key components: preventive care; traditional medical coverage health care that is subject to the deductible; savings; catastrophic protection for Out-of-Pocket expenses; and health education resources and account management tools.




TermDefinition
  • Preventive care

You have access to preventive care services, such as periodic health evaluations (e.g., annual physicals), screening services (e.g., mammograms), well-child care, and immunizations from within our network or outside our network. Preventive care services are covered in full if you use an In-Network provider. Please see Section 5 Preventive care for a complete description of the preventive care benefits.

  • Traditional medical coverage

After you have paid the Plan’s deductible, we pay benefits under traditional medical coverage described in Section 5.  You typically pay the deductible, then the applicable copayment or 20% coinsurance for In-Network services. For Out-of-Network services, you are responsible for meeting your deductible, then 40% coinsurance applies.

Covered services include:

  • Medical services and supplies provided by physicians and other health care professionals
  • Surgical and anesthesia services provided by physicians and other health care professionals
  • Hospital services other facility or ambulance services
  • Emergency services/accidents
  • Mental health and substance abuse benefits
  • Prescription drug benefits
  • Accidental injury dental benefits
  • Savings

Health Savings Accounts or Health Reimbursement Arrangements provide a means to help you pay out-of-pocket expenses (see page 79-82 for more details).

  • Health Savings Accounts (HSA)

By law, HSAs are available to members who are not enrolled in Medicare, cannot be claimed as a dependent on someone else's tax return, have not received VA (except for veterans with a service-connected disability) and/or Indian Health Service (IHS) benefits within the last three months or do not have other health insurance coverage other than another High Deductible Health Plan. In 2021 for each month you are eligible for an HSA premium pass through, we will contribute to your HSA $83.33 per month for a Self Only enrollment, $166.66 per month for a Self Plus One enrollment or $166.66 per month for a Self and Family enrollment. In addition to our monthly contribution, you have the option to make additional tax-free contributions to your HSA, as long as total contributions do not exceed the limit established by law, which is $3,600 for an individual and $7,200 for a family. See maximum contribution information on page 81. You can use funds in your HSA to help pay your health plan deductible. You own your HSA, so the funds can go with you if you change plans or employment.

Federal tax tip: There are tax advantages to fully funding your HSA as quickly as possible. Your HSA contribution payments are fully deductible on your Federal tax return. By fully funding your HSA early in the year, you have the flexibility of paying medical expenses from tax-free HSA dollars or after tax out-of-pocket dollars. If you don't deplete your HSA and you allow the contributions and the tax-free interest to accumulate, your HSA grows more quickly for future expenses.

HSA features include:

  • Your HSA is administered by HealthEquity. They govern your HSA account in regards to options and fees;
  • Your contributions to the HSA are tax-deductible;
  • You may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions (i.e., Employee Express, MyPay, etc.)
  • Your HSA earns tax-free interest;
  • Investment options are available on your HSA account and are managed by you through HealthEquity once contributions exceed the required transactional balance. Investment earnings are also tax free;
  • You can make tax-free withdrawals for qualified medical expenses for you, your spouse and dependents (see IRS publication 502 for a complete list of eligible expenses);
  • Your unused HSA funds and interest accumulate from year to year;
  • It’s portable - the HSA is owned by you and is yours to keep, even when you leave Federal employment or retire; and
  • When you need it, funds up to the actual HSA balance are available.

Important consideration if you want to participate in a Health Care Flexible Spending Account (FSA): If you are enrolled in this HDHP with a Health Savings Account (HSA), and start or become covered by a health care flexible spending account (such as FSAFEDS offers – see Section 11), this HDHP cannot continue to contribute to your HSA. Instead, when you inform us of your coverage in an FSA, we will establish an HRA for you.

  • Health Reimbursement Arrangements (HRA)

If you are not eligible for an HSA, for example, you are enrolled in Medicare or have another health plan, we will administer and provide an HRA instead. You must notify us that you are ineligible for an HSA.

In 2021 we will give you an HRA credit of $83.33 per month for a Self Only enrollment, $166.66 for a Self Plus One enrollment or $166.66 per month for a Self and Family enrollment.  You can use funds in your HRA to help pay your health plan deductible and/or for certain expenses that don’t count toward the deductible. 

HRA plans are sanctioned and regulated by the IRS. All procedures followed are required by the Federal IRS regulations. In order to maintain the tax-free status of this money, all IRS rules must be followed. As a result, in order to be reimbursed for an expense if you file a claim, you will need to submit copies of your receipts of provider billing statement. In the case where you use the debit card provided with the HRA plan to pay your provider, you may be asked to submit copies of your receipts in order to meet IRS guidelines.

Therefore, you must keep copies of all receipts and itemized statements (not the credit card receipt) for each purchase. In some cases, you’ll receive a letter requesting the documentation and you will be required to submit this information to substantiate the expense according to IRS regulations.

HRA features include:

  • For our HDHP option, the HRA is administered by HealthEquity;
  • Your HRA credit is available to you as it accumulates from month to month;
  • Tax-free credit can be used to pay for qualified medical expenses for you and any individuals covered by this HDHP;
  • Unused credits carryover from year to year;
  • HRA credit does not earn interest;
  • HRA credit is forfeited if you leave Federal employment or switch health insurance plans; and
  • An HRA does not affect your ability to participate in an FSAFEDS Health Care Flexible Spending Account. However, you must meet FSAFEDS eligibility requirements.
  • Catastrophic protection for Out-of-Pocket expenses

Your annual maximum for Out-of-Pocket expenses (deductibles, coinsurance and copayments) for covered In-Network services is limited to $6,950 per person or $13,900 for Self Plus One or Self and Family enrollment. Your annual maximum for Out-of-Pocket expenses (deductibles and coinsurance) for covered Out-of-Network services is limited to $10,000 per person or $20,000 for Self Plus One or Self Plus Family enrollment. For both the In-Network and Out-of-Network Out-of-Pocket Maximums, no individual in a Self Plus One or a Self and Family will exceed the Self Only Out-of-Pocket Maximum. However, certain expenses do not count toward your Out-of-Pocket Maximum and you must continue to pay these expenses once you reach your Out-of-Pocket Maximum (such as expenses in excess of the Plan’s allowable amount or benefit maximum). Refer to Section 4 Your catastrophic protection Out-of-Pocket Maximum and HDHP Section 5 Traditional medical coverage subject to the deductible for more details.

  • Dental fund

Your dental fund is an established annual amount that is available for you to use to pay for dental expenses rendered by any licensed dentist. The dental fund is not subject to the deductible, the annual catastrophic maximum or Out-of-Pocket Maximum. You determine how you will use your dental fund. Any unused amount at the end of the year will not roll over to subsequent year(s). You cannot use the dental fund for cosmetic dentistry (see page 121 for more details).

  • Health education resources and account management tools
HDHP Section 5(i) describes the health education resources and account management tools available to you to help you manage your health care and your health care dollars.



Section 5. Savings – HSAs and HRAs (HDHP)

TermDefinition 1Definition 2

Administrator

The Plan will facilitate and administer an HSA for you with HealthEquity. 

The address for HealthEquity is:

15 W. Scenic Pointe Drive, Ste.100

Draper, UT 84020

www.HealthEquity.com

866.346.5800

The Plan will facilitate and administer an HRA for you with HealthEquity.

The address for HealthEquity is:

15 W. Scenic Pointe Drive, Ste.100

Draper, UT 84020

www.HealthEquity.com

866.346.5800

Fees

None.

None.

Eligibility

You must:

  • Enroll in this HDHP
  • Have no other health insurance coverage (does not apply to specific injury, accident, disability, dental, vision or long-term care coverage)
  • Not be enrolled in Medicare
  • Not be claimed as a dependent on someone else’s tax return
  • Not have received VA (except for veterans with a service-connected disability) and/or Indian Health Service (IHS) benefits in the last three months
  • Complete all banking paperwork and confirm your HSA eligibility prior to receiving the funds that FEHB has approved for deposit into your HSA account. An HSA or HRA cannot be established without your consent.

You must enroll in this HDHP.

Eligibility for credits is determined on the first day of the month following your effective day of enrollment and will be prorated for length of enrollment.

Confirmation of your ineligibility to establish an HSA will result in the establishment of our HRA.

Funding

If you are eligible for HSA contributions, a portion of your monthly health plan premium is deposited to your HSA each month. Premium pass through contributions are based on the first day of the month following your effective date of enrollment in the HDHP.

Note: If your effective date in the HDHP is after the 1st of the month, the earliest your HSA will be established is the 1st of the following month.

In addition, you may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions (i.e., Employee Express, MyPay, etc.).

If you are eligible for HRA credits, a portion of your monthly health plan premium is deposited to your HRA each month. Premium pass through credits are based on the first day of the month following your effective date of enrollment in the HDHP.

  • Self Only enrollment

For 2021, a monthly premium pass through of $83.33 will be made by the HDHP directly into your HSA each month.

For 2021, your HRA monthly credit is $83.33 (prorated for mid-year enrollment).

  • Self Plus One enrollment

For 2021, a monthly premium pass through of $166.66 will be made by the HDHP directly to your HSA each month.

For 2021, your HRA monthly credit is $166.66 (prorated for mid-year enrollment).

  • Self and Family
    enrollment

For 2021, a monthly premium pass through of $166.66 will be made by the HDHP directly into your HSA each month.

For 2021, your HRA monthly credit is $166.66 (prorated for mid-year enrollment).

Contributions/credits

The maximum that can be contributed to your HSA is an annual combination of the HDHP premium pass through and enrollee contribution funds, which when combined, does not exceed the maximum contribution amount set by the IRS of $3,600 for an individual and $7,200 for a family.

If you enroll during Open Season, you are eligible to fund your account up to the maximum contribution limit set by the IRS. To determine the amount you may contribute, subtract the amount the Plan will contribute to your account for the year from the maximum allowable amount. 

You are eligible to contribute up to the IRS limit for partial year coverage as long as you maintain your HDHP enrollment through the testing period. The testing period requires that you remain an eligible individual in December of the partial year through December of the following year. If you do not remain an eligible individual, a portion of your tax reduction is lost and a 10% penalty is imposed. There is an exception for death or disability.

If you do not remain an eligible individual through the testing period, the maximum contribution amount is reduced by 1/12 for each month you were ineligible to contribute to an HSA.

To determine the maximum allowable contribution, take the amount of your deductible divided by12, times the number of full months enrolled in the HDHP. Subtract the amount the Plan will contribute to your account for the year from the maximum allowable contribution to determine the amount you may contribute.

You may rollover funds you have in other HSAs to this HDHP HSA (rollover funds do not affect your annual maximum contribution under this HDHP).

HSAs earn tax-free interest (does not affect your annual maximum contribution).

Catch-up contribution discussed on page 84.

The full HRA credit will be available, subject to proration, on the effective date of enrollment.  The HRA does not earn interest.

  • Self Only enrollment

You may make an annual maximum contribution of $2,600.04.

You cannot contribute to the HRA

  • Self Plus One enrollment

You may make an annual maximum contribution of $5,200.08.

You cannot contribute to the HRA.

  • Self and Family enrollment

You may make an annual maximum contribution of $5,200.08.

You cannot contribute to the HRA.

Access funds

You may access funds by using your HSA Visa debit card at the point of service or you can transfer funds from your HSA account with HealthEquity, online or mobile app to your provider for payment.

You may access your funds by using your HRA Visa debit card at the point of service.  If submitting claims manually, you can utilize direct deposit for a quicker turnaround of reimbursement to you.  You can also make payment to providers online or by the mobile app.

Distributions/withdrawals

  • Medical

You can pay the Out-of-Pocket expenses for yourself, your spouse or your dependents (even if they are not covered by the HDHP) from the funds available in your HSA.

See IRS Publication 502 for a list of eligible medical expenses.

You can pay the Out-of-Pocket expenses for qualified medical expenses for individuals covered under the HDHP.

Non-reimbursed qualified medical expenses are allowable if they occur after the effective date of your enrollment in this Plan.

See Availability of funds below for information on when funds are available in the HRA.

See IRS Publication 502 for a list of eligible medical expenses. Physician prescribed over-the-counter drugs and Medicare premiums are also reimbursable. Medical insurance premiums are not reimbursable.

  • Non-medical

If you are under age 65, withdrawal of funds for non-medical expenses will create a 20% income tax penalty in addition to any other income taxes you may owe on the withdrawn funds.

When you turn age 65, distributions can be used for any reason without being subject to the 20% penalty, however they will be subject to ordinary income tax.		Not applicable – distributions will not be made for anything other than non-reimbursed qualified medical expenses (as defined by IRS Code 213 (d)).
Availability of fundsEmployees have access to the funds that have been deposited in their account to date.

