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.

The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. Benefits will not be available to your spouse until you are married.

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

Contact your 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.

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.

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

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

Family members covered under your Self and Family enrollment are your spouse (including your spouse by valid common-law marriage 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 doesn’t 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 2024 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 31^st 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 60^th day after the end of the 31 day temporary extension.

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

If you are 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 be automatically 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, 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  coverage in your state. For assistance in finding coverage, please contact us at 1-800-851-3379 or visit our website at www.healthalliance.org

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

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 1-800-851-3379 or write to us at Health Alliance, 3310 Fields South Drive, Champaign, IL 61822. You may also request replacement cards through our website at www.healthalliance.org.

You can get care from both In Network and Out of Network providers. In Network Providers will submit claims to us on your behalf and obtain any necessary prior authorization. You have direct access to In-Network Providers without a referral from your Primary Care Provider or by another participating provider in the network. You can also get care from Out of Network providers. It is your responsibility to obtain prior authorization for Out of Network services that require pre-authorization. If you use In Network providers, you will pay less.

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

Plan providers are in-network providers 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 service 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 at www.healthalliance.org.

This plan recognizes that transgender, non-binary and other gender diverse members require health care delivered by healthcare providers experienced in gender affirming health.

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

This plan provides for Care Coordination for complex conditions and can be reached at 1-800-851-3379 or www.healthalliance.org 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 at www.healthalliance.org.

You can go to any In-network provider, but in some circumstances, we must approve your care in advance. You also have Out-of-Network benefits under this plan. If you receive care from an Out-of-Network provider, you will be responsible for the deductible and coinsurance amount and you may be responsible for the differnce in our allowed amount and the billed amount. Please see Section 4, "Your Cost for Covered Services" for benefit information.

Your primary care provider can be a family or general practitioner, internist, or pediatrician. We encourage you to utilize an In Network Primary Care Provider to assist in coordination of your healthcare services under this Plan. Your primary care provider will provide most of your healthcare, or give you a referral to see a specialist.

If you want to change primary care provider or if your primary care provider leaves the Plan, call us. We will help you select a new one.

Your primary care provider will refer you to a specialist for needed care. When you receive a referral from your primary care provider, you must return to the primary care provider after the consultation, unless your primary care provider authorized a certain number of visits without additional referrals. The primary care provider must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care provider gives you a referral. However, you may receive optometric care for routine eye exams and females may see a Woman’s Principal Health Care Provider without a referral. You are responsible for making sure your primary care provider refers you to an in-network specialist. Please refer to your provider directory or you can view our provider directory on our website at www.healthalliance.org. Here are some other things you should know about specialty 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 that allows you to see your specialist for a certain number of visits without additional referrals.

Your primary care provider will create your treatment plan. The physician may have to get an authorization or approval from us beforehand. If you are seeing a specialist when you enroll in our Plan, talk to your primary care provider. If they decide to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

• If you are seeing a specialist and your specialist leaves the Plan, call your primary care provider, who will arrange for you to see another specialist.
• 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; or
  • 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 specialists 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.

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our Customer Service Department immediately at 1-800-851-3379. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

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

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

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

You must get prior approval for certain services. Failure to do so will result in the service not being eligible for coverage. When using out of network providers, you are responsible for ensuring that all services are preauthorized before you receive the service. 

If the prior authorization request is approved, both you and your Provider will be notified of the Effective Dates and the kind of care and services you are authorized to receive. Once your prior authorization approval expires, it is your responsibility to notify your Provider so he/she can determine whether further care is needed, and if so, submit another prior authorization request to Health Alliance.

If your prior authorization request is denied, you and your Provider will be notified in writing. If the prior authorization request is denied, Health Alliance will not provide coverage for the requested services. Health Alliance maintains a list of services that require prior authorization for medical necessity. Prior authorization can be initiated by calling Health Alliance at the number on the back of your Health Alliance Identification Card.

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 call this review and approval process “prior authorization”. Your physician must obtain prior authorization before sending you to a provider outside your service area or to a non-Plan provider. Some of the services requiring prior authorization are listed below (a complete listing of services requiring prior authorization can be found at www.healthalliance.org:

• Ambulance (non-urgent air and non-urgent ground)
• Bariatric surgery
• Breast reconstruction surgeries
• Breast implant surgeries
• Gynecomastia surgery
• Reduction mammoplasty, female
• Cardiac imaging and procedures (echo, echo stress, cardiac rhythm implantable devices, myocardial perfusion imaging, nuclear medicine, diagnostic heart catheterization)
• Chiropractic and massage therapy
• Clinical trials, phase I, II, III and IV
• Durable Medical Equipment
• Experimental and investigational services
• Gender reassignment procedures
• Genetic testing (including molecular diagnostics)
• Imaging
• CT, CTA, MRI, MRA, PET, 3D
• Obstetrical and diagnostic ultrasound
• Infertility (all diagnostic tests, medications, treatments, etc.)
• Inpatient rehabilitative services
• Interventional pain management
• Joint surgery—select
• Private duty nursing
• Radiation therapy, including but not limited to:
  • Proton beam therapy
  • Stereotactic radiosurgery
• Rehabilitative therapies
  • Occupational therapy
  • Physical therapy
  • Speech therapy
• Skilled nursing facility
• Sleep diagnostics, evaluations and supplies
• Transplant services

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

First, your physician, your hospital, you or your representative, must call us at
1-800-851-3379 before admission or services requiring prior authorization are rendered.
Next, provide the following information:

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

For non-urgent care claims, we will tell the physician and/or hospital that 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 judgement 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 1-800-851-3379. You may also call OPM's FEHB 2 at 1-202-606-3818 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at 1-800-851-3379. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim)

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

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

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

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 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 received the claim.

Your responsiblity for obtaining prior authorization depends on whether you use an In Network or Out of Network provider. In Network providers are responsible for obtaining the prior authorization for services you receive. When seeing an Out of Network provider, you are responsible for ensuring that all services listed are Preauthorized before you receive 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 precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below. If your claim is in reference to a contraceptive, call 1-800-851-3379.

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

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

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

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

2. Ask you or your provider for more information. 

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

3. We will write to you with our decision.

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

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

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

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

Example:  When you see your primary care provider, you pay a copayment of $30 per office visit.

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

• The calendar year deductible for In Network providers is $750 per person for Self Only or Self Plus One enrollments. Under a Self and Family enrollment, benefits are payable for any individual when the $750 per person deductible is satisfied, or the deductible is considered satisfied and benefits are payable for all family members when the combined expenses applied to the calendar year deductible for all family members reach $1500.
• The calendar year deductible for Out of Network providers is $1500 per person for Self Only or Self Plus One enrollments and $3000 for Self and Family enrollment.

Deductibles for In Network providers and Out of Network providers are accumulated separately.

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

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

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

Example: You pay 25% of our allowance for durable medical equipment with In Network Providers and you pay 50% of our allowance with Out of Network Providers .

Our "Plan Allowance" is the amount we use to calculate our payment for certain types of covered services. 

When you see In Network Providers for covered services, your cost consists only of your deductible, coinsurance and/or copayment.

When you see Out of Network Providers for covered services, your cost consists of your deductible and coinsurance, and potentially the difference between our maximum plan allowance and the billed amount. 

Be aware that when you use the services of an Out of Network Provider for a covered service in Non-Emergency situations, benefit payments to such Out of Network Provider are not based upon the amount billed. The basis of your benefit payment will be determined according to your Plan's fee schedule, and the Maximum Allowable Charge. Non-Participating Providers may bill Members for any amount up to the billed charge after the Plan has paid its portion of the bill as provided in Section 356z.3a of this Code. In network Providers have agreed to accept discounted payments for services with no additional billing to the Member other than Copayments, Coinsurance and Deductible amounts. 

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.

In Network, after your deductible, copayments, and coinsurance total $7,350 for Self Only or $7,350 per person for Self Plus One, or $14,700 per Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. 

The Out of Network out of pocket maximum is $14,700 for Self Only, or $29,400 for Self Plus One and Self Plus Family enrollment.

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.

The No Surprises Act (NSA) is a federal law that provides you with protection 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 non-participating 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 a nonparticipating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan.

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

In addition, your health plan adopts and complies with the surprise billing laws of Illinois, Iowa and Indiana.

For specific information on surprise billing, the rights and protections you have, and your responsibilities, go to www.healthalliance.org or contact the health plan at 800-851-3379.

• 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 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

$30 per office visit to a Primary Care Provider. No deductible.

$60 per office visit to a Specialist. No deductible.

50% coinsurance per office/outpatient visit, deductible applies

Professional services of physicians

• In an urgent care center
• Office medical consultation
• Second surgical opinion
• Advance care planning
• At home
• Virtual visit

$30 per office visit to a Primary Care Provider. No deductible.

$60 per office visit to a Specialist. No deductible.

Nothing (No deductible) for the first 6 visits per calendar year for any covered Virtual acute care visit; $30 copayment per Virtual visit beginning with the 7^th visit with a virtual Primary Care Provider or the 7th acute virtual visit respectively (No deductible) (combined with Primary Care Provider, Mental Health/Substance Use Disorder)

50% per office visit to a Primary Care Provider, deductible applies

50% per office visit to a Specialist, deductible applies

Professional services of physicians

• During a hospital stay
• In a skilled nursing facility

25% coinsurance, deductible applies

50% coinsurance, deductible applies

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap tests
• Pathology
• X-ray
• Non-routine mammogram
• Ultrasound
• Electrocardiogram and EEG
• Surveillance test for ovarian cancer

25% coinsurance, deductible applies

50% coinsurance, deductible applies

• CT Scans
• MRI
• PET Scans

25% coinsurance, deductible applies

50% coinsurance, deductible applies

Routine physical every 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 for interpersonal and domestic violence. For a complete list of preventive care benefits for women go to the Health and Human Services (HHS) website at https://www.hrsa.gov/womens-guidelines
• To build your personalized list of preventive services go to  https://health.gov/myhealthfinder

Nothing.

50% coinsurance, deductible applies

• Routine mammogram

Nothing.

50% coinsurance, deductible applies

• 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.

50% coinsurance, deductible applies

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.

50% coinsurance, deductible applies

• 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.

See Section 5(f) for cost share requirements for anti-obesity medications.

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.

See Section 5(b) for surgery requirements and cost share.

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

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

Nothing.

50% coinsurance, deductible applies

• You can 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.

Nothing.

50% coinsurance, deductible applies

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.

50% coinsurance, deductible applies

• 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.

See Section 5(f) for cost share requirements for anti-obesity medications.

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.

See Section 5(b) for surgery requirements and cost share.

See Section 5(b) for surgery requirements and cost share.

Complete maternity (obstetrical) care, such as:

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

Note: Here are some things to keep in mind:

• 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 do not need to precertify your vaginal or cesarean delivery; see Section 3, How to Get Care Maternity for Inpatient hospital admission for other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.
• We cover routine nursery care of the newborn child during the covered portion of the mother’s hospital stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. 
• 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.

$60 copay nothing thereafter for routine prenatal care. No deductible.

Note: You are responsible for 25% coinsurance for inpatient or outpatient facility charges. Please refer to Section 5(c) Services provided by a hospital or other facility and ambulance services for information.

50% per office visit for for routine prenatal care, deductible applies

50% Coinsurance for inpatient stay, deductible applies

Breastfeeding and lactation support, supplies and counseling for each birth.

50% coinsurance, deductible applies

Contraceptive counseling on an annual basis

50% coinsurance, deductible applies

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

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

Note: Your plan offers voluntary female sterilization surgery coverage at no cost to members without prior authorization. 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). 

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

Females pay nothing if done for contraceptive purposes. You pay only your office visit copayment.

$30 per office visit to a Primary Care Provider. No deductible.

$60 per office visit to a Specialist. No deductible.

25% coinsurance per outpatient surgical admission, deductible applies

Note: If for males or reasons other than contraceptive or family planning purposes, then you pay the appropriate deductible, copayment (office visit, surgical, durable medical equipment) or coinsurance.

50% coinsurance, deductible applies

Voluntary male sterilization

$30 per office visit to a Primary Care Provider. No deductible.

$60 per office visit to a Specialist. No deductible.

25% coinsurance per outpatient surgical admission, deductible applies

50% coinsurance, deductible applies

Genetic Testing

• Genetic testing and molecular diagnostic testing is covered when determined to be Medically Necessary. 

Note: Prior authorization and approval is required. Testing that is determined to be experimental or investigational is not covered.

$30 per office visit to a Primary Care Provider. No deductible.

$60 per office visit to a Specialist. No deductible.

25% coinsurance other covered services while done in the office, deductible applies

25% coinsurance per outpatient surgical admission, deductible applies

50% coinsurance, deductible applies

Not covered:

• Reversal of voluntary surgical sterilization

All charges.

All charges.

A failure to establish a pregnancy or to carry a pregnancy to live birth after 12 months of unprotected sexual intercourse if the individual with female reproductive organs is 35 years of age or younger (on or prior to 35th birthday), or after 6 months of unprotected sexual intercourse if the individual with female reproductive organs is over 35 years of age (after 35th birthday).

For individuals with female reproductive organs without male partners and no regular exposure to sperm, to demonstrate a diagnosis of infertility, Intrauterine Insemination (IUI) treatment is required (coverage of donor sperm is included). 

Diagnosis and treatment of infertility specific to:

• Artificial insemination (AI)
• Assisted Reproductive Technologies (ART)
• Intravaginal insemination (IVI)
• Intracervical insemination (ICI)
• Intrauterine insemination (IUI)
• In Vitro Fertilization (IVF)
• Uterine embryo lavage
• Embryo transfer
• Gamete intrafallopian tube transfer
• Zygote intrafallopian tube transfer
• Low tubal ovum transfer

Note: Approval of infertility services must follow the Plan medical policy.

Note: Infertility services after reversal of sterilization are covered if there is a successful reversal of Sterilization and if the  diagnosis meets the definition of Infertility.

Note: Fertility drugs, including injectables, specialty pharmacy drugs and oral fertility drugs, are paid under the prescription drug benefit; see Section 5(f) Prescription Drug Benefits.

Please also see Section 10 Definitions of Terms We Use in This Brochure for infertility definitions.

$30 per office visit to a Primary Care Provider. No deductible.

$60 per office visit to a Specialist. No deductible.

25% coinsurance per outpatient surgical admission, deductible applies

50% coinsurance, deductible applies

Fertility Preservation Services

• This plan covers standard fertility preservation services for members when a medically necessary treatment may directly or indirectly result in impairment of fertility by surgery, radiation, chemotherapy or other medical treatment affecting the reproductive organs or processes. 

Note: Prior authorization and Health Alliance approval is required.

$30 per office visit to a Primary Care Provider. No deductible.

$60 per office visit to a Specialist. No deductible.

25% coinsurance per outpatient surgical admission, deductible applies

50% coinsurance, deductible applies

Not covered:

• Non-medical cost of donor sperm
• Non-medical cost of donor egg

All charges.

• Testing and treatment
• Allergy injections

$30 per office visit to a Primary Care Provider. No deductible.

$60 per office visit to a Specialist. No deductible.

25% coinsurance other covered services while done in the office, deductible applies

50% coinsurance per office/outpatient visit deductible applies

50% coinsurance other covered services while done in the office, deductible applies

25% coinsurance, deductible applies

50% coinsurance, deductible applies

Not covered:

• Provocative food testing and sublingual  allergy desensitization

• Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants.

• Respiratory and inhalation therapy
• Cardiac rehabilitation following a qualifying event or condition
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy
• Applied Behavior  Analysis (ABA) - Children with autism spectrum disorder
• Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit.

Note: We only cover GHT when we preauthorize the treatment.  We will ask you to submit information that establishes that the GHT is medically necessary.  Ask us to authorize GHT before you begin treatment.  We will only cover GHT services and related services and supplies that we determine are medically necessary.  See Other services under You need prior Plan approval for certain services on page 19.

$30 per office visit to a Primary Care Provider. No deductible.

$60 per office visit to a Specialist. No deductible.

25% coinsurance during a covered inpatient admission, deductible applies

IV or oral specialty drugs are covered under the specialty drug benefit. 

50% coinsurance, per office/outpatient visit deductible applies

50% coinsurance during a covered inpatient admission, deductible applies

A combined total of 60 visits per condition per calendar year for the outpatient services of each of the following:

• Qualified physical therapists
• Occupational therapists
• Qualified speech therapists

Note: We only cover therapy when a provider as listed above:

• 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,

Inpatient rehabilitation services are covered under the Extended care benefits/skilled nursing facility benefits/rehabilitation benefits heading of Section 5(c). 

$30 per office visit to a Primary Care Provider. No deductible.

$60 per office visit to a Specialist. No deductible.

25% coinsurance during a covered inpatient admission, deductible applies

50% per office/outpatient visit, deductible applies

50% coinsurance per covered inpatient admission, deductible applies

Not covered:

• Long-term rehabilitative therapy
• Exercise programs
• Phase III cardiac rehabilitation

• External Hearing Aids

All charges.

• Screening and testing services for hearing aids

All charges.

Not covered:

All charges.

All charges.

• One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts)
• Annual eye refractions and exams

$60 per vision exam. No deductible.

50% per vision exam, deductible applies

Not covered:

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

All charges.

All charges.

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

See Orthopedic and prosthetic devices for information on podiatric shoe inserts

$30 per office visit to a Primary Care Provider. No deductible.

$60 per office visit to a Specialist. No deductible.

50% coinsurance per office/outpatient visit, deductilbe applies

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 and eyes
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
• Internal prosthetic devices, such as artificial joints, pacemakers and surgically implanted breast implant following mastectomy.
• Custom molded foot orthotics
• Lumbosacral supports

Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b) Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals. 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.

25% coinsurance, deductible applies

50% coinsurance, deductible applies

Not covered:

• Orthopedic and corrective shoes(except for diabetic shoes when medical criteria is met), arch supports,heel pads, and feel cups
• Corsets, trusses, elastic stockings, support hose and other supportive devices
• Prosthetic replacements provided less than five years after the last one we covered, unless it is irreparable and the member has properly maintained it.

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include:

• Oxygen
• Dialysis equipment
• Hospital beds
• Wheelchairs
• Crutches
• Walkers
• Blood glucose monitors
• Insulin pumps
• Audible prescription reading devices
• Speech generating devices
• Lancets

Note: Call us at 1-800-851-3379 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.

25% coinsurance, deductible applies

50% coinsurance, deductible applies

50 home healthcare service visits are covered per calendar year.

• Home healthcare ordered by a Plan physician and provided by a registered nurse (RN), licensed practical nurse (LPN), licensed vocational nurse (LVN) or home health aide
• Services include oxygen therapy, intravenous therapy and medications

25% coinsurance, deductible applies

50% coinsurance, deductible applies

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

All charges.

All charges.

• Manipulation of the spine and extremities is covered if referred by the Primary Care Provider and approved by a medical director.
• Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy and cold pack application are covered as rehabilitative therapy services and are subject to 60 treatments per condition per calendar year. Hot/cold pack therapy used in conjunction with approved manipulation and mobilization is covered. X-rays and other diagnostic testing are covered under diagnostic and treatment services and must be provided by a Plan provider.

Note: Spinal manipulations and mobilizations are covered when long-term significant improvement can be expected from such treatment.

$60 per office visit. No deductible.

50% coinsurance, deductible applies

• Acupuncture - by a doctor of medicine or osteopathy, or licensed or certified acupuncture practitioner
  • Combined total of 15 treatments for the diagnosis of low back pain, neck pain and headaches

$30 per office visit. No deductible.

50% coinsurance, deductible applies

• Biofeedback - under certain circumstances

$60 per office visit to a Specialist. No deductible.

50% coinsurance, deductible applies

• Dry needling - by a licensed or certified provider

$60 per office visit to a Specialist. No deductible.

50% coinsurance, deductible applies

Not covered:

• Naturopathic services
• Hypnotherapy

All charges.

Coverage is provided for:

• Tobacco Cessation program, including individual/group/telephone counseling, over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence.
• Diabetes self management training and education

$30 per office visit to a Primary Care Provider. No deductible.

$60 per office visit to a Specialist. No deductible.

50% coinsurance, deductible applies

Tobacco cessation programs, including individual/group/phone counseling, and for physician prescribed over the counter (OTC) and prescription drugs approved by the FDA to treat nicotine dependence.

• Health Alliance offers QuitForLife, a telephone-based tobacco cessation program. Interested members may call 1-866-784-8454 to determine their readiness to quit. If they are ready, they may enroll in the program and choose the level of phone support they want from our trained health coaches. Enrollees will receive a free quit kit by mail. In addition, the member’s health coach will follow up with the member and the member’s physician throughout the year. Members are eligible to enroll in Quit4Life twice per 12 month period.
• Enrollees may get nicotine replacement therapy (gum, lozenges or patches) or the option prescriptions drugs Zyban®, prescription Chantix® or Bupropion (generic Zyban) for each quit attempt with no copayment. The plan will pay for 30 day supply at a time. These medications must be obtained by prescription.  

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

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

50% coinsurance, deductible applies

This plan covers enteral-parenteral nutritional products when determined to be Medically Necessary.

Note: Prior authorization and Health Alliance approval is required.

$30 per office visit to a Primary Care Provider. No deductible.

$60 per office visit to a Specialist. No deductible.

25% coinsurance other covered services while done in the office, deductible applies

50% coinsurance, deductible applies

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) if medical criteria determined by the plan are met.  See services requiring our approval in Section 3 How to Get Care or www.healthalliance.org/federal.
• Insertion of internal prosthetic devices. See Orthopedic and prosthetic devices in Section 5(a) Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals for device coverage information
• Treatment of burns

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)

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

$30 per office visit to a Primary Care Provider. No deductible.

$60 per office visit to a Specialist. No deductible.

25% coinsurance if you are an inpatient or outpatient in a hospital or at an ambulatory surgical facility, deductible applies

50% coinsurance per office/outpatient visit, deductible applies

50% coinsurance if you are an inpatient or outpatient in a hospital or at an ambulatory surgical facility, deductible applies.

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot (see Foot care)   

• 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, 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
  • Gender Affirmation Surgery
    • Surgical Gender Affirmation treatment requires meeting Gender Affirmation Medical necessity criteria and:
    • Member is 18 years of age or older, and
    • Documentation that the member has the capacity to make a fully informed decision and consent to treatment, and
    • Documentation that the member has lived continuously for at least 12 months in the gender role that is consistent with the preferred gender, without periods of time returning to the individual’s original gender, and
    • Member has completed at least 12 months of continuous hormonal sex reassignment therapy unless medically contraindicated (not required before mastectomy in FtM transition), 
  • Covered surgical procedures including but not limited to:
    • Female-to-male surgical reassignment-FtM (all procedures require prior authorization submitted by the member’s primary care provider and medical director review).
      • Bilateral mastectomy or breast reduction, hormone therapy is not required before mastectomy.
      • Hysterectomy and salpingo-oophorectomy.
      • Vaginectomy (including colpectomy, metoidioplasty with initial phalloplasty, urethroplasty, urethromeatoplasty)
    • Male-to-female surgical reassignment-MtF (all procedures require prior authorization submitted by the member’s primary care provider and medical director review).
      • Orchiectomy
      • Vaginoplasty (including colovaginoplasty, penectomy, labiaplasty, clitoroplasty, vulvoplasty, penile skin inversion, repair of introitus, construction of vagina with graft, coloproctostomy)
  • Not Covered:
    • Reversal of previous hormonal and/or surgical Gender Affirmation procedures.
    • Procedures considered cosmetic
    • Procedures considered investigational, based upon limited literature evidence for their use for transgender individuals

$30 per office visit to a Primary Care Provider. No deductible.

$60 per office visit to a Specialist. No deductible.

25% coinsurance if you are an inpatient or outpatient in a hospital or at an ambulatory surgical facility, deductible applies

50% coinsurance per office/outpatient visit, deductible applies

50% coinsurance if you are an inpatient or outpatient in a hospital or at an ambulatory surgical facility, deductible applies.

Not covered:

• Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury and/or for medically necessary procedures as noted above for Gender Affirming Care Services.

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
• Other surgical procedures that do not involve the teeth or their supporting structures

$30 per office visit to a Primary Care Provider. No deductible.

$60 per office visit to a Specialist. No deductible.

25% coinsurance if you are an inpatient or outpatient in a hospital or at an ambulatory surgical facility, deductible applies

50% coinsurance per office/outpatient visit, deductible applies

50% coinsurance if you are an inpatient or outpatient in a hospital or at an ambulatory surgical facility, deductible applies.

Not covered:

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

All charges.

These solid organ transplants are covered. 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

25% coinsurance, deductible applies

50% coinsurance, deductible applies

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

• Autologous tandem transplants for 
  • AL Amyloidosis
  • Multiple myeloma (de novo and treated)
  • Recurrent germ cell tumors (including testicular cancer)

25% coinsurance, deductible applies

50% coinsurance, deductible applies

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 (MPD's)
  • Advanced neuroblastoma
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) 
  • 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)
  • Muscopolysaccharidosis (e.g., Hunter's syndrome, Hurler's syndrome, Sanfillippos's syndrome, Maroteaux-Lamy syndrome variants)
  • Myelodysplasia/Myelodysplastic syndromes
  • Myeloproliferative disorders
  • Paroxysmal Nocturnal Hemoglobinuria
  • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell anemia
  • X-linked lymphoproliferative syndrome
•  Autologous transplants for
  • Acute lymphocytic or 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
  • Myelodysplasia/Mylodysplastic syndromes
  • Neuroblastoma
  • Pineoblastoma
  • Testicular, mediastinal, retroperitoneal, and ovarian germ cell tumors.

25% coinsurance, deductible applies

50% coinsurance, deductible applies

Mini-transplants performed in a clinical trial setting (non-myeloblative, 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 myleoid 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

25% coinsurance, deductible applies

50% coinsurance, deductible applies

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of Heath 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 (nonmyeloablative allogeneic transplants or reduced intensity condition (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  (MDD's)
  • Myelodysplasia/Myelodysplastic Syndromes
  • 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 leukemia/small lymphocytic lymphoma (CSS/SLL)
  • Chronic myelogenous leukemia
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Epithelial ovarian cancer
  • Mantle cell (Non-Hodgkin lymphoma)
  • Multiple sclerosis
  • Small cell lung cancer
  • Systemic lupus erythematosus
  • Systemic sclerosis

25% coinsurance, deductible applies

50% coinsurance, deductible applies

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.

25% coinsurance, deductible applies

50% coinsurance, deductible applies

Please contact Health Alliance at 1-800-851-3379 for the current per diem reimbursement rates.

Not covered:

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

Professional services provided in –

• Hospital (inpatient)

25% coinsurance, deductible applies

50% coinsurance, deductible applies

Professional services provided in –

• Hospital outpatient department
• Skilled nursing facility
• Ambulatory surgical center
• Office

25% coinsurance, deductible applies

50% coinsurance, deductible applies

Room and board, such as

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

25% coinsurance, deductible applies

50% coinsurance, deductible applies

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
• Dressings, splints, casts and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Rehabilitative services

25% coinsurance, deductible applies

50% coinsurance, deductible applies

Not covered:

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

25% coinsurance, deductible applies

50% coinsurance, deductible applies

Not covered:

• Blood and blood derivatives not replaced by the member

Up to 75 days are covered per calendar year.

Extended care benefit: Rehabilitative services received in an acute inpatient setting.

25% coinsurance, deductible applies

50% coinsurance, deductible applies

Not covered:

• Custodial care   

25% coinsurance, deductible applies

50% coinsurance, deductible applies

Not covered:

• Independent nursing, homemaker services

25% coinsurance, deductible applies

50% coinsurance, deductible applies

Local professional and air ambulance service when medically appropriate

$100 copayment per occurrence for emergency ambulance transportation. No deductible.

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

$60 per urgent care visit. No deductible.

$300 per emergency room visit. No deductible.

$60 per urgent care visit. No deductible.

$300 per emergency room visit. No deductible.

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

$60 urgent care visit. No deductible.

$300 per emergency room visit. No deductible.

$60 urgent care visit. No deductible.

$300 per emergency room visit. No deductible.

Not covered:

• Elective care or non-emergency care and follow-up care recommended by non-Plan providers that has not been approved by the Plan or provided by Plan providers
• Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
• Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

Professional ambulance service when medically appropriate.

Note: See section 5(c) Services Provided By a Hospital or Other Facility and Ambulance Services for non-emergency service.

When part of a treatment plan we approve, 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.

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
• Virtual visit

$30 per office visit. No deductible.

Nothing (No deductible) for the first 3 visits per calendar year for any covered Virtual visit; $30 copayment per Virtual visit beginning with the 4th visit (No deductible) (combined with Primary Care Provider, Mental Health/Substance Use Disorder)

50% coinsurance per office visit, deductible applies

• 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

25% coinsurance, deductible applies

50% coinsurance per office visit, deductible applies

• Outpatient CT Scans, PET Scans and MRI's provided and billed by a licensed mental health and substance abuse practitioner.
• Outpatient CT Scans, PET Scans and MRI's provided and billed by a hospital or other covered facility.
• Inpatient CT Scans, PET Scans and MRI's provided and billed by a hospital or other covered facility.

25% coinsurance, deductible applies

50% coinsurance, deductible applies

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.
• Inpatient treatment in a Psychiatric Medical Institution for Children (PMIC) is covered for a child diagnosed with a biologically-based mental illness who meets the Iowa medical assistance program criteria for admission to a PMIC.

25% coinsurance, deductible applies

50% coinsurance, deductible applies

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

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

25% coinsurance, deductible applies

50% coinsurance per office visit, deductible applies

Not covered: Services we have not approved.

All charges.

All charges.

To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following network authorization processes:

Except in a medical emergency or when a Primary Care Provider has designated another Plan physician to see patients when they are unavailable, you must contact your Primary Care Physician for a referral before seeing any other Plan physician or obtaining specialty services. Referral to a Plan specialist in your service area is given at the Primary Care Provider’s discretion. If specialists or consultants are required beyond those participating in the Plan, a Plan medical director must make the approval.

A list of the Plan’s mental health/substance abuse providers can be found in the Plan’s provider directory for your service area or you may contact the Customer Service Department at 1-800-851-3379 to see which mental health/substance abuse providers participate with the Plan in your service area.

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

• Prescription drugs prescribed by a Plan or referring physician and obtained at a Plan pharmacy will be dispensed for up to a 30-day supply or manufacturer’s standard package.  
• Members who take maintenance medication and choose the options of mail order or Retail 90^Rx at a participating pharmacy for a 90-day supply, will pay 2.75 copayments (instead of three copayments) for a 90-day supply.
• Drugs and medications that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered.
• Insulin and diabetic supplies including glucagon emergency kits, syringes and needles, oral legend agents for controlling blood sugar, and test strips for glucose monitors.
• Disposable needles and syringes for the administration of covered medications
• Drugs for sexual dysfunction
  • Must be medically necessary
  • Member must be 18 years or older
  • Covered quantity limited to four tablets per 30-day period
  • Member cannot be on nitrates
  • No coverage for women
• Prescription contraceptives 
• Drugs to treat gender dysphoria
  • Including estrogens, progestins, testosterone, and gonadotropin-releasing hormone (GnRH) agonists in oral, topical, and injectable formulations.
  • Some therapies require Prