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

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

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

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

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

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

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

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

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

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

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event.  A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

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

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. Please tell us immediately of changes in family member status including your marriage, divorce, annulment, or when your child reaches age 26. We will send written notice to you 60 days before we proactively disenroll your child on midnight of their 26th birthday unless your child is eligible for continued coverage because they are incapable of self-support due to a physical or mental disability that began before age 26.

We will send written notice to you 60 days before we proactively disenroll your child on midnight of their 26th birthday unless your child is eligible for continued coverage because they are incapable of self-support due to a physical or mental disability that began before age 26. If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage. For a complete list of 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 members covered under your Self and Family enrollment are your spouse (including your spouse by valid common-law marriages from 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 below.

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

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

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

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

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

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

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

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

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

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

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

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

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2025 benefits of your prior plan or option.  If you have met (or pay cost-sharing that results in your meeting) the Out-of-Pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option.  However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 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, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).

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

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

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

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

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

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

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC).  For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, or if you are a covered child and you turn 26. 

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

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

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll.  Finally, if you qualify for coverage under another group health plan (such as your spouse’s plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program coverage.

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

• Your coverage under TCC or the spouse equity law ends (if you canceled your coverage or did not pay your premium, you cannot convert);
• You decided not to receive coverage under TCC or the spouse equity law; or
• You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal 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.

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

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call 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

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.

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

Plan providers are physicians and other healthcare professionals in our service area that we contract with to provide covered services to our members. Services by Plan Providers are covered when acting within the scope of their license or certification under applicable state law. We credential Plan providers according to national standards.

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

We list Plan providers in the provider directory, which we update periodically. The list is also on our website.

Benefits described in this brochure are available to all members meeting medically necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender.

This plan provides Care Coordinators for complex conditions and can be reached at 716-631-8701 or 800-501-3439 or view on our website at www.independenthealth.com for assistance.

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.

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.

HMO (High, Standard and HDHP Options)

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

Independent Health offers a wide choice of participating specialists. Your primary care provider 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 provider 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 provider will develop a treatment plan and recommend a specialist. Your primary care provider 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 provider. Your primary care provider will decide what treatment you need. If they recommend 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 provider, 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.

Your Plan primary care provider 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.

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.

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.

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 provider 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.

We require provider preauthorization for certain services. Your primary care provider 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.

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:

• 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
• Crisis Residence Facilities including Sub-acute Mental Treatment at a Crisis Residence facility
• 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
  • Power wheelchairs and accessories
  • Wearable Defibrillator Vests
• Elective hospital/facility admissions to include, for instance:
  • Admissions for transplants
  • Inpatient rehabilitation and habilitation admissions (Physical, Speech and Occupational Therapy)
  • Inpatient Mental Health admissions 
  • Medical admissions 
  • Skilled nursing facility admission
  • Substance use inpatient admissions
  • Surgical admissions
• Extracorporeal Shock Wave Therapy (ECSWT) for Chronic Plantar Fasciitis
• Genetic Testing 
• Gender Reassignment - Surgical Treatments
• Home Births
• Home Health Care Services excluding Home Infusion Nursing visits
• Hyperbaric Oxygen Therapy (Systemic and Topical)
• Implantable Defibrillators
• Intensity Modulate Radiation Therapy (IMRT)
• Therapeutic Radiopharmaceuticals: Zevalin, Lutathera, Hicon, Xofigo
• Partial Hospitalization for Mental Health Services
• Partial Hospitalization for Substance Use
• Proton Beam Radiation
• Precutaneous Left Atrial Appendage Occlusion e.g. Watchman
• Electronic Artificial Limbs
• Mental Health Residential Treatment
• Non-Emergent Ambulance, Planned Transfer including Air Ambulance
• Stereotactic Radiosurgery (SRS) including Gamma Knife and Stereotactic Body Radiotherapy
• Substance Use Residential Treatment
• Skin Substitutes
• Sleep Studies Facility Based
• Surgical Procedures:
  • Back and Neck Surgery
  • Bariatric Surgery (weight loss surgery)
  • Breast Surgery: Implant Removal, non-cancer diagnosis Breast Reconstruction, Breast Reduction Mammoplasty (male and female)
  • Cardiac Catheterization 
  • Cosmetic Procedures (medically necessary)
  • Joint Replacements - Hips, Knees & Shoulders
  • Oral Surgeries (Orthognathic)
  • Reconstructive Procedures
  • Septorhinoplasty & Rhinoplasty
  • Spinal Cord Stimulation
  • Temporomandibular (TMJ) Joint Disorder
  • Uvulopalatopharyngoplasty (UPPP)
• Total Artificial Heart
• Transcatheter Aortic Valve Replacement (TAVR) and MitraClip
• Transcranial Magnetic Stimulation
• Transplant Procedures
• Vagus Nerve Stimulation
• Varicose Vein Procedures
• Vision Therapy
• Wireless Capsule Endoscopy (WCE)