Funds are not available for withdrawal until all the following steps are completed:

Your enrollment in this HDHP is effective (effective date is determined by your agency in accordance with the event permitting the enrollment change).

The HDHP receives record of your enrollment and initially establishes your HSA account with the fiduciary by providing information it must furnish and by contributing the minimum amount required to establish an HSA.

The Plan will contribute funds once you have verified your eligibility to establish an HSA or HRA. Forms will be provided to you to complete for this verification and must be returned to us for contributions to begin.

You have completed and returned the requested paperwork required by the fiduciary to establish your account.		Funds are not available for withdrawal until all the following steps are completed:

Your enrollment in this HDHP is effective (effective date is determined by your agency in accordance with the event permitting the enrollment change).

The HDHP receives record of your enrollment and initially establishes your HRA account and the initial premium pass through credit is applied to your account

The plan will contribute funds in your HRA once you have verified your ineligible for an HSA. Forms will be provided to you to complete for this verification and must be returned to us for contribution to begin.

Employees have access to the funds that have been deposited in their account to date.
Account owner FEHB enrolleeHDHP

Portable

You can take this account with you when you change plans, separate or retire.

If you do not enroll in another HDHP, you can no longer contribute to your HSA. See page 79 for HSA eligibility.

If you retire and remain in this HDHP, you may continue to use and accumulate credits in your HRA.

If you terminate employment or change health plans, only eligible expenses incurred while covered under the HDHP will be eligible for reimbursement subject to timely filing requirements. Unused funds are forfeited.

Annual rollover Yes, accumulates without a maximum cap.Yes, accumulates without a maximum cap.



If You Have an HSA (HDHP)

If you have an HSA



TermDefinition
  • Contributions

All contributions are aggregated and cannot exceed the maximum contribution amount set by the IRS.  You may contribute your own money to your account through payroll deductions, or you may make lump sum contributions at any time, in any amount not to exceed an annual maximum limit.  If you contribute, you can claim the total amount you contributed for the year as a tax deduction when you file your income taxes.  Your own HSA contributions are either tax-deductible or pre-tax (if made by payroll deduction).  You receive tax advantages in any case.  To determine the amount you may contribute, subtract the amount the Plan will contribute to your account for the year from the maximum contribution amount set by the IRS.  You have until April 15 of the following year to make HSA contributions for the current year.

If you newly enroll in an HDHP during Open Season and your effective data is after January 1st or you otherwise have partial year coverage, you are eligible to fund your account up to the maximum contribution limit set by the IRS as long as you maintain your HDHP enrollment for 12 months following the last month of the year of your first year of eligibility.  If you do not meet this requirement, a portion of your tax reduction is lost and a 10% penalty is imposed.  There is an exception for death or disability.

  • Catch-up contributions

If you are age 55 or older, the IRS permits you to make additional “catch-up” contributions to your HSA. The allowable catch-up contributions is $1,000. Contributions must stop once an individual is enrolled in Medicare. Additional details are available on the U.S. Department of Treasury Website at www.treasury.gov/resource-center/faqs/Taxes/Pages/Health-Savings-Accounts.aspx.

  • If you die

If you have not named a beneficiary, and you are married, your HSA becomes your spouse's; otherwise, your HSA becomes part of your taxable estate.

  • Qualified expenses

You can pay for “qualified medical expenses,” as defined by IRS Code 213(d). These expenses include, but are not limited to, medical plan deductibles, diagnostic services covered by your plan, long-term care premiums, health insurance premiums if you are receiving Federal unemployment compensation, physician prescribed over-the-counter drugs, LASIK surgery, and some nursing services.

When you enroll in Medicare, you can use the account to pay Medicare premiums or to purchase health insurance other than a Medigap policy. You may not, however, continue to make contributions to your HSA once you are enrolled in Medicare.

For a detailed list of IRS-allowable expenses, request a copy of IRS Publication 502 by calling 800-829-3676, or visit the IRS Website at www.irs.gov and click on “Forms and Publications.” Note: Although physician prescribed over-the-counter drugs are not listed in the publication, they are reimbursable from your HSA. Also, insurance premiums are reimbursable under limited circumstances.

  • Non-qualified expenses
You may withdraw money from your HSA for items other than qualified health expenses, but it will be subject to income tax and if you are under 65 years old, an additional 20% penalty tax on the amount withdrawn.
  • Tracking your HSA balance
You will receive a periodic statement that shows the “premium pass through”, withdrawals, and interest earned on your account.
  • Minimum reimbursements from your HSA
You can request reimbursement in any amount.



If You Have an HRA (HDHP)

TermDefinition
  • Why an HRA is established
If you don’t qualify for an HSA when you enroll in this HDHP, or later become ineligible for an HSA, we will establish an HRA for you. If you are enrolled in Medicare or are covered under another Health Plan, you are ineligible for an HSA and we will establish an HRA for you. You must notify us if you become ineligible to contribute to an HSA.
  • How an HRA differs

Please review the chart on pages 80-83 which details the differences between an HRA and an HSA. The major differences are:

  • you cannot make contributions to an HRA
  • funds are forfeited if you leave the HDHP
  • an HRA does not earn interest
  • HRAs can only pay for qualified medical expenses, such as deductibles, copayments, and coinsurance expenses, for individuals covered by the HDHP. FEHB law does not permit qualified medical expenses to include services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest.



Section 5. Preventive Care (HDHP)

Important things you should keep in mind about these benefits:

  • In-Network preventive care services listed in this Section are not subject to the deductible.
  • You must use providers that are part of our network.
  • For all other covered expenses, please see Section 5 - Traditional medical coverage subject to the deductible.
  • You must select a primary care physician (pcp) and notify us of the provider's name.



Benefit Description : Preventive care, adultHDHP (You pay )

Professional Services, such as:

  • Routine physicals
  • Routine screenings
  • Routine immunizations endorsed by the Centers for Disease control and Prevention (CDC)
  • Routine prenatal care
  • Tobacco cessation programs
  • Obesity weight programs
  • Diabetes weight loss programs
  • Disease management programs

In-Network: Nothing

Out-of-Network: Deductible and 40% coinsurance, plus any difference between our payment and the billed charges

Routine physical examination

  • Once every plan year

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

  • Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV).  For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/
  • Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening.  For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org
  • Individual counseling on prevention and reducing health risks
  • Well woman care such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening to interpersonal and domestic violence.  For a complete list of Well Women preventive care services please visit the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/

In-Network: Nothing

Out-of-Network: Deductible and 40% coinsurance, plus any difference between our payment and the billed charges

  • Routine mammogram — covered for women

In-network: Nothing

Out-of-Network:  Deductible and 40% coinsurance, plus any difference between our payment and the billed charges

  • Adult immunizations based on USPSTF recommendations

In-Network: Nothing

Out-of-Network: Deductible and 40% coinsurance, plus any difference between our payment and the billed charges.

  • Routine exams limited to:
    • One routine eye exam every 12 months
    • One routine hearing exam every 12 months

In-Network: Nothing

Out-of-Network: Deductible and 40% coinsurance, plus any difference between our payment and the billed charges

Not covered:

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

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

All charges

Benefit Description : Preventive care, childrenHDHP (You pay )
  • Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics.  For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
  • Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella.  For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html
  • You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org

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

In-Network: Nothing

Out-of-Network: Deductible and 40% coinsurance, plus any difference between our payment and the billed charges

Not covered:

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

All charges




Section 5. Traditional Medical Coverage Subject to the Deductible (HDHP)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • In-Network preventive care is covered at 100% (see page 85) and not subject to the calendar year deductible.
  • The deductible is $2,000 for Self Only or $4,000 for Self Plus One or Self and Family. Under Self Plus One or Self and Family enrollment, the deductible must be satisfied in full by one or more family members before we will begin paying benefits. The deductible applies to all benefits except covered In-Network preventive care.
  • After you have satisfied your annual deductible, your traditional medical coverage begins. Under your traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions.
  • When you use network providers, you are protected by an annual catastrophic maximum on Out-of-Pocket expenses for covered services.  After your coinsurance, copayments and deductibles total $6,950 per person, $13,900 per Self Plus One enrollment or per Self and Family enrollment in any calendar year, you do not have to pay any more for covered services from network providers.  Your Out-of-Network Out-of-Pocket Maximum is $10,000 for Self Only and $20,000 for Self Plus One and Self and Family per calendar year.  However, certain expenses do not count toward your Out-of-Pocket Maximum and you must continue to pay these expenses once you reach your Out-of-Pocket Maximum (such as expenses in excess of the Plan’s benefit maximum, or amounts in excess of the Plan allowance if you use Out-of-Network providers).  
  • You limit your liability for covered services by using providers who are part of the Independent Health network. In-Network benefits apply only when you use a network provider. Out-of-Network benefits apply to services from providers that are not part of the network.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • You must select a primary care physician (pcp) and notify us of the provider's name



Benefit Description : Deductible before Traditional medical coverage beginsYou Pay (You pay After the calendar year deductible... )

The deductible applies to almost all benefits in this Section. In the You Pay column, we say "No deductible" when it does not apply.  When you receive covered services from network providers, you pay the allowable charges until you meet the deductible.

100% of allowable charges, until you meet the deductible of $2,000 under Self Only enrollment or $4,000 under Self Plus One or Self and Family enrollment. You may choose to pay the deductible from your HSA/HRA or Out-of-Pocket.

After you meet the deductible, we pay the allowable charge (less your coinsurance or copayment) until you meet the annual catastrophic Out-of-Pocket Maximum.

In-Network: After you meet the deductible, you pay the indicated coinsurance or copayments for covered services. You may choose to pay the coinsurance and copayments from your HSA/HRA or you can pay for them Out-of-Pocket.

Out-of-Network: After you meet the deductible, you pay the indicated coinsurance plus any difference between our Plan allowance and the billed amount. You may choose to pay the coinsurance or any difference between our Plan allowance and the billed amount from your HSA/HRA or you can pay for them Out-of-Pocket.




Section 5(a). Medical Services and Supplies Provided by Physicians and Other Health Care Professionals (HDHP)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • You limit your liability for covered services by using providers who are part of the Independent Health network. In-Network benefits apply only when you use a network provider. Out-of-Network benefits apply to services from providers that are not part of the network.
  • The deductible is $2,000 for Self Only or $4,000 for Self Plus One or Self and Family. Under Self Plus One or Self and Family enrollment, the deductible must be satisfied in full by one or more family members before we will begin paying benefits. The deductible applies to all benefits except covered In-Network preventive care.
  • After you have satisfied your annual deductible, your traditional medical coverage begins. Under your traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare. The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care.
  • Look in Section 5(c) for charges associated with the facility (i.e. hospital, surgical center, etc.).



Benefit Description : Diagnostic and treatment servicesHDHP (You pay After the calendar year deductible… )

Professional services of physicians

  • In a physician's office
  • Office medical consultations
  • Second surgical opinions
  • At home

Note: The office visit copayment may not cover all services that you may receive during your visit. Please refer to the specific benefits description for information on the amount(s) you owe for additional services that your doctor may perform during your visit.

In-Network: $20 copayment per office visit

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

  • In an urgent care center
  • During a hospital stay
  • In a covered skilled nursing facility
  • Advance care planning

In-Network: Nothing

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges
Benefit Description : Telehealth ServicesHDHP (You pay After the calendar year deductible… )
  • Telehealth - the use of electronic and communication technologies by a provider to deliver covered services when the member's location is different than the provider's location.

Note: You may inquire with a provider to see if he/she offers telehealth or contact Member Services at 716-631-8701.

In-Network: $20 copayment per office visit

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges.

  • Telemedicine Program - The telemedicine program is an online video or phone consultation service administered by a unique network of U.S. board-certified physicians who participate in our telemedicine program.  Teladoc physicians use electronic health records to diagnose and treat conditions, including writing prescriptions. The service is intended to provide a solution for non-emergency medical situations and should not be used if you are experiencing a medical emergency. Telemedicine offers you an alternative option to an urgent care facility or when you are unable to obtain services from your primary care physician for many common medical issues including but not limited to cold and flu symptoms, allergies, pink eye, urinary tract infection and respiratory infection. 

Additionally, Teladoc services are available for behavioral health services (i.e. mental health and substance use).

Note: To utilize the telemedicine program visit teladoc.com or call 800-TELADOC (800-835-2362). This service is available 24/7 and may be accessed if traveling throughout most of the United States.

In-Network: 

General Medicine: $20 copayment per consultation

Behavioral Health: $0 copayment per consultation

Out-of-Network: Not covered

Benefit Description : Lab, X-ray and other diagnostic testsHDHP (You pay After the calendar year deductible… )

Tests, such as:

  • Blood tests
  • Urinalysis
  • Non-routine pap tests
  • Pathology

In-Network: Nothing

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Preventive radiology procedures - for the detection of breast cancer

  • Ultrasound 
  • MRI
  • Diagnostic Mammograms 

In-Network: Nothing

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Radiology procedures and advanced radiology procedures such as:

  • X-rays
  • CT Scans/MRI
  • Ultrasound

Diagnostic tests, such as:

  • Electrocardiogram and EEG

In-Network: 20% coinsurance

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Benefit Description : Maternity careHDHP (You pay After the calendar year deductible… )

Maternity (obstetrical) care, such as:

  • Prenatal care
  • Screening for gestational diabetes for pregnant women 
  • Delivery and inpatient hospital visits
  • Anesthesia services
  • Screening for diabetes mellitus after pregnancy
  • Postnatal care

Here are some things to keep in mind:

  • You do not need to preauthorize your vaginal delivery; see below for other circumstances, such as extended stays for you or your baby 
  • You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary
  • We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or a 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.
  • Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

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

In-Network: Nothing

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Breastfeeding support, supplies and counseling for each birth

In-Network: Nothing

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Benefit Description : Family planning HDHP (You pay After the calendar year deductible… )

Contraceptive counseling on an annual basis

In-Network: Nothing

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

A range of voluntary family planning services, limited to:

  • Voluntary sterilization for women limited to tubal ligation
  • Surgically implanted contraceptives (See Surgical procedures Section 5 (b))
  • Injectable contraceptive drugs (such as Depo Provera)  (see Surgical procedures Section 5(b))
  • Intrauterine devices (IUDs)
  • Diaphragms
  • Genetic testing is covered based on medical necessity 

Note: We cover oral contraceptives and certain contraceptive devices under the prescription drug benefit.

In-Network: Nothing

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Voluntary sterilization for men limited to: 

  • Vasectomy

In-Network: 20% coinsurance

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Not covered:

  • Reversal of voluntary surgical sterilization
All charges
Benefit Description : Infertility servicesHDHP (You pay After the calendar year deductible… )

Diagnosis and treatment of infertility such as:

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

Covered diagnostic tests and procedures including but not limited to the following procedures:

  • Hysterosalpingogram
  • Hysteroscopy
  • Endometrial biopsy
  • Laparoscopy
  • Sonohysterogram
  • Post Coital tests
  • Testis biopsy
  • Semen analysis
  • Blood tests
  • Ultrasound
  • Sperm washing
  • Electroejaculation
  • Fertility drugs

Note: We cover self injectable and oral fertility drugs under the prescription drug benefit.

In-Network: $20 copayment per office visit; 20% coinsurance for outpatient medical/surgical procedures and radiology; nothing for laboratory and inpatient procedures.

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Note:  We will cover medical or surgical procedures which are medically necessary to diagnose or correct a malformation, disease, or dysfunction, resulting in infertility, and diagnostic tests and procedures that are necessary to determine infertility.

We limit infertility coverage to correctable medical conditions that have resulted in infertility. Your applicable office visit copayment or outpatient facility coinsurance (inpatient is covered in full) will depend on the type and location of treatment or services (See Section 5(a), 5(b) and 5(c)). Correctable medical conditions include: endometriosis, uterine fibroids, adhesive disease, congenital septate uterus, recurrent spontaneous abortions, and varicocele.

In order to be eligible for Infertility services, you must:

  • be at least 21 years of age and no older than 44; except for diagnosis and treatment for a correctable medical condition which incidentally results in infertility
  • have a treatment plan submitted in advance to us by a physician who has the appropriate training, experience and meets other standards for diagnosis and treatment of infertility as promulgated by New York State
  • have a treatment plan that is in accordance with standards and guidelines established and adopted by the American College of Obstetricians and Gynecologists, the American Society for Reproductive Medicine, and the American Hospital Formulary Service
  • the number of allowable artificial insemination procedures is based on accepted medical practices.

In-Network: $20 copayment per office visit; 20% coinsurance for outpatient medical/surgical procedures and radiology; nothing for laboratory and inpatient procedures.

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Not covered:

  • Services for an infertility diagnosis as a result of current or previous sterilization procedures(s) and/or procedures(s) for reversal of sterilization.
  • 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 donor egg and all related services
  • Over-the-counter medications, devices or kits, such as ovulation kits
  • Cloning or any services incident to cloning

All charges

Benefit Description : Allergy careHDHP (You pay After the calendar year deductible… )

  • Testing and treatment

  • Allergy injections

In-Network: $20 copayment per office visit

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Allergy serum

In-Network: Nothing

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Not covered:

  • Provocative food testing
  • Sublingual allergy desensitization
All charges
Benefit Description : Treatment therapiesHDHP (You pay After the calendar year deductible… )
  • Applied Behavior Analysis (ABA) Therapy for Autism Spectrum Disorder

In-Network: Nothing

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

  • 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 on pages 103-106.

  • Respiratory and inhalation therapy
  • Cardiac rehabilitation following qualifying event/condition is provided for up to 36 sessions
  • Dialysis – hemodialysis and peritoneal dialysis
  • Growth hormone therapy (GHT)

In-Network: 20% coinsurance

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges.

  • Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy
  • Injections administered in a physician’s office (for example, B-12 and steroid injections)
  • Hormonal therapies

Note: Growth hormone is covered under the prescription drug benefits. We only cover GHT when we preauthorize treatment. You or your doctor must submit information that establishes that the GHT is medically necessary and 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.

Benefit Description : Physical and occupational therapies – Rehabilitative and HabilitativeHDHP (You pay After the calendar year deductible… )

Up to 60 combined visits per calendar year:

  • Qualified physical therapists
  • Occupational therapists

Note: The 60-visit limit applies to any combination of physical, occupational, and/or speech therapy.  When autism is the primary diagnosis, no visit limitation applies.

Note: We only cover therapy when a physician:

  • Orders the care
  • identifies the specific professional skills the patient requires and the medical necessity for skilled services; and 
  • indicates the length of time the services are needed.

In-Network: 20% coinsurance

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Not covered:

  • Long-term rehabilitative therapy
  • Exercise programs
All charges
Benefit Description : Speech therapy – Rehabilitative and HabilitativeHDHP (You pay After the calendar year deductible… )

Up to 60 total visits combined per calendar year for the services from a licensed speech therapist.  When autism is the primary diagnosis, no visit limitation applies.

Note: The 60-visit limit applies to any combination of physical, occupational, and/or speech therapy.

In-Network: 20% coinsurance

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges
  • Assistive communication devices for the diagnosis of Autism Spectrum Disorder

In-Network: Nothing

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Benefit Description : Hearing services (testing, treatment, and supplies)HDHP (You pay After the calendar year deductible… )
  • For hearing 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% coinsurance

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

  • Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants. 

Note: See 5(b) for coverage of the surgery to insert the device.

In-Network: Nothing

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Not covered:

  • Hearing services that are not shown as covered
  • Hearing aid, supplies, examinations, fitting
All charges
Benefit Description : Vision services (testing, treatment, and supplies)HDHP (You pay After the calendar year deductible… )
  • One pair of eyeglasses to correct an impairment directly caused by accidental ocular injury or intraocular surgery. 
  • Contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts).  
  • Eye examinations for medical conditions such as glaucoma, retinitis pigmentosa, and macular degeneration

Note: Benefits are limited to one pair of replacement lenses, or contact lenses per incident prescribed within one year of injury

In-Network: 20% coinsurance

Out of Network: 40% coinsurance, plus any difference between our payment and the billed charges 

Not covered:

  • Eye exercises and orthoptics
  • Radial keratotomy and other refractive surgery
  • Eyeglasses or contact lenses, except as shown above

All charges
Benefit Description : Foot care HDHP (You pay After the calendar year deductible… )

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

Note: See Section 5a Orthopedic and prosthetic devices for information on podiatric shoe inserts.

In-Network: $20 copayment per office visit; 20% for medical/surgical procedures

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

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)
All charges
Benefit Description : Orthopedic and prosthetic devices HDHP (You pay After the calendar year deductible… )
  • Artificial limbs*
  • Artificial eyes
  • Prosthetic sleeve or sock
  • Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
  • Compression stockings**

*Note: One prosthetic device per limb, per lifetime.  Replacement limbs may be considered based on medical necessity

**Note: Compression stockings, including below the knee and thigh, are limited to a total of 12 units (6 pair) per year with a compression type of 30-40 mmHg and 40-50 mmHg 

In-Network: 20% coinsurance

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges
  • Implanted hearing-related devices, such as bone-anchored hearing aids (BAHA) and cochlear implants.
  • 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. Note: See 5(b) for coverage of the surgery to insert the device.
  • Ostomy supplies

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.

In-Network: Nothing

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Not covered:

  • Hearing aids
  • Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
  • Lumbosacral supports
  • Corsets, trusses, and other supportive devices
  • Compression stockings with a compression of less than 30 mmHg
  • Wigs and hair prosthesis

All charges
Benefit Description : Durable medical equipment (DME)HDHP (You pay After the calendar year deductible… )

We cover rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician. Under this benefit, we cover:

  • Oxygen and oxygen equipment
  • Dialysis equipment
  • Hospital beds
  • Wheelchairs
  • Crutches
  • Walkers

Note:  Call us at 716-631-8701 as soon as your Plan physician prescribes this equipment.  We will arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

In-Network: 20% coinsurance

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

 

Diabetic equipment such as;

  • Insulin pumps
  • Blood glucose monitors
  • Diabetic shoes and inserts

Note:  Call us at 716-631-8701 as soon as your Plan physician prescribes this equipment.  We will arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

In-Network: $20 copayment per item

Out-of-Network: 40% coinsurance per item, plus any difference between our payment and the billed charges

Not covered:

  • Personal convenience items
  • Humidifiers, air conditioners
  • Athletic or exercise equipment
  • Computer assisted communication devices (except for the diagnosis of Autism Spectrum Disorder)

All charges
Benefit Description : Home health servicesHDHP (You pay After the calendar year deductible… )
  • Home health care ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide.  
  • Services include oxygen therapy, intravenous therapy and medications.
    • Unlimited visits per year as long as medically necessary

In-Network: 20% coinsurance

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

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
  • Private duty nursing
All charges
Benefit Description : Chiropractic HDHP (You pay After the calendar year deductible… )
  • Manipulation of the spine and extremities

Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

Note: Chiropractic care must be provided in connection with the detection and correction by manual or mechanical means, of any structural imbalance, distortion or subluxation in the human body.

In-Network: 20% coinsurance

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Benefit Description : Alternative treatmentsHDHP (You pay After the calendar year deductible… )

No benefit.

All charges
Benefit Description : Educational classes and programsHDHP (You pay After the calendar year deductible… )

Coverage is provided for:

  • Tobacco Cessation programs, including individual/group/telephone counseling, and over the counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence.

In-Network: Nothing for counseling for up to two quit attempts per year.

In-Network: Nothing for OTC and prescription drugs approved by the FDA to treat tobacco dependence.

Out-of-Network:  40% coinsurance, plus any difference between our payment and the billed charges

  • Diabetes self-management
  • Nutritional counseling
  • Childhood obesity education

In-Network: Nothing

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges




Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Health Care Professionals (HDHP)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • The deductible is $2,000 for Self Only or $4,000 for Self Plus One or Self and Family.  Under Self Plus One or Self and Family enrollment, the deductible must be satisfied in full by one or more family members before we will begin paying benefits. The deductible applies to all benefits except covered In-Network preventive care.
  • After you have satisfied your annual deductible, your traditional medical coverage begins.
  • Under the Traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions
  • The services listed below are for the charges billed by a physician or other health care professional for your surgical care. See Section 5(c) for charges associated with the facility (i.e. hospital, surgical center, etc.).
  • YOU MUST GET PREAUTHORIZATION FOR SOME SURGICAL PROCEDURES.  Please refer to Section 3 to be sure which procedures require preauthorization.



Benefit Description : Surgical proceduresHDHP (You pay After the calendar year deductible… )

A comprehensive range of services, such as:

  • Operative procedures
  • Treatment of fractures, including casting
  • Normal pre- and post-operative care by the surgeon
  • Correction of amblyopia and strabismus
  • Endoscopy procedures
  • Biopsy procedures
  • Removal of tumors and cysts
  • Correction of congenital anomalies (see Reconstructive surgery)
  • Voluntary sterilization for men (vasectomy) 
  • Surgical treatment of morbid obesity (bariatric surgery)
  • Insertion of internal prosthetic devices. See 5(a) – Orthopedic and prosthetic devices for device coverage information
  • Treatment of burns

Note:  Reference www.independenthealth.com for medical policy criteria for bariatric surgery.

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.

In-Network:

Office and Outpatient: 20% coinsurance

Inpatient: Nothing

Out-of-Network: 40% coinsurance, plus
any difference between our payment and the billed charges
  • Abortions
  • Voluntary sterilization for women (tubal ligation)

Note: Services, drugs or supplies covered at no member liability only when the life of the mother would be endangered if the fetus were carried to full term or when the pregnancy is a result of rape or incest.

In-Network: Nothing

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Not covered:

  • Reversal of voluntary sterilization
  • Routine treatment of conditions of the foot; see Foot care
  • Abortions, except those stated above
All charges
Benefit Description : Reconstructive surgery HDHP (You pay After the calendar year deductible… )
  • 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; and webbed fingers and toes.
  • All stages of breast reconstruction surgery following a mastectomy, such as:
    • Surgery to produce a symmetrical appearance of breasts;
    • Treatment of any physical complications, such as lymphedemas;
    • Breast prostheses and surgical bras and replacements (see Prosthetic devices)
  • Surgical treatment for gender reassignment considered medically necessary for procedures including but not limited to:
    • Complete hysterectomy
    • Orchiectomy
    • Penectomy
    • Vaginoplasty
    • Vaginectomy
    • Clitoroplasty
    • Labiaplasty
    • Salpingo-oophorectomy
    • Scrotoplasty
    • Urethroplasty
    • Phalloplasty

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

In-Network:

Inpatient: Nothing

Office and Outpatient: 20% coinsurance

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Not covered:

  • Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury
  • Surgeries related to gender reassignment that are not considered medically necessary (including but not limited to):
    • Breast augmentation other than when performed as part of the initial gender reassignment surgery
    • Blepharoplasty
    • Collagen injections
    • Rhinoplasty
    • Lip reduction/enhancement
    • Face or forehead lift
    • Chin implant
    • Nose implant
    • Trachea shave/reduction thyroid chondroplasty
    • Laryngoplasty or shortening of the vocal cords
    • Liposuction
    • Electrolysis
    • Jaw shortening
    • Facial bone reduction
    • Hair removal or transplantation
All charges
Benefit Description : Oral and maxillofacial surgery HDHP (You pay After the calendar year deductible… )

Oral surgical procedures, limited to:

  • Reduction of fractures of the jaws or facial bones;
  • Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
  • Removal of stones from salivary ducts;
  • Excision of leukoplakia or malignancies;
  • Excision of cysts and incision of abscesses when done as independent procedures; and
  • Other surgical procedures that do not involve the teeth or their supporting structures.

In-Network:

Office and Outpatient: 20% coinsurance

Inpatient: Nothing

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Not covered:

  • Oral implants and transplants
  • Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
All charges
Benefit Description : Organ/tissue transplantsHDHP (You pay After the calendar year deductible… )

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan.  Refer to other services in Section 3 for prior authorization procedures.

  • 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

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity for review by the Plan. Please refer to 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)

In-Network:

Inpatient: Nothing

Outpatient: 20% coinsurance

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Blood or marrow stem cell transplants 

The Plan extends coverage for the diagnoses as indicated below
Allogeneic transplants for

  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Marrow Failure and related disorders (i.e. Fanconi's, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • 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)
  • Amyloidosis
  • Breast cancer
  • Ependymoblastoma
  • Epithelial ovarian cancer
  • Ewing's sarcoma
  • Multiple myeloma
  • Medullablastoma
  • Neuroblastoma
  • Pineoblastoma
  • Testicular, Mediastinal, Retroperitoneal, and ovarian germ cell tumors

In-Network:

Inpatient: Nothing

Outpatient: 20% coinsurance

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

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 Hodgkins's lymphoma with recurrence (relapsed)
    • Advanced Myeloproliferative Disorders (MPDs)
    • Amyloidosis
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Hemoglobinopathy
    • Marrow failure and related disorders (i.e., Fanconi's, PNH, 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

In-Network:

Inpatient: Nothing

Outpatient: 20% coinsurance

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

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

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

Allogeneic transplants for

  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Beta Thalassemia Major
  • Chronic inflammatory demyelination polyneuropathy (CIDP)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Sickle cell anemia

Mini-transplants (non myeloblative allogeneic, reduced intensity conditioning  or RIC) for:

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

Autologous Transplants for

  • Advanced childhood kidney cancers
  • Advanced Ewing's sarcoma
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Aggressive non-Hodgkin's lymphomas
  • Childhood rhabdomyosarcoma
  • Chronic lymphocytic leukemia/small lymphocytic leukemia (CLL/SLL)
  • Chronic myelogenous leukemia
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Epithelial Ovarian Cancer
  • Mantle cell (Non-Hodgkin's lymphoma)
  • Small cell lung cancer
  • Systemic sclerosis

Note: You must obtain our preauthorization for all organ/tissue transplants. Contact us directly for information at 716-631-8701.

Note: We cover related medical and hospital expenses of the donor when we cover the recipient. We cover donor testing for the actual solid organ donor or up to four bone marrow/stem cell transplant donors in addition to the testing of family members.

In-Network:

Inpatient: Nothing

Outpatient: 20% coinsurance

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Not covered:

  • Donor screening tests and donor search expenses, except as shown above
  • Implants of artificial organs
  • Transplants not listed as covered
All charges
Benefit Description : Anesthesia HDHP (You pay After the calendar year deductible… )

Professional services provided in –

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

In-Network:

Inpatient: Nothing

Outpatient: 20% coinsurance

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges




Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services (HDHP)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • The deductible is $2,000 for Self Only or $4,000 for Self Plus One or Self and Family. Under Self Plus One or Self and Family enrollment, the deductible must be satisfied in full by one or more family members before we will begin paying benefits. The deductible applies to all benefits except covered In-Network preventive care.
  • After you have satisfied your annual deductible, your traditional medical coverage begins. 
  • Under your traditional medicinal coverage, you will be responsible for your coinsurance amounts or co-payments for eligible medical expenses or prescriptions.
  • Be sure to read Section 4, Your costs for covered services for valuable information about how cost-sharing works. The office visit copayment may not cover all services that you may receive during your visit. Please refer to the specific benefits description for information on the amount(s) you owe for additional services that your doctor may perform during your visit. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge     (i.e., physicians, etc.) are in Sections 5(a) or (b).
  • YOUR PHYSICIAN MUST GET PREAUTHORIZATION FOR HOSPITAL STAYS. Please refer to Section 3 to be sure which services require preauthorization. 



Benefit Description : Inpatient hospitalHDHP (You pay After the calendar year deductible… )

Room and board, such as

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

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

Note:  Copayment is waived if readmitted within 90 days from date of last discharge.

In-Network: $1,000 copayment per admission

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

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, blood plasma and other plasma
  • Blood or blood plasma, if not donated or replaced
  • Dressings, splints, casts, and sterile tray services
  • Take-home items
  • Medical supplies and equipment, including oxygen
  • Anesthetics, including nurse anesthetist services
  • Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

In-Network: Nothing

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Not covered:

  • Custodial care
  • Non-covered facilities, such as nursing homes, schools
  • Personal comfort items, such as telephone, television, barber services, guest meals and beds
  • Private nursing care
All charges
Benefit Description : Outpatient hospital or ambulatory surgical centerHDHP (You pay After the calendar year deductible… )
  • 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.

In-Network: 20% coinsurance

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Abortions

Note: Services, drugs or supplies covered at no member liability only when the life of the mother would be endangered if the fetus were carried to full term or when the pregnancy is a result of rape or incest.

In-Network: Nothing

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Not covered:

  • Abortions, except those stated above

All charges

Benefit Description : Extended care benefits/Skilled nursing care facility benefitsHDHP (You pay After the calendar year deductible… )

Skilled nursing facility (SNF) and subacute facility: We provide a comprehensive range of benefits for up to 45 days per calendar year combined In and Out-of-Network when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by Plan.

All necessary services are covered, including:

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

Note: Copayment is not waived when discharged from a hospital/facility and admitted to a Skilled Nursing Facility.

In-Network: $1,000 copayment per admission

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Not covered:

  • Custodial care, maintenance care, respite care, or convenience care
All charges
Benefit Description : Hospice careHDHP (You pay After the calendar year deductible… )

We cover hospice services on an inpatient or outpatient basis (including medically necessary supplies and drugs) for a terminally ill member. Covered care is provided in the home or hospice facility under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six months or less. As a part of hospice care, we cover bereavement counseling for covered family.

In-Network: Nothing

Out-of-Network:  40% coinsurance, plus any difference between our payment and the billed charges

Not covered:

  • Independent nursing, homemaker services
All charges
Benefit Description : End of life careHDHP (You pay After the calendar year deductible… )

End of life care includes Advance Care Planning (ACP) prior to admittance to a hospice Plan program or facility. ACP means home visits from a program sponsored by a plan hospice provider to assist members in preparing for issues they face following a life threatening or terminal diagnosis. ACP is limited to a maximum of six (6) ACP visits per calendar year. This benefit is in addition to the hospice care benefit described above.

  • Advanced Care Planning

Nothing

Benefit Description : AmbulanceHDHP (You pay After the calendar year deductible… )
  • Local professional ambulance service when medically appropriate. See 5(d) for emergency service
In and Out-of-Network: 20% coinsurance per trip

Not covered:

  • Wheelchair van transportation
All charges



Section 5(d). Emergency Services/Accidents (HDHP)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • The deductible is $2,000 for Self Only or $4,000 for Self Plus One or Self and Family. Under Self Plus One or Self and Family enrollment, the deductible must be satisfied in full by one or more family members before we will begin paying benefits. The deductible applies to all benefits except covered In-Network preventive care.
  • After you have satisfied your annual deductible, your traditional medical coverage begins.
  • Under your traditional medical coverage, you will be responsible for your coinsurance amounts and co-payments for eligible medical expenses and prescriptions.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.



What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick action.

What to do in case of emergency:

Emergencies within our service area:

If you believe that you have an emergency, call 911 or go to the nearest emergency room. If you aren’t sure, call your primary care doctor as soon as you can. You may also contact Independent Health’s 24-hour Medical Help Line at 800-501-3439. A nurse will return your call and tell you what to do at home or to go to the primary care doctor’s office or the nearest emergency room.

Emergencies outside our service area:

Go to the nearest emergency room. Call Independent Health as soon as you can (within 48 hours if possible). For urgent care services, call Independent Health’s 24-hour Medical Help Line at 800-501-3439. If you do not contact us, you will owe a deductible and coinsurance. 




Benefit Description : Emergency within our service areaHDHP (You pay After the calendar year deductible… )
  • Emergency care at a doctor’s office
  • Emergency care at an urgent care center

In-Network doctor's office: $20 copayment per office visit

Urgent Care Center: $50 copayment per visit

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Emergency care in the outpatient department of a hospital, including doctors’ services

Note: Health care forensic examinations performed by trained medical personnel for gathering evidence of a sexual assault in a manner suitable for use in a court of law will not be subject to cost-sharing.

In and Out-of-Network: 20% coinsurance

Not covered:

  • Elective care or non-emergency care
All charges
Benefit Description : Emergency outside our service areaHDHP (You pay After the calendar year deductible… )
  • Emergency care at a doctor’s office
  • Emergency care at an urgent care center
  • Urgent care at a doctor’s office or urgent care center

$50 copayment per date of service

Emergency care as an outpatient or inpatient at a hospital, including
doctors’ services

In and Out-of-Network: 20% coinsurance

Not covered:

  • Elective care or non-emergency care
  • Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
All charges
Benefit Description : AmbulanceHDHP (You pay After the calendar year deductible… )

Professional ambulance service for the prompt evaluation and treatment of a medical emergency and/or transportation to a hospital for the treatment of an emergency condition.

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

In and Out-of-Network: 20% coinsurance per trip

Not covered:

  •  Wheelchair van transportation
All charges



Section 5(e). Mental Health and Substance Use Disorder Benefits (HDHP)

Important things to keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • The deductible is $2,000 for Self Only or $4,000 for Self Plus One or Self and Family. Under Self Plus One or Self and Family enrollment, the deductible must be satisfied in full by one or more family members before we will begin paying benefits. The deductible applies to all benefits except covered In-Network preventive care.
  • After you have satisfied your annual deductible, your traditional medical coverage begins.
  • Under your Traditional medical coverage, you will be responsible for your coinsurance amounts for eligible medical expenses or copayments for eligible prescriptions.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.
  • YOU MUST GET PREAUTHORIZATION FOR CERTAIN SERVICES. Please see pages 23-25 for a list of procedures that require preauthorization.



Benefit Description : Professional servicesHDHP (You pay After the calendar year deductible… )

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.

Your cost-sharing responsibilities are no greater that for other illnesses or conditions. 

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 or group therapy visits)
  • Diagnosis and treatment of alcoholism and drug use, including detoxification, treatment and counseling
  • Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
  • Electroconvulsive therapy

In-Network: Office visit and outpatient: Nothing

In-Network Inpatient: Nothing

Out-of-Network: 40% coinsurance plus any difference between our payment and the billed charges.

Benefit Description : DiagnosticsHDHP (You pay After the calendar year deductible… )
  • 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
  • Psychological and neuropsychological testing necessary to determine appropriate psychiatric treatment

In-Network:

Laboratory tests: Nothing

Inpatient diagnostic tests: Nothing

All other diagnostic tests: 20% coinsurance

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Benefit Description : Inpatient hospital or other covered facilityHDHP (You pay After the calendar year deductible… )

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

  • Room and board, such as semi-private or intensive accommodations, general nursing care, meals and special diets, and other hospital services
  • Residential treatment for mental health and substance misuse

Note: Copayment is waived if readmitted within 90 days from date of last discharge.

In-Network: $1,000 copayment per admission

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges

Benefit Description : Outpatient hospital or other covered facilityHDHP (You pay After the calendar year deductible… )

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

In-Network: Nothing

Out-of-Network: 40% coinsurance, plus any difference between our payment and the billed charges




Section 5(f). Prescription Drug Benefits (HDHP)

Here are some important things to keep in mind about these benefits:

  • We cover prescribed drugs and medications, as described in the chart beginning on page 116.
  • Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Federal law prevents the pharmacy from accepting unused medications.
  • Members must make sure their prescribers obtain prior approval/authorizations for certain prescription drugs and supplies before coverage applies.  Prior approval/authorizations must be renewed periodically.
  • The deductible is $2,000 for Self Only or $4,000 for Self Plus One or Self and Family. Under Self Plus One or Self and Family enrollment, the deductible must be satisfied in full by one or more family members before we begin paying benefits.  The deductible applies to all benefits except covered In-Network preventive care.
  • After you have satisfied your deductible, your Traditional medical coverage begins.
  • Under your Traditional medical coverage, you will be responsible for your coinsurance amounts for eligible medical expenses or copayments for eligible prescriptions.
  • You must get preauthorization for certain prescriptions. In order to be covered by the Plan, certain prescriptions require preauthorization in accordance with the Independent Health Prescription Drug Formulary. These drugs are noted on the formulary with a symbol “PA” next to the drug name. Please work with your prescribing practitioner for authorization from Independent Health. You may obtain a copy of the prescription drug formulary by contacting Member Services at 716-631-8701 or 800-501-3439. 
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works.  Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.



There are important features you should be aware of. These include:

  • Who can write your prescription.  A licensed physician or dentist, and in states allowing it, licensed certified providers with prescriptive authority prescribing within their scope of practice must prescribe your medication. 
  • Where you can obtain them. You must fill the prescription at a Plan pharmacy. In addition to the many local pharmacies that are available, our national pharmacy network provides access to more than 52,000 pharmacies across the country. To find a list of participating pharmacies, visit our website at www.independenthealth.com or contact our Member Services Department at 716-631-8701 or 800-501-3439.To take advantage of our National Pharmacy Network, simply present your member ID card at a participating pharmacy.  
  • We use a formulary. We use a 5-tier prescription drug formulary. It is a list of drugs that we have approved to be dispensed through Plan pharmacies. Our formulary has more than 1,000 different medications and covers all classes of drugs prescribed for a variety of diseases. Tier 1 generally contains preferred generic and some over-the-counter drugs. Tier 2 contains preferred brand name drugs. Tier 3 contains non-preferred drugs. Tier 4 contains preferred specialty drugs. Tier 5 contains non-preferred specialty drugs. To obtain a copy of the formulary, visit our website at www.independenthealth.com or contact our Member Services Department at 716-631-8701 or 800-501-3439. Our Pharmacy and Therapeutics Committee, which consists of local doctors and pharmacists, meets quarterly to review the formulary. The committee’s recommendations are forwarded to our Board Quality Review Oversight Committee who makes the final decision.
  • These are the dispensing limitations.   You may obtain up to a 30-day supply or up to a 90-day supply for maintenance medications.   For contraceptives you may obtain up to a 12-month supply of contraceptives.  For all opioids (excluding medication assisted treatment) issued for acute conditions there will be a 7-day initial fill (excluding oncology, hospice and sickle-cell) dispensed.  If an additional supply is required, your provider may issue a prescription for up to a 30-day supply.  Plan pharmacies fill prescriptions using FDA-approved generic equivalents if available. All other prescriptions are filled using FDA-approved brand name pharmaceuticals. Most antibiotics are limited to a 10-day supply with one refill within 15 days of the original fill. Prescriptions written by an emergency room physician are limited to a 10-day supply with no refills. If you are in the military and called to active duty, please contact us if you need assistance in filling a prescription before your departure.
  • A generic equivalent will be dispensed if it is available, unless your physician requires a name brand. If you receive a name brand drug when a Federally-approved generic drug is available, and your physician has not specified Dispense as Written for the name brand drug, you have to pay the difference in cost between the name brand drug and the generic.
  • Why use generic drugs?  Generic drugs offer a safe and economic way to meet your prescription drug needs. Generic drugs contain the same active ingredients and are equivalent in strength and dosage to the original brand name product. The U.S. Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same standards for safety, purity, strength and equivalence as brand-name drugs. Generic drugs are generally less expensive than brand name drugs, in most instances are the most cost effective therapy available, and may save you money.
  • Split Fill Program  The split fill dispensing program is designed to prevent wasted prescription drugs if your prescription drug or dose changes. The prescription drugs that are included under this program have been identified as requiring more frequent follow up to monitor response to treatment and reactions.  You will initially get up to a 15-day supply of your prescription order for certain drugs filled by a plan pharmacy instead of the full prescription order.  You pay no cost-share for the initial 15-day fill.  You pay the full copayment (30-day script) for the second half of the prescription.  The therapeutic classes of prescription drugs that are included in this program are: Mental/Neurologic Disorders and Oncology.  The Split Fill Program will not apply to all drugs in these categories, nor will it apply to any medications outside of these categories. As new drugs come to market, they will be reviewed for inclusion on the Split Fill Program medication list. Medications that are reviewed for this list are costly, have a high discontinuation rate, and can be dispensed easily in 14-15-day supplies (e.g. oral tablets).  This program applies for the first 30 days when you start a new prescription drug. You or your provider may opt out by contacting us.

Maintenance Medications

  • Retail Pharmacy.  You may obtain a 90-day supply of your maintenance medications (following the issuance of a 30-day supply) at select participating pharmacies at a cost of 2.5 copayments for Tier 1 drugs or the full applicable coinsurance for all other Tiers. Please visit our website at www.independenthealth.com or contact our Member Services Department at 716-631-8701 or 800-501-3439 to obtain a list of the select participating pharmacies.
  • Mail Order Pharmacy. In addition to Independent Health's pharmacy network, you may also obtain your maintenance medications through Wegmans or ProAct Pharmacy Services. When using mail order pharmacies, your medications are shipped to you by standard delivery at no additional cost to you (express shipping is available for an additional charge). Maintenance medications must be dispensed in 90-day supply quantities (2.5 copayments apply for Tier 1 drugs or the full applicable coinsurance for all other Tiers).  You must have received a 30-day supply before a 90-day supply can be requested.  Before using Wegmans or ProAct Pharmacy Services for the first time, you will have to register with the mail order pharmacy of your choice.

Here's how to register:

  • By mail: please contact our Member Services Department at 716-631-8701 or 800-501-3439 for a registration form for the pharmacy of your choice.
  • Online: www.wegmans.com/pharmacy or www.proactrx.com
  • By Phone:
    • Wegmans: 888-205-8573 (TTY/TDD: 877-409-8711)
    • ProAct Pharmacy Services: 888-425-3301 (TTY National 711 Relay Service)
  • To obtain your mail order pharmacy prescription
    • You will first need a new prescription written by your doctor. Please ask your doctor to write a new prescription for a 90-day supply for mail service plus refills for up to 1 year (as appropriate). Please check the Independent Health drug formulary for covered medications.
    • Please note: when placing your initial order, you should have at least a 14-day supply of that medication on hand to hold you over. If you do not have enough medication, you may need to ask your doctor for another prescription for a 30-day supply to be filled at your local retail network pharmacy.
  • To order refills:
    • You can easily refill your prescriptions online, by telephone or by mail. Have your Member ID ready and your prescription number for the medication available. If you choose to pay by credit card, please have that number available as well. To make sure you don't run out of medication, remember to re-order 14 days before your medication runs out.
  • When you do have to file a claim.  If you do not have access to a Plan pharmacy in an emergency situation and you paid for prescriptions filled at a non-Plan pharmacy, please send a copy of the paid receipt along with your member ID number and a Medical/Pharmacy General Claim form to: Independent Health, 511 Farber Lakes Drive, Buffalo, NY 14221 Attn: Pharmacy Department.  The Medical/Pharmacy General Claim form can be obtained on our website at  www.independenthealth.com.



Benefit Description : Covered medications and suppliesHDHP (You pay After the calendar year deductible… )

We cover the following medications and supplies prescribed by a licensed provider and obtained from a Plan pharmacy:

  • Drugs and medications that by Federal law of the United States require a provider’s prescription for their purchase, except those listed as Not covered.
  • Growth hormones 
  • Contraceptives and contraceptive devices, including diaphragms
  • Nutritional supplements medically necessary for the treatment of phenylketonuria (PKU) and other related disorders 
  • Self-administered injectable drugs
  • Fertility drugs when you meet specific criteria (See Section 5(a) Infertility Services)
  • Hormonal drugs
  • Sexual dysfunction drugs 

Note: The following drug categories do not apply towards the deductible:

  • ACE inhibitors
  • Anti-resorptive therapy medications
  • Beta-blockers
  • Oral agents
  • Selective Serotonin Reuptake Inhibitors (SSRI’s)
  • Statins (under age 40 and over age 75)

Note: Intravenous fluids and medication for home use, implantable drugs, and injectable or implantable contraceptives are covered under Medical and Surgical Benefits.

Note: For all opioids (excluding medication assisted treatment) issued for acute conditions there will be a 7-day initial fill (excluding oncology, hospice and sickle-cell) dispensed.  If an additional supply is required, your provider may issue a prescription for up to a 30-day supply.

Note: Some drugs require preauthorization.  See our Drug formulary at www.independenthealth.com.

Note: Some drugs have dispensing limitations.  Contact us for details.

Unless otherwise indicated,
Retail Pharmacy 

  • $7 copayment per 30-day supply of a Tier 1 drug (preferred generics)

  • 35% per 30-day supply of a Tier 2 drug (preferred brand drugs)

  • 50% per 30-day supply of a Tier 3 drug (non-preferred brand drugs)

  • 35% per 30-day supply for Tier 4 drug (preferred specialty drugs)

  • 50% per 30-day supply for Tier 5 drug (non-preferred specialty drugs)

Maintenance Medications 
Retail or Mail Order Pharmacy 

  • $17.50 copayment per 90-day supply of a Tier 1 (preferred generics)

  • 35% per 90-day supply of a Tier 2 drug (preferred brand drugs)

  • 50% per 90-day supply of a Tier 3 drug (non-preferred brand drugs)

  • 35% per 90-day supply of Tier 4 drug (preferred specialty drugs)

  • 50% per 90-day supply of Tier 5 drug (non-preferred specialty drugs)


Note: If there is no Tier 1 equivalent available, you will still have to pay the Tier 2 or Tier 3 member liability.

Oral ChemotherapyNothing for up to a 30-day supply

Women's contraceptive drugs and devices

  • Tier 1 and Tier 2 oral contraceptive drugs and devices
  • Select Tier 3 oral contraceptive drugs and devices 

Note: Not subject to deductible

Note: Over-the counter contraceptive drugs and devices approved by the FDA require a written prescription by an approved provider.

Note: For contraceptives you may obtain up to a 12-month supply of contraceptives.  

Nothing per 30-day supply

  • Insulin and oral agents
  • Diabetic supplies such as test strips for glucose monitors and visual reading and urine testing strips, syringes, lancets and cartridges for the visually impaired
    • Disposable needles and syringes needed to inject insulin

Note:

For non-insulin dependent members: 100 test strips limit for a 30-day supply and a 300 test strip limit for a 90-day supply

For insulin dependent members: 300 test strip limit for a 30-day supply and a 900 test strip limit for a 90-day supply.

$20 copayment or the applicable prescription member liability, whichever is less

  • Needles and syringes necessary to inject covered medication

$20 copayment

Benefit Description : Preventive medicationsHDHP (You pay After the calendar year deductible… )
  • Aspirin ( 81 mg) for adults age 50-59 
  • Folic acid supplements for women of childbearing age 400 & 800 mcg
  • Liquid iron supplements for children age 6 months - 1 year
  • Prenatal vitamins for pregnant women
  • Fluoride tablets, solution ( not toothpaste, rinses) for children age 0-6
  • Statins used for the primary prevention of cardiovascular disease (CVD) for adults age 40-75 with no history of CVD, 1 or more CVD risk factors, and a calculated 10 year CVD event risk of 10% or greater
  • Naloxone-based agents
  • HIV PrEP medications

Note: Preventive medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a health care 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

Nothing

Not covered:

  • Drugs and supplies for cosmetic purposes
  • Drugs to enhance athletic performance
  • Fertility drugs when you do not meet the New York State-mandated criteria for coverage or when related to non-covered infertility procedures
  • Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies
  • Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them, except as noted above
  • Medical supplies such as dressings and antiseptics
  • Prescription refills beyond one year from the original date written
  • Nonprescription medications

Note: Over-the-counter and prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco cessation program benefit (See page 99)

All charges



Section 5(g). Dental Benefits (HDHP)

Important things you should keep in mind about these benefits:

  • When you join this Plan, you will have access to a Dental fund ($150 for Self Only or $300 for Self Plus One or Self and Family) to share between you and your enrolled family members. Your Dental fund is not subject to the deductible. Any unused balance at the end of the calendar year will be forfeited.
  • You can visit any licensed dentists for services under the Dental fund. However, you can make
    your dental fund go further by taking advantage of the negotiated rates offered by participating
    network dentists.
  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • The deductible for accidental injury is $2,000 for Self Only or $4,000 for Self Plus One or Self and Family. Under Self Plus One or Self and Family enrollment, the deductible must be satisfied in full by one or more family members before we will begin paying benefits. The deductible applies to all benefits except covered In-Network preventive care.
  • After you have satisfied your annual deductible, your traditional medical coverage begins. Under your traditional medical coverage, you will be responsible for your coinsurance amounts and copayments for eligible medical expenses and prescriptions.
  • The office visit copayment may not cover all services received during your visit. Please refer to the specific benefits description for information on the amount(s) you owe for additional services that your doctor may perform during the visit.
  • We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. See Section 5(c) for inpatient hospital benefits. We do not cover the dental procedure unless it is described below.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with Medicare.



Benefit Description : Accidental injury benefitHDHP (You pay After the calendar year deductible… )

  • We cover restorative services and supplies necessary to repair (but not replace) sound natural teeth within twelve months of the accident. The need for these services must result from an accidental injury.

Note: The office visit copay may not cover all services received during your visit. Please refer to the specific benefits description for information on the amount(s) you owe for additional services that your doctor may perform during your visit.

$20 copayment per office visit

20% coinsurance for medical/surgical procedures

Benefit Description : Dental fund benefitHDHP (You pay After the calendar year deductible… )

Dental fund expenses include routine, preventive, dental and orthodontic services up to a maximum of $150 for Self Only or $300 for Self Plus One and Self and Family enrollment.

Note: Any unused remaining balance in your Dental fund at the end of the calendar year cannot be rolled over to the next year.  Annual deductible and catastrophic Out-of-Pocket Maximums for expenses are excluded from your Dental fund.

Nothing, until you exhaust your Dental fund.

Not covered: 

  • Dental treatment for cosmetic purposes
All charges



Section 5(h). Wellness and Other Special Features (HDHP)

Feature : FeatureFeature (Description)

Flexible benefits option

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

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

24-Hour Medical Help Line

Independent Health's 24-Hour Medical Help Line is ideal for those times when you can't reach your doctor right away and you have concerns and questions about an illness or you need to reach a medical resource management (MRM) case manager. Our registered nurses are on call to assist you 24 hours a day, 7 days a week, and can even coordinate a trip to the hospital in case of an emergency. Call 716-631-8701 or 800-501-3439 to get the help you need when you need it most.

Services for hearing impaired

 TTY National 711 Relay Service

Case Management

The purpose of case management is to identify high-risk members and coordinate care such that the member receives appropriate care in the appropriate setting. Members are referred from many sources. Those cases, which are referred to the Case Management team, will have an assessment and phone call to the member/family within 48 hours of the referral.

Travel Benefit/services overseas

You have worldwide coverage for emergency care services. This does not include travel-related expenses. Contact us for details.
Well-being Assessment

FitWorks:

· Online tool that provides a Well-being Assessment allowing you to identify your strengths, opportunities to improve your health and well-being, and health risks.

· Provides targeted recommendations for improvement of physical and mental well-being.

· Allows you to take a more active role in your health by setting and tracking goals, as well as through engaging in challenges and social networking.

· Get started by creating your FitWorks account at www.ihfitworks.com

Zipongo

Independent Health has partnered with Zipongo to offer members an easy new way to eat well. Zipongo is a free new app and website that gives you access to personalized healthy-eating tools. Get recipes, nutrition tips, weekly meal planning tools and money-saving discounts at your favorite grocery stores. Register for Zipongo now through your online member account at www.independenthealth.com/login

Brook Health Companion

Brook Health Companion is a new way to access 24/7 support for general health and chronic conditions, such as diabetes and hypertension – all from the convenience of your smartphone. Using an intuitive blend of technology, Brook provides personalized advice and chat-based coaching from health experts! Learn more by visiting www.brook.health and get Brook now. 




Section 5(i). Health Education Resources and Account Management Tools (HDHP)

TermDefinition
Health education resourcesA newsletter is published to keep you informed on a variety of issues related to your health. Visit us on our website at www.independenthealth.com for information on tools provided by Independent Health to assist in your medical decision making process

Online access

Verify coverage, view a benefit summary, check claim status, order ID cards, and update your phone number and e-mail address.  Visit us on our website at www.independenthealth.com for information. 

Health coaching

Healthcare staff is available to provide guidance in assisting you in making informed health care decisions.  Visit us on our website at www.independenthealth.com for information. 

Treatment Cost Advisor

Provides approximate costs of specific health care services in your area.  Visit us on our website at www.independenthealth.com for information. 

Health and wellness programs

We offer a variety of wellness programs and workshops aimed at keeping you healthy-including weight management, smoking cessation, and nutrition classes.  Visit us on our website at www.independenthealth.com for information. 

Account management tools

You will receive an explanation of benefits which will itemize the deductible applied to your claim.

If you have an HSA:

You will receive a statement outlining your account balance and activity for the month.

You may also access your account on-line at www.HealthEquity.com.

If you have an HRA:

Your HRA balance will be available online through www.HealthEquity.com.

Your balance will also be shown on your reimbursement stub.

Consumer choice information (HDHPs)

As a member of this HDHP, you may choose any provider. However, you will receive a lower cost share when you see a Plan provider. Directories are available online at www.independenthealth.com.

Pricing information for medical care and prescription drugs is available at www.independenthealth.com. 

Educational materials on the topics of HSAs, HRAs and HDHPs are available at www.independenthealth.com.

Care support

Case Management support and guidance is available to assist with management of chronic conditions.  Contact Customer Service at 716-631-8701 or 800-501-3439.




Non-FEHB Benefits Available to Plan Members

The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection Out-of-Pocket Maximums. These programs and materials are the responsibility of the Plan, and all appeals must follow their guidelines. For additional information contact the Plan at 716-631-8701 or 800-501-3439 or visit their website at www.independenthealth.com.




TermDefinition

Wellness Programs

Independent Health covers a number of wellness programs through our Health Education and Wellness Department. These include: Nutritional Consulting, Parenting Classes, and Stress Management workshops to name just a few. Please contact Independent Health's Member Services Department at 716-631-8701 or 800-501-3439 or visit our website at www.independenthealth.com for more information on these expanded benefits as well as our new member discount program. The discount program includes savings on alternative therapies, fitness and nutrition classes, dental services, hearing aids, and more.

Independent Health's Medicare Plans:

Independent Health offers Medicare recipients a wide variety of health plan options, including HMO and PPO. The Encompass plans are Independent Health's HMO brand of Medicare which provides more comprehensive coverage than you would receive from traditional Medicare and the option to add Medicare Prescription Drug Coverage. To be eligible for Independent Health's Medicare coverage, you must be entitled to Medicare A and enrolled in Medicare Part B. Our HMO service area includes Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans or Wyoming counties of New York State and you must not be out of the service area for more than six months. The Passport plans are Independent Health's PPO Medicare offering. The Passport plans offer comprehensive coverage with In-Network providers along with the added flexibility of choosing a health care provider outside of our network. This allows you more flexibility and benefits with lower premiums than Medicare supplement plans.

If you are interested in enrolling, contact your retirement system for information on joining Independent Health’s Medicare Plan. You may also choose to enroll in Independent Health's Medicare Plan and retain your enrollment in Independent Health's FEHB plan. For more information on plan benefits, copayments, and premiums, contact Independent Health's Marketing Department at 716-631-9452 or 800-453-1910, Monday through Friday, 8 a.m. until 5 p.m.

For more information, be sure to visit our web site at www.independenthealth.com

EyeMed Vision Program

EyeMed is a national company that delivers vision benefits to Independent Health members. EyeMed is part of Luxottica, the world's leading frame manufacturer of quality eyeglass frames. EyeMed’s network includes many independent optical providers and retail stores. You must use a participating EyeMed provider to obtain these benefits. EyeMed will cover one refractive eye exam every twelve months. You may contact EyeMed at 877-842-3348.




Independent Health's EyeMed vision program

Benefit

HMO You Pay
(High Option)

HMO You Pay
(Standard Option)

HDHP You Pay

Refractive Eye Exam

$10 copayment

$20 copayment

$15 copayment

Single vision plastic lenses

$50 copayment

$50 copayment

$50 copayment

Bifocal plastic lenses

$70 copayment

$70 copayment

$70 copayment

Trifocal plastic lenses

$105 copayment

$105 copayment

$105 copayment

Lenticular plastic lenses

$105 copayment

$105 copayment

$105 copayment

Progressive plastic lenses

$135 copayment

$135 copayment

$135 copayment

UV coating

$15

$15

$15

Tint

$15

$15

$15

Standard scratch resistance

$15

$15

$15

Standard polycarbonate

$40

$40

$40

Standard anti-reflective

$45

$45

$45

Other services

80% of retail price

80% of retail price

80% of retail price

Conventional contact lenses

85% of retail price

85% of retail price

85% of retail price

Frames

60% of retail price

60% of retail price

60% of retail price

U.S. Laser Network for Lasik or PRK

15% off retail price or 5% off promotional pricing

15% off retail price or 5% off promotional pricing

15% off retail price or 5% off promotional pricing

Eligible discount beyond plan coverage

80% off retail price

80% off retail price

80% off retail price




Section 6. General Exclusions – Services, Drugs and Supplies We Do Not Cover

The exclusions in this section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of this brochure.  Although we may list a specific service as a benefit, we will not cover it unless medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition. For information on obtaining prior approval for specific services, such as transplants, see Section 3 When you need prior Plan approval for certain services.

We do not cover the following:

  • Care by non-Plan providers except for authorized referrals or emergencies (see Emergency services/accidents).
  • Services, drugs, or supplies you receive while you are not enrolled in this Plan.
  • Services, drugs, or supplies not medically necessary.
  • Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice.
  • Experimental or investigational procedures, treatments, drugs or devices (see specifics regarding organ/tissue transplants).
  • Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest.
  • Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.
  • Services, drugs, or supplies you receive without charge while in active military service.
  • Services or supplies we are prohibited from covering under the Federal Law.




Section 7. Filing a Claim for Covered Services

This section primarily deals with post-service claims (claims for services, drugs or supplies you have already received). See Section 3 for information on pre-service claims procedures (services, drugs or supplies requiring prior plan approval), including urgent care claims procedures. When you see Plan providers, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, coinsurance, or deductible.

You will only need to file a claim when you receive emergency services from non-Plan providers. Sometimes these providers bill us directly. Check with the provider.

If you need to file the claim, here is the process:




TermDefinition

Medical and hospital benefits

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 716-631-8701 or 800-501-3439, or at our Web site at www.independenthealth.com.

When you must file a claim – such as for services you receive outside the Plan’s service area – 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 statement are not acceptable substitutes for itemized bills.

Submit your claims to:
Independent Health
PO Box 9066
Buffalo, NY 14231-1642
Attn: Claims Department

Prescription drugs

Submit your claims to:
Independent Health
511 Farber Lakes Drive
Buffalo, NY 14221
Attn: Pharmacy Department

Other supplies or services

Submit your claims to:
Independent Health
PO Box 9066
Buffalo, NY 14231-1642
Attn: Claims Department

Deadline for filing your claimSend us all the documents for your claim as soon as possible.  You must submit the claim by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.
Post-service claims procedures

We will notify you of our decision within 30 days after we receive the claim.  If matters beyond our control require an extension of time, we may take up to an additional 15 days for review as long as we 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.

Authorized RepresentativeYou 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 health care 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.
Notice Requirements

If you live in a county where at least 10 percent 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 telephone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language.  The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

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



Section 8. The Disputed Claims Process

You may appeal directly to the Office of Personnel Management (OPM) if we do not follow required claims processes. For more information about situations in which you are entitled to immediately appeal to OPM, including additional requirements not listed in Sections 3, 7 and 8 of this brochure, please call your plan’s customer service representative at the phone number found on your enrollment card, plan brochure, or plan website.

Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your post-service claim (a claim where services, drugs or supplies have already been provided). In Section 3 If you disagree with our pre-service claim decision, we describe the process you need to follow if you have a claim for services, referrals, drugs or supplies that must have prior Plan approval, such as inpatient hospital admissions. 

To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan documents under our control relating to your claim, including those that involve any expert review(s) of your claim. To make your request, please contact our Customer Service Department by writing: Independent Health, 511 Farber Lakes Drive, Buffalo, NY 14221 or calling 716-631-8701 or 800-501-3439.

Our reconsideration will take into account all comments, documents, records, and other information submitted by you relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.

When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical necessity, experimental/investigational), we will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who was not involved in making the initial decision.

Our reconsideration will not take into account the initial decision. The review will not be conducted by the same person, or his/her subordinate, who made the initial decision.

We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support the denial of benefits.

Disagreements between you and the CDHP or HDHP fiduciary regarding the administration of an HSA OR HRA are not subject to the disputed claims process.




StepDescription
1

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: Independent Health-Benefit Administration Department, P.O. Box 2090, Buffalo, NY 14231; 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.

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

2 

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

a)    Pay the claim or

b)    Write to you and maintain our denial or

c)    Ask you or your provider for more information

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

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

3

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

You must write to OPM within:

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

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, Health Insurance 3, 1900 E Street, NW, Washington, DC 20415-3630.

Send OPM the following information:

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

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

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

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

4

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 preauthorization or prior approval.  This is the only deadline that may not be extended.

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

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




Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call our Member Services Department at 716-631-8701 or 800-501-3439 or send a fax to 716-635-3504.  We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal.  You may call OPM’s Health Insurance 3 at 202-606-0755 between 8 a.m. and 5 p.m. Eastern Time.

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




Section 9. Coordinating Benefits with Medicare and Other Coverage

TermDefinition
When you have other health coverage

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

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

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

When we are the secondary payor, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance.

If you or your health care provider fails to file a timely no-fault claim or take any other action necessary to receive no-fault benefits, we will not pay benefits for those expenses for which no-fault benefits would have been recoverable.

TRICARE and CHAMPVA

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

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

Workers' Compensation

We do not cover services that:

  • You (or a covered family member) need because of a workplace-related illness or injury that the Office of Workers’ Compensation Programs (OWCP) or a similar Federal or State agency determines they must provide; or
  • OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care.

Medicaid

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

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

When other Government agencies are responsible for your careWe do not cover services and supplies when a local, State, or Federal government agency directly or indirectly pays for them.
When others are responsible for your injuriesOur 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.

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

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

Clinical Trials

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. These costs are covered by this plan.
  • Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care.  This plan does not cover these costs.
  • Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes.  These costs are generally covered by the clinical trials. This plan does not cover these costs.         

When you have Medicare

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

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

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

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

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

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 our Member Services Department at 716-631-8701 or 800-501-3439 or visit our web site at www.independenthealth.com.

We do not waive any costs if the Original Medicare Plan is your primary payor.

Please review the following table it illustrates your cost share if you are enrolled in Medicare Part B.  We do not waive any costs for Medicare Part B




Benefit Description : Benefit DescriptionHigh, Standard & HDHP Options You pay without Medicare (You Pay)High, Standard & HDHP Options You pay with Medicare Part B (You Pay)

Deductible

High Option: $0 for Self Only, Self Plus One or Self and Family

Standard Option: $0 for Self Only, Self Plus One or Self and Family

HDHP Option: $2000 Self Only, $4000 Self Plus One or Self and Family

High Option: $0 for Self Only, Self Plus One or Self and Family

Standard Option: $0 for Self Only, Self Plus One or Self and Family

HDHP Option: $2000 Self Only, $4000 Self Plus One or Self and Family

Out-of-Pocket Maximum

High Option: $8,550 Self Only, $17,100 Self Plus One or Self and Family

Standard Option: $8,550 Self Only, $17,100 Self Plus One or Self and Family

HDHP Option: $6,950 Self Only, $13,900 Self Plus One or Self and Family

High Option: $8,550 Self Only, $17,100 Self Plus One or Self and Family

Standard Option: $8,550 Self Only, $17,100 Self Plus One or Self and Family

HDHP Option: $6,950 Self Only, $13,900 Self Plus One or Self and Family

Part B Premium Reimbursement Offered

No

No

Primary Care Physician

High Option: $25 copayment

Standard Option: $30 copayment

HDHP Option: $20 copayment

High Option: $25 copayment

Standard Option: $30 copayment

HDHP Option: $20 copayment

Specialist

High Option: $40 copayment

Standard Option: $50 copayment

HDHP Option: $20 copayment

High Option: $40 copayment

Standard Option: $50 copayment

HDHP Option: $20 copayment

Inpatient Hospital

High Option: $500 copayment per admission

Standard Option: $750 copayment per admission

HDHP Option: $1,000 copayment per admission

High Option: $500 copayment per admission

Standard Option: $750 copayment per admission

 HDHP Option: $1,000 copayment per admission

Outpatient Hospital

High Option: $75 copayment

Standard Option: $100 copayment

HDHP Option: 20% Coinsurance

High Option: $75 copayment

Standard Option: $100 copayment

HDHP Option: 20% Coinsurance

Incentives offered

N/A

N/A




TermDefinition
  • Tell us about your Medicare coverage

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

  • Medicare Advantage
    (Part C)

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

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

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

This Plan and our Medicare managed care plan: You may enroll in our Medicare Advantage plan and also remain enrolled in our FEHB plan. In this case, we do not waive any of our co-payments or coinsurance for your FEHB coverage.

This Plan and another plan’s Medicare managed care 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 co-payments, coinsurance, or deductibles. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

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

  • Medicare prescription drug coverage (Part D)

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.

HSA Qualified High Deductible Health Plans that include pharmacy coverage are not considered creditable coverage for participation in Medicare Prescription Part D Drug Plans. If you are nearing retirement age consult your plan administrator for a plan option to best meet your needs.




Primary Payor Chart

A. When you – or your covered spouse are age 65 or over and have Medicare and you...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have FEHB coverage on your own as an active employee ✓
2) Have FEHB coverage on your own as an annuitant or through your spouse who is an annuitant ✓
3) Have FEHB through your spouse who is an active employee ✓
4) Are a reemployed annuitant with the Federal government and your position is excluded from the FEHB (your employing office will know if this is the case) and you are not covered under FEHB through your spouse under #3 above ✓
5) Are a reemployed annuitant with the Federal government and your position is not excluded from the FEHB (your employing office will know if this is the case) and...
  • 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
✓
6) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge) and you are not covered under FEHB through your spouse under #3 above ✓
7) Are enrolled in Part B only, regardless of your employment status ✓ for Part B services ✓ for other services
8) Are a Federal employee receiving Workers' Compensation disability benefits for six months ✓ *


B. When you or a covered family member...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have Medicare solely based on end stage renal disease (ESRD) and..
  • 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
✓
2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and...
  • 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
✓
3) Have Temporary Continuation of Coverage(TCC) and...
  • 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)
✓


C. When either you or a covered family member are eligible for Medicare solely due to disability and you...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have FEHB coverage on your own as an active employee or through a family member who is an active employee ✓
2) Have FEHB coverage on your own as an annuitant or through a family member who is an annuitant ✓
D. When you are covered under the FEHB Spouse Equity provision as a former spouse ✓

*Workers' Compensation is primary for claims related to your condition under Workers’ Compensation.




TermDefinition
  • Medicare prescription drug coverage (Part D)

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.

HSA Qualified High Deductible Health Plans that include pharmacy coverage are not considered creditable coverage for participation in Medicare Prescription Part D Drug Plans. If you are nearing retirement age consult your plan administrator for a plan option to best meet your needs.




Section 10. Definitions of Terms We Use in This Brochure

TermDefinition
Allowable ExpenseThe necessary, reasonable, and customary item of expense for covered health care.
Calendar yearJanuary 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.

Clinical Trials Cost Categories

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.

Coinsurance

See Section 4, page 28.

Copayment

See Section 4, page 28.

Copayment maximum

The total amount of copayments you are responsible for in a calendar year.

Cost-sharing

See Section 4, page 28.

Covered servicesCare we provide benefits for, as described in this brochure.
Custodial care Custodial care is care which does not require the continuing attention of a trained medical person. Examples of custodial care are activities of daily living, such as bathing, dressing, feeding and toileting. Custodial care is not covered under this contract.

Deductible

See Section 4, page 28.

Group health coverageIn general, a health plan offered by an employer or employee organization that provides health coverage to employees and their families.
Dental fund Your HDHP dental fund is an established benefit amount, which is available for you to use to pay for covered dental expenses during each calendar year. Whether you have an HSA or an HRA account, you are entitled to the annual Dental fund.
Experimental or investigational serviceMedical, surgical or other treatments, procedures, techniques, and drug or pharmacological therapies that have not yet been proven to be safe and efficacious treatment. We do not cover procedures that are ineffective or are in a stage of being tested or researched with question(s) as to safety and efficacy.
Health care professionalA physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with state law.
Health Reimbursement Arrangement (HRA) HRAs are employer-funded accounts that repay employees’ unreimbursed medical expenses (e.g. deductibles).
Health Savings Account (HSA) An HSA is a tax-exempt savings vehicle available to individuals covered by a high deductible health plan (HDHP). Funds in the account are used to pay for qualified medical expenses.
High Deductible Health Plan (HDHP) HDHP is a consumer driven health plan that combines a preferred provider organization (PPO) health plan with separate medical and dental funds that help you pay for covered medical and dental expenses. This new type of health plan product combines HDHP health care coverage with a tax-advantaged program to help you build savings for future medical needs.

Home Health Agency

A public or private agency that specializes in giving skilled nursing services in the home.
Medical Director This person is a licensed provider that we have designated to exercise general supervision over medical care.
Medical necessity Medical necessity is the term we use for health services that are required to preserve and maintain your health as determined by acceptable standards of medical practice. Independent Health’s Medical Director has the right to determine whether any health care rendered to you meets medical necessity criteria.
Member PreauthorizationAuthorization that you must obtain from us prior to receiving any of the services that are identified in this brochure as needing preauthorization in order to receive the maximum allowable coverage.
Out-of-Network ServicesA term that applies to POS and HDHP benefits. These are services from non-Plan providers.
Out-of-Pocket-MaximumThe dollar limit (or ceiling) that you are responsible for in a calendar year.

Plan Allowance

Our plan allowance is essentially our fee schedule amount.  We set our allowances at a level that is simultaneously fair and market based and allows us to maintain our robust network of high quality and efficient participating providers. In order to maintain relativity among the thousands of CPT codes, Independent Health assigns allowances based on the industry standard Relative Value Scale.  Some exceptions are made for specialties and services in our area. Our participating providers have agreed to accept the allowed amount as payment in full, less any co-pay or deductibles amounts collected from the member.

Point of Service (POS) Benefits Coverage that we provide for covered services from non plan providers. 
Post-service claimsAny claims that are not pre-service claims.  In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits.

Premium Contribution

The total monthly premium is your contribution as well as your employer contribution.

Premium Pass-through

The funds FEHB forwards to the Plan, which in turn are deposited into your HSA or HRA.

Pre-service claimsThose claims (1) that require preauthorization, prior approval, or a referral and (2) where failure to obtain preauthorization, prior approval, or a referral results in a reduction of benefits.
Private Duty Nursing Care provided by an LPN or RN and required when the member has a continuous skilled need as opposed to an intermittent skilled need such as a dressing change. Private duty nursing is care that is provided in shifts as opposed to an episodic skilled nursing visit in the member’s home. Private Duty Nursing is not covered under this Contract.
Provider PreauthorizationAuthorization from us that a provider must obtain prior to receiving any of the services that are identified in this brochure as needing preauthorization.
Reimbursement A carrier's pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, and the terms of the carrier's health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.
Step Therapy A process of trying to determine the most efficient way to treat a patient via use of protocols that call for one type of medication or therapy use before proceeding to something more difficult or expensive. This may mean that two medications are used together if they are more effective.
SubrogationA carrier's pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier's health benefits plan

Telehealth

The use of electronic and communication technologies by a provider to deliver covered services when the member's location is different than the provider's location.

Telemedicine Program

The telemedicine program is an online video or phone consultation services administered by a unique network of U.S. board-certified participating physicians in the Teladoc network.

Usual, Customary and Reasonable (UCR)

UCR means Usual, Customary and Reasonable (UCR). Usual rate means the fee regularly charged and received for a given service or supply by a provider. Customary and Reasonable means the fee for a service or supply that Independent Health determines is the most standard and reasonable amount charged by providers in the locality where the charge for such service or supply is incurred. Locality means an area whose size is large enough, in Independent Health’s judgment, to give an accurate representation of standard charges for that type of service or supply. Our allowance is based on the lesser of the non-Plan provider’s charges, the negotiated rate, or the 80th percentile of UCR on the High, Standard and HDHP Options.

Us/We “Us” and “We” refer to Independent Health.
You “You” refers to the enrollee and each covered family member.

Urgent care claims

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

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

We will judge whether a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

Urgent care claims usually involve Pre-services claims and not Post-service claims. We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our Member Services Department at 800-501-3439.  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.




Index

Do not rely on this page; it is for your convenience and may not show all pages where terms appear.




Index Entry
(Page numbers solely appear in the printed brochure)
Accidental Injury
Allogeneic (donor) bone marrow transplant
Organ/tissue transplants
Ambulance
Anesthesia
Autologous bone marrow transplant
Biopsy
Blood and blood plasma
Casts
Catastrophic protection (Out-of-Pocket Maximum)
protection against catastrophic costs
Your catastrophic protection
Changes for 2021
Chemotherapy
Chiropractic
Cholesterol tests
Total cholesterol
Claims
Coinsurance
Colorectal cancer screening
Congenital anomalies
Contraceptive drugs and devices
Cost-sharing
Covered charges
Crutches
Deductible
Definitions
Dental care
Dental fund
Diagnostic services
diagnostic and treatment services
Disputed claims review
The disputed claims process
Donor expenses
donor screening
Dressings
Effective date of enrollment
Emergency
Experimental or investigational
Family planning
Fraud
General exclusions
Hearing services
Home health services
Hospital
Immunizations
Insulin
Licensed Practical Nurse (LPN)
licensed practical nurse
Magnetic Resonance Imagings (MRIs)
Cat Scans
Mammogram
Maternity
Medicaid
Medically Necessary
Medicare
Member Preauthorization
Mental Health/Substance Misuse Benefits
mental health and substance misuse
Newborn care
newborn
Non-FEHB benefits
Nurse
Nurse Anesthetist (NA)
inpatient hospital
Occupational therapy
Office visits
Oral and maxillofacial surgical
surgical and anesthesia services provided by physicians and other health care professionals
Out-of-pocket expenses
Outpatient
Oxygen
pap test
Physician
Point of Service (POS)
summary of benefits
Preferred Provider Organization (PPO)
Prescription drugs
Preventive care, adult
Preventive care, children
Preventive services
Prior approval
Prosthetic devices
Provider Preauthorization
Psychologist
Radiation therapy
Room and board
Second surgical opinion
Skilled nursing facility care
diagnostic and treatment services
Social worker
Splints
Subrogation
Surgery
Temporary Continuation of Coverage (TCC)
Tobacco cessation
Transplants
Treatment therapies
Wheelchairs
Workers Compensation
Coordinating benefits with Medicare and other coverage
X-rays



Summary of Benefits for the High Option HMO with POS for Independent Health – 2021

  • Do not rely on this chart alone. All benefits provided are subject to the definitions, limitations, and exclusions in this brochure. You can obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.Independentheath.com. On this page we summarize specific expenses we cover; for more detail, look inside.
  • If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
  • Under the HMO benefits, we only cover services provided or arranged by Plan providers, except in emergencies. This summary reflects the HMO benefits.
  • For the High Option, there is no annual In-Network deductible.



TermDefinition 1Definition 2

Medical services provided by physicians:

Diagnostic and treatment services provided in the office (see section 5 for specific benefit information and applicable fees)

Office visit copayment: Primary: $25 copayment; Specialist: $40 copayment

32

Services provided by a hospital:

  • Inpatient

$500 copayment per admission

56

  • Outpatient

$75 copayment per visit

57

Emergency benefits:

  • In-area

$25/$40 copayment per physician’s office visit

$50 copayment per urgent care center visit

$150 copayment hospital emergency room visit

60

  • Out-of-area

$50 copayment per physician's office visit and urgent care center

$150 copayment per hospital emergency room visit

61-62

Mental health and substance use disorder treatment:

Outpatient: $25 copayment per visit

Inpatient: $500 copayment per admission

63-64

Prescription drugs:

  • Retail pharmacy - 30 day supply

Tier 1 (preferred generics) - $7 copayment

Tier 2 (preferred brand drugs) - 35%; Tier 4 (preferred specialty drugs) - 35%

Tier 3 (non-preferred brand drugs) - 50%; Tier 5 (non-preferred specialty drugs) - 50%

65-69

Point of Service benefits:

Deductible and Coinsurance

73

Protection against catastrophic costs (Out-of-Pocket Maximum):

In-Network: $8,550 Self-Only/$17,100 Self Plus One or Self and Family for covered services

Out-of-Network: $10,000 Self-Only/$20,000 Self Plus One or Self and Family for covered services

28




Summary of Benefits for the Standard Option HMO with POS of Independent Health - 2021

  • Do not rely on this chart alone. All benefits provided are subject to the definitions, limitations, and exclusions in this brochure. You can obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.Independentheath.com. On this page we summarize specific expenses we cover; for more detail, look inside.
  • If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
  • Under the HMO benefits, we only cover services provided or arranged by Plan providers, except in emergencies. This summary reflects the HMO benefits.
  • For the Standard Option, there is no In-Network annual deductible.



TermDefinition 1Definition 2

Medical Services provided by physicians:

Diagnostic and treatment services provided in the office  (see section 5 for specific benefit information and applicable fees)

Office visit copayment: Primary $30 copayment; Specialist: $50 copayment

32

Services provided by a hospital:

  • Inpatient

$750 copayment per admission

56

  • Outpatient

$100 copayment per visit

57

Emergency benefits:

  • In-area

$30/$50 copayment per physician's office visit

$75 copayment per urgent care center visit

$150 copayment hospital emergency room visit

60

  • Out-of-area

$75 copayment per physician's office visit and urgent care center visit

$150 copayment hospital emergency room visit

61-62

Mental health and substance use disorder treatment:

Outpatient: $30 copayment per visit

Inpatient: $750 copayment per admission

63-64

Prescription drugs:

  • Retail pharmacy - 30 day supply

Tier 1 (preferred generics) - $7 copayment

Tier 2 (preferred brand drugs) - 35%; Tier 4 (preferred specialty drugs) - 35%

Tier 3 (non-preferred brand drugs) - 50%; Tier 5 (non-preferred specialty drugs) - 50%

65-69

Point of Service benefits:

Deductible and Coinsurance

73

Protection against catastrophic costs (Out-of-Pocket Maximum):

In-Network: $8,550 Self-Only/$17,100 Self Plus One or Self and Family for covered services

Out-of-Network: $10,000 Self-Only/$20,000 Self Plus One or Self and Family for covered services

28




Summary of Benefits for the HDHP of Independent Health - 2021 (HDHP)

  • Do not rely on this chart alone. This is a summary.  All benefits are subject to the definitions, limitations, and exclusions in this brochure. Before making a final decision, please read this FEHB brochure.  You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.Independentheath.com.  If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
  • In 2021, for each month you are eligible for the Health Savings Account (HSA), we will deposit $83.33 per month for Self Only enrollment, $166.66 for Self Plus One per month or $166.66 per month for Self and Family enrollment to your HSA. For the HSA, you may use your HSA or pay out of pocket to satisfy your calendar year deductible of $2,000 for Self Only or $4,000 for Self Plus One or Self and Family. Once you satisfy your calendar year deductible, Traditional medical coverage begins. 
  • For the Health Reimbursement Arrangement (HRA), your health charges are applied to your monthly HRA Fund of $83.33 for Self Only, $166.66 for Self Plus One or $166.66 for Self and Family. Once your HRA is exhausted, you must satisfy your calendar year deductible.  Once your calendar year deductible is satisfied, Traditional medical coverage begins.
  • For the HDHP option, the annual combined In-Network deductible is $2,000 under Self Only and $4,000 under Self Plus One or Self and Family enrollment.  The deductible must be satisfied in full by one or more family members before we will begin paying benefits.



TermDefinition 1Definition 2

Medical services provided by physicians:

Diagnostic and treatment services provided in the office * (see Section 5 for specific benefit information and applicable fees)

In-Network: $20 copayment per office visit or 20% coinsurance for certain procedures

90

Services provided by a hospital:

  • Inpatient *

In-Network: $1,000 copayment per admission

107, 108

  • Outpatient *

In-Network: 20% coinsurance

108

Mental health and substance use disorder treatment *

In-Network Inpatient: $1,000 copayment per admission
In-Network Outpatient: Nothing

112, 113

Prescription drugs:

  • Retail pharmacy - 30 day supply *

Tier 1 (preferred generics) - $7 copayment
Tier 2 (preferred brand drugs) - 35%; Tier 4 (preferred specialty drugs) - 35%
Tier 3 (non-preferred brands) - 50%; Tier 5 (non-preferred specialty drugs) - 50%

114, 119

Point of Service benefits:

Deductible and Coinsurance 

Protection against catastrophic costs (Out-of-Pocket Maximum):

In-Network: $6,950 Self Only/$13,900 Self Plus One or Self and Family
Out-of-Network: $10,000 Self Only/$20,000 Self Plus One or Self and Family

88




2021 Rate Information for Independent Health

To compare your FEHB health plan options please go to www.opm.gov/fehbcompare.  To review premium rates for all FEHB health plan options please go to www.opm.gov/FEHBpremiums or www.opm.gov/Tribalpremium.

Non-Postal rates apply to most non-Postal employees. If you are in a special enrollment category, contact the agency that maintains your health benefits enrollment. 

Postal rates apply to certain United States Postal Service employees as follows:

  • Postal Category 1 rates apply to career bargaining unit employees who are represented by the following agreement: NALC. 
  • Postal Category 2 rates apply to career bargaining unit employees who are represented by the following agreement: PPOA.

Non-Postal rates apply to all career non-bargaining unit Postal Service employees and career bargaining unit employees who are represented by the following agreements: APWU, IT/AS, NPMHU, NPPN and NRLCA.  Postal rates do not apply to non-career Postal employees, Postal retirees, and associate members of any Postal employee organization who are not career Postal employees.

If you are a Postal Service employee and have questions or require assistance, please contact:  USPS Human Resources Shared Service Center: 1-877-477-3273, option 5, Federal Relay Service 1-800-877-8339.

Premiums for Tribal employees are shown under the monthly non-Postal column.  The amount shown under employee contribution is the maximum you will pay. Your Tribal employer may choose to contribute a higher portion of your premium. Please contact your Tribal Benefits Officer for exact rates.




New York
Type of EnrollmentEnrollment CodeNon-Postal Premium
BiWeekly
Gov't Share		Non-Postal Premium
BiWeekly
Your Share		Non-Postal Premium
Monthly
Gov't Share		Non-Postal Premium
Monthly
Your Share		Postal Premium
BiWeekly
Category 1 Your Share		Postal Premium
BiWeekly
Category 2 Your Share
High Option Self OnlyQA1$241.58$123.47$523.42$267.52$120.11$110.05
High Option Self Plus OneQA3$517.46$413.42$1,121.16$895.75$406.23$384.67
High Option Self and FamilyQA2$562.25$423.39$1,218.21$917.34$415.58$392.16
HDHP Option Self OnlyQA4$207.45$69.15$449.48$149.82$66.38$57.39
HDHP Option Self Plus OneQA6$510.84$170.28$1,106.82$368.94$163.47$141.33
HDHP Option Self and FamilyQA5$537.01$179.00$1,163.52$387.84$171.84$148.57
New York
Type of EnrollmentEnrollment CodeNon-Postal Premium
BiWeekly
Gov't Share		Non-Postal Premium
BiWeekly
Your Share		Non-Postal Premium
Monthly
Gov't Share		Non-Postal Premium
Monthly
Your Share		Postal Premium
BiWeekly
Category 1 Your Share		Postal Premium
BiWeekly
Category 2 Your Share
Standard Option Self OnlyC54$241.58$91.72$523.42$198.73$88.36$78.30
Standard Option Self Plus OneC56$517.46$332.46$1,121.16$720.33$325.27$303.71
Standard Option Self and FamilyC55$562.25$337.66$1,218.21$731.60$329.85$306.43