First, you, your representative or your provider, 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)

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

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

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

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

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

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 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).

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.

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.

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

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

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

If 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.

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.

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 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 your claim is in reference to a contraceptive, call 716-631-8701 or 800-501-3439.

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

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

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

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

2. Ask you or your provider for more information.

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

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

3. Write to you and maintain our denial.

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

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

Independent Health offers a wide choice of participating specialists. Your primary care provider 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 provider 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 provider will develop a treatment plan and recommend a specialist. Your primary care provider 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 provider. Your primary care provider will decide what treatment you need. If they recommend 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 provider, 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.

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.

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 provider who is part of our network.

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 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.

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. 

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

For the High and Standard Options, after your In-Network Out-of-Pocket expenses, (including any applicable deductibles, copayments and coinsurance) total $9,100 for Self Only, or $18,200 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 $18,200 in total Out-of-Pocket costs but no one individual in the family may exceed $9,100.

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 $7,100 for Self Only, or $14,200 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 $14,200 must be satisfied in full by one or more family members before you do not have to pay any more for covered services.

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).

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

A surprise bill is an unexpected bill you receive for:

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

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

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

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to https://www.independenthealth.com/IndividualsFamilies/Tools,FormsMore/SurpriseBillLaw or contact the health plan at 716-631-8701.

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

Professional services of physicians

• 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 

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 they offer 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 provider 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) and dermatology services.

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: Nothing

Behavioral Health: Nothing

Dermatology: $40 copayment per consultation

General Medicine: Nothing

Behavioral Health: Nothing

Dermatology: $50 copayment per consultation

Tests, such as:

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

Preventive radiology procedures - for the detection of breast cancer:

• Ultrasound 
• MRI
• Diagnostic mammogram

Nothing

Nothing

Radiology procedures such as:

• Routine X-ray
• Ultrasound

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

$50 copayment per visit for radiology procedures in addition to any copayment for office services

Advanced Radiology such as:

• CT scan
• MRI/MRA
• PET scan
• 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 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.

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

Routine physical every plan year:

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

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

Nothing       

Nothing

• Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC) based on the Advisory Committee on Immunization Practices (ACIP) schedule. For a complete list of endorsed immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/
  
  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

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider.

Nothing

Nothing

• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines. See Section 5(f) for cost share requirements for anti- obesity medications

• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity. See Section 5(b) for surgery requirements and cost share

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.

• 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
• Children's Immunizations endorsed by the Centers for Disease Control (CDC) including DTaP/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella.  For a complete list of immunizations go to the website at https://www.cdc.gov/vaccines/schedules/index.html
• You may also find a complete list of U.S. Preventive Services Task Force (USPSTF) A and B recommendations online at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations

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

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider

Nothing

Nothing

• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines. See Section 5(f) for cost share requirements for anti- obesity medications

• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity. See Section 5(b) for surgery requirements and cost share

Complete maternity (obstetrical) care, such as:

• Prenatal and Postpartum care
• Screening for gestational diabetes
• Delivery
• Screening and counseling for prenatal and postpartum depression

Breastfeeding and lactation support, supplies and counseling for each birth

Note: Here are some things to keep in mind:

You do not need to preauthorize your vaginal delivery.

Nothing

Nothing

• As part of your coverage, you have access to in-network certified nurse midwives, home nurse visits and board-certified lactation specialists during the prenatal and post-partum period.
• You may remain in the hospital up to 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   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. 
• 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 hospital stay, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits. In addition, circumcision is covered at the same rate as for regular medical or surgical benefits.

Not covered

All charges

All charges

Contraceptive counseling on an annual basis

Services for advanced infertility:

• Coverage is limited to Three (3) cycles of IVF treatment over the life of the insured.
• Cryopreservation and storage of sperm, ova, and embryos in connection with in vitro fertilization.

A “cycle” is all treatment that starts when: preparatory medications are administered for ovarian stimulation for oocyte retrieval with the intent of undergoing in vitro fertilization using a fresh embryo transfer, or medications are administered for endometrial preparation with the intent of undergoing in vitro fertilization using a frozen embryo transfer.

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

$50 copayment per visit for routine radiology services

$75 copayment for advanced radiology services

A range of voluntary family planning services, without cost sharing, that includes at least one form of contraception in each of the categories on the HRSA list. This list includes:

• Voluntary female sterilization
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo Provera)
• Intrauterine devices (IUDs)
• Diaphragms
• Genetic testing and counseling

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

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

Reimbursement for over-the-counter contraceptives can be submitted by calling 716-631-8701 or 800-501-3439.

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

Nothing                

Nothing

Voluntary male sterilization (See Surgical Procedures Section 5 (b)

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

Infertility is a disease or condition characterized by the incapacity to impregnate another person or conceive defined by the failure to establish a clinical pregnancy after 12 months of egg-sperm contact when the individual is under age 35 and 6 months for an individual age 35 and over.  Infertility may also be supported through evidence based on medical history and diagnostic testing.

Diagnosis and treatment of infertility specific to:

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

Fertility preservation

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 (See Section 5f)

Note: We cover self injectable and oral fertility drugs under the prescription drug benefit, including three (3) cycles of IVF drugs per year.

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

Note: We cover fertility preservation only when there is the possibility of iatrogenic infertility.  The storage fee will apply the laboratory services copayment of $0.

Note: Coverage for artificial insemination is based on your provider's assessment of your medical history.

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

$50 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.
• 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

• 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

• Provocative food testing
• Sublingual allergy desensitization

• Radiation therapy
• Respiratory and inhalation therapy
• Cardiac rehabilitation
• 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 48-52.

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

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.

$40 copayment per outpatient visit 

Nothing per visit during covered inpatient admission

$50 copayment per outpatient visit 

Nothing per visit during covered inpatient admission

Not covered:

• Long-term rehabilitative therapy
• Exercise programs

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.

$40 copayment per outpatient visit

Nothing per visit during covered inpatient admission

$50 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

• 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

• 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

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)

• 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

• 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.

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

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 healthcare 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 healthcare provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

Nothing

Nothing

Not covered:

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

• Home healthcare 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

$40 copayment per visit

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

$50 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

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.

$40 copayment per office visit

$50 copayment per office visit

No benefit.

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.
• Diabetes self management

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 

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

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)
• Surgical treatment of severe obesity (bariatric surgery)
• Insertion of internal prosthetic devices. See 5(a) – Orthopedic and prosthetic devices for device coverage information
• Treatment of burns

Note: Bariatric surgery is subject to medical necessity review, contact Independent Health for more information.

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

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

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

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

• 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)

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

• Gender Affirming Surgery

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

• Facial gender affirming surgery
• Complete hysterectomy
• Orchiectomy
• Penectomy
• Vaginoplasty
• Vaginectomy
• Clitoroplasty
• Labiaplasty
• Salpingo-oophorectomy
• Scrotoplasty
• Urethroplasty
• Phalloplasty

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

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)

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 neuroblastoma
• Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
• Amyloidosis
• Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
• Hematopoietic stem cell transplant
• Hemoglobinopathy
• Infantile malignant osteopetrosis
• Kostmann's syndrome
• Leukocyte adhesion deficiencies
• Marrow Failure and related disorders (i.e. Fanconi's, Paroxysmal Nocturnal Hemoglobinu
• Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
• Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s syndrome, Sanfillippo’s syndrome, Maroteaux-Lamy syndrome variants)
• 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
• Medulloblastoma
• Multiple myeloma
• Pineoblastoma
• 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 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, PNH, Pure Red Cell Aplasia)
  • Myelodysplasia/Myelodysplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia

Nothing 

Nothing 

• 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
  • Medulloblastoma
  • Multiple myeloma
  • Pineoblastoma
  • 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 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, 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

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

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

Allogeneic transplants for:

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

Mini-transplants (non-myeloblative allogeneic transplants or reduced intensity conditioning (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 (MDDs)
• Non-small cell lung cancer
• Ovarian cancer
• Prostate cancer
• Renal cell carcinoma
• Sarcomas
• Sickle cell disease

Autologous transplants for

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

Nothing 

Nothing 

National Transplant Program (NTP) –

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.

Not covered:

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

Professional services provided in –

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

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

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

• 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

Skilled nursing facility (SNF) and subacute facility: We provide a comprehensive range of benefits for up to 45 days per year, 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

• Custodial care, maintenance care, respite care, or convenience care

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

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

• 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

• 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: Healthcare 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. 

• 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

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

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 substance use disorders, including detoxification, treatment and counseling
• Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
• Electroconvulsive therapy

$25 copayment per visit

$30 copayment per visit

• Opioid Treatment Program administered at a Certified OASAS Facility

Nothing

Nothing

• 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;

$25 copayment per visit for outpatient diagnostic tests

Nothing for inpatient 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;

$30 copayment per visit for outpatient diagnostic tests

Nothing for inpatient diagnostic tests

$50 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.

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

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

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, including three (3) cycles per year of IVF drugs, when you meet specific criteria (See Section 5(a) Infertility Services)
• Hormonal drugs
• Sexual dysfunction drugs 
• Drugs to treat gender dysphoria
• Medications prescribed to treat obesity

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.

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

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

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

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

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

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

Note: 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.  

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

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

• 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

Nothing

Nothing

• 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

Preventive medications with USPSTF A and B recommendations. These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients.  For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

In addition to the USPSTF recommendations above, the following medications are also considered preventive:

• Ace Inhibitors
• Antiresorptive Therapy Medications
• Beta-Blockers
• Diabetic Oral Agents
• Selective Serotonin Reuptake Inhibitors (SSRI's)
• Statins (under age 40 and over age 75)
• Angiotensin Receptive Blocker

Nothing

Nothing

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

For more information consult the FDA guidance at: https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose

Or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go to https://www.findtreatment.samhsa.gov/

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 unless specifically indicated elsewhere

All charges

All charges

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.

Not covered:

• Injury to the teeth caused by eating or chewing

Not covered:

• Dental services listed above

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.

TTY National 711 Relay Service

TTY National 711 Relay Service

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.

Care for You Program

The Care for You program was created to assist members who have chronic health conditions get both the medical care and assistance they need without the frustration of navigating the health care system alone.

Our team will help coordinate your appointments, transportation and other matters related to your care – taking away the burden of having to do this. By knowing who to call and what to ask for, we’re able to get the answers you need quickly with less hassle – so you can spend more time focusing on your health and wellness. Independent Health will contact you if you are eligible for this benefit.

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.

With preauthorization, you have access to certain facilities through Optum Healthcare 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.

Health Risk Assessment (HRA)

• Health is everything. Complete a Health Risk Assessment (HRA) online to get your personal health summary.
• It’s an easy way to see where you’re on track and where you can make a few healthy changes.
• Log in to your MyIH account at MyIH.com, or download the MyIH app, to get started!

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

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!

Diabetes Prevention Program

The Diabetes Prevention Program is an evidence-based, educational and support program, taught by trained Lifestyle Coaches that is designed to prevent or delay the onset of type 2 diabetes.  Contact your PCP for more information. 

The Diabetes Prevention Program is an evidence-based, educational and support program, taught by trained Lifestyle Coaches that is designed to prevent or delay the onset of type 2 diabetes.  Contact your PCP for more information. 

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.

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.

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

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).

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 2025 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 $4,300 for an individual and $8,550 for a family. See maximum contribution information on page 82. 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 Healthcare Flexible Spending Account (FSA): If you are enrolled in this HDHP with a Health Savings Account (HSA), and start or become covered by a healthcare 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.

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 2025 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 Healthcare Flexible Spending Account. However, you must meet FSAFEDS eligibility requirements.

Your annual maximum for Out-of-Pocket expenses (deductibles, coinsurance and copayments) for covered In-Network services is limited to $7,100 per person or $14,200 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.

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 126 for more details).

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

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

None.

None.

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.

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

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.

For 2025, a monthly premium pass through of $83.33 will be made by the HDHP directly into your HSA each month.

For 2025, your HRA monthly credit is $83.33.

For 2025, a monthly premium pass through of $166.66 will be made by the HDHP directly to your HSA each month.

For 2025 your HRA monthly credit is $166.66.

For 2025, a monthly premium pass through of $166.66 will be made by the HDHP directly into your HSA each month.

For 2025, your HRA monthly credit is $166.66.

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 $4,300 for an individual and $8,550 for a family.

If you enroll during Open Season, you are eligible to fund your account up to the maximum contribution 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 maximum 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 by 12, 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).

Additional contributions discussed on page 85.

If you are eligible for HRA credits, a portion of your monthly health plan premium is deposited to your HRA each month. The HRA does not earn interest.

You may make an annual maximum contribution of $3,300.04.

You cannot contribute to the HRA

You may make an annual maximum contribution of $6,550.08

You cannot contribute to the HRA.

You may make an annual maximum contribution of $6,550.08

You cannot contribute to the HRA.

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.

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 Publications 502 and 969 for information on 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 Publications 502 and 969 for information on eligible medical expenses. Over-the-counter drugs and Medicare premiums are also reimbursable. Medical insurance premiums are not reimbursable.

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.

Employees 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 you are 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.

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.

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.

If you are age 55 or older, the IRS permits you to make additional contributions to your HSA. The allowable additional contribution is $1,000. Contributions must stop once an individual is enrolled in Medicare. Additional details are available on the IRS website at www.irs.gov or request a copy of IRS Publication 969 by calling 1-800-829-3676. 

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.

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, 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 detailed information of IRS-allowable expenses, request a copy of IRS Publications 502 and 969 by calling 800-829-3676, or visit the IRS Website at www.irs.gov and click on “Forms and Publications.” Note: Although over-the-counter drugs are not listed in the publication, they are reimbursable from your HSA. Also, insurance premiums are reimbursable under limited circumstances.

Please review the chart on pages 79-82 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.

Routine physical examination

• Once every plan year

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

• U.S. Preventive Services Task Force (USPSTF) A and B recommended  screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer.  For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at  https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening to interpersonal and domestic violence.  For a complete list of preventive care benefits for women please go to the Health and Human Services (HHS) website at https://www.hrsa.gov/womans-guidelines 

In-Network: Nothing

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

• Routine mammogram

In-network: Nothing

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

• Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC) based on the Advisory Committee on Immunization Practices (ACIP) schedule. For a complete list of endorsed immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/
  
  

In-Network: Nothing

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

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider.

In-Network: Nothing

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

• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines. See Section 5(f) for cost share requirements for anti-obesity
  medications.

• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity. See Section 5(b) for surgery requirements and cost share.

• 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.

All charges

• Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics.  For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
• Children's Immunizations endorsed by the Centers for Disease Control (CDC) including DTaP/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella.  For a complete list of immunizations go to the website at https://www.cdc.gov/vaccines/schedules/index.html
• You may also find a complete list of U.S. Preventive Services Task Force (USPSTF) A & B recommendations online at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations

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

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider.
  
  

In-Network: Nothing

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

• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines. See Section 5(f) for cost share requirements for anti-obesity
  medications.

• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity. See Section 5(b) for surgery requirements and cost share.

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

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.

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

• 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 they offer 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 provider 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) and dermatology services.

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: Nothing

Behavioral Health: Nothing

Dermatology: $20 copayment per consultation

Out-of-Network: Not covered

Tests, such as:

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

In-Network: Nothing

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 (CAT) 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

Maternity (obstetrical) care, such as:

• Prenatal and Postpartum care
• Screening for gestational diabetes
• Delivery
• Screening and counseling for prenatal and postpartum depression

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 
• As part of your coverage, you have access to in-network certified nurse midwives, home nurse visits and board-certified lactation specialists during the prenatal and post-partum period.
• You may remain in the hospital up to 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. 
• 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 hospital stay, the newborn is considered a patient in their own right.  If the newborn is eligible for coverage, regular medical or surgical benefits may apply rather than maternity benefits. In addition, circumcision is covered at the same rate as for regular medical or surgical benefits. . In addition, circumcision is covered at the same rate as for regular medical or surgical benefits

In-Network: Nothing

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

Breastfeeding and lactation 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

Contraceptive counseling on an annual basis

In-Network: Nothing

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

Services for advanced infertility:

• Coverage is limited to Three (3) cycles of IVF treatment over the life of the insured.
• Cryopreservation and storage of sperm, ova, and embryos in connection with in vitro fertilization.

A “cycle” is all treatment that starts when: preparatory medications are administered for ovarian stimulation for oocyte retrieval with the intent of undergoing in vitro fertilization using a fresh embryo transfer, or medications are administered for endometrial preparation with the intent of undergoing in vitro fertilization using a frozen embryo transfer.

In-Network: 

Primary: $20 copayment per visit for services performed at an office

Specialist: $20 copayment per visit for services performed at an office

20% coinsurance per visit for surgical services provided at an outpatient hospital

20% coinsurance per visit for surgical services provided at an ambulatory surgical center

Nothing for laboratory and inpatient procedures

20% coinsurance per visit for routine radiology services

20% coinsurance for advanced radiology services

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

A range of voluntary family planning services, without cost sharing, that includes at least one form of contraception in each of the categories on the HRSA list. This list includes:

• Voluntary female sterilization
• 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: See additional Family Planning and Prescription drug coverage Section 5(f)

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

Reimbursement for over-the-counter contraceptives can be submitted by calling 716-631-8701 or 800-501-3439.

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

In-Network: Nothing

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

Voluntary male sterilization: 

• 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

Infertility is a disease or condition characterized by the incapacity to impregnate another person or conceive defined by the failure to establish a clinical pregnancy after 12 months of egg-sperm contact when the individual is under age 35 and 6 months for an individual age 35 and over.  Infertility may also be supported through evidence based on medical history and diagnostic testing.

Diagnosis and treatment of infertility specific to:

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

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 (See Section 5f)

Note: We cover self injectable and oral fertility drugs under the prescription drug benefit, including three (3) cycles of IVF drugs per year.

Note: Coverage for artificial insemination is based on your provider's assessment of your medical history.

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 cover fertility preservation only when there is the possibility of iatrogenic infertility.  The storage fee will apply the laboratory services copayment of $0 after the deductible.

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.
• 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

• 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

Not covered:

• Provocative food testing
• Sublingual allergy desensitization

• 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
• Respiratory and inhalation therapy
• Cardiac rehabilitation
• 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.

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

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

• 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

• 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

• 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

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)

• 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: 50% coinsurance

Out-of-Network: 50% 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
• Ostomy Supplies

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

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

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 healthcare 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: 50% coinsurance

Out-of-Network: 50% coinsurance, plus any difference between our payment and the billed charges

Diabetic equipment such as;

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

In-Network: Nothing

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)

• Home healthcare 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

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

• 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

No benefit.

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

In-Network: Nothing

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

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)
• Surgical treatment of severe obesity (bariatric surgery)
• Insertion of internal prosthetic devices. See 5(a) – Orthopedic and prosthetic devices for device coverage information
• Treatment of burns

Note: Bariatric surgery is subject to medical necessity review, contact Independent Health for more information.

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

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

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

In-Network:

Office and Outpatient: 20% coinsurance

Inpatient: Nothing

• 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

• 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)

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

• Gender Affirming Surgery

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

• Facial gender affirming surgery
• Complete hysterectomy
• Orchiectomy
• Penectomy
• Vaginoplasty
• Vaginectomy
• Clitoroplasty
• Labiaplasty
• Salpingo-oophorectomy
• Scrotoplasty
• Urethroplasty
• Phalloplasty

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

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)

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

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 neuroblastoma
• Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
• Amyloidosis
• Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
• Hematopoietic stem cell transplant
• Hemoglobinopathy
• Infantile malignant osteopetrosis
• Kostmann’s syndrome
• Leukocyte adhesion deficiencies
• Marrow Failure and related disorders (i.e. Fanconi's, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
• Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
• Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s syndrome, Sanfillippo’s syndrome, Maroteaux-Lamy syndrome variants)
• 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
• Medulloblastoma
• Multiple myeloma
• Medullablastoma
• Pineoblastoma
• Neuroblastoma
• 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 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, 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

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 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
• Multiple myeloma
• Multiple sclerosis
• Sickle cell anemia

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

• Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
• Advanced Hodgkin’s lymphoma
• Advanced non-Hodgkin’s lymphoma
• Breast cancer
• Chronic lymphocytic leukemia
• Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
• Chronic myelogenous leukemia
• Colon cancer
• Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
• Multiple myeloma
• Myelodysplasia/Myelodysplastic Syndromes
• Multiple sclerosis
• Myeloproliferative disorders (MDDs)
• 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 sarcoma
• Advanced Hodgkin's lymphoma
• Advanced non-Hodgkin's lymphoma
• Aggressive non-Hodgkin's lymphomas
• Breast Cancer
• Childhood rhabdomyosarcoma
• Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL) 
• Chronic myelogenous leukemia
• Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
• Epithelial Ovarian Cancer
• Mantle cell (Non-Hodgkin's lymphoma)
• Multiple sclerosis
• Small cell lung cancer
• Systemic lupus erythematosus
• 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

National Transplant Program (NTP) - 

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.

National Transplant Program (NTP) - 

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.

Not covered:

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

Professional services provided in –

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

In-Network:

Inpatient: Nothing

Outpatient: 20% coinsurance

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

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

• 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
• Ostomy supplies
• 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

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

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

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

• Local professional ambulance service when medically appropriate. See 5(d) for emergency service

Not covered:

• Wheelchair van transportation

• 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: Healthcare 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.

Not covered:

• Elective care or non-emergency care

• 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

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

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

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 substance use disorders, including detoxification, treatment and counseling
• Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
• Electroconvulsive therapy

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.

• 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:

Nothing for laboratory tests

Nothing for diagnostic tests

20% coinsurance for radiology services

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

Opioid Treatment Program administered at a Certified OASAS Facility

Nothing

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

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

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

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, including three (3) cycles per year of IVF drugs, when you meet specific criteria (See Section 5(a) Infertility Services)
• Hormonal drugs
• Sexual dysfunction drugs 
• Drugs to treat gender dysphoria
• Medications prescribed to treat obesity

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.

20% coinsurance or the applicable prescription member liability, whichever is less, for up to a 30-day supply

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

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

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

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

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

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

Note: 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.  

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

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

Nothing per 30-day supply

• Insulin and oral agents

$100 cap applies to insulin only

$20 copayment or the applicable prescription member liability, whichever is less but not more than $100 in member liability for a 30-day supply for an insulin drug

• 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

Nothing

• 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

Preventive medications with USPSTF A and B recommendations. These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients.  For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

In addition to the USPSTF recommendations above, the following medications are also considered preventive:

• Ace Inhibitors
• Antiresorptive Therapy Medications
• Beta-Blockers
• Diabetic Oral Agents
• Selective Serotonin Reuptake Inhibitors (SSRI's)
• Statins (under age 40 and over age 75)
• Angiotensin Receptive Blocker

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

For more information consult the FDA guidance at https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose

Or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go to https://www.findtreatment.samhsa.gov/

Nothing

Not covered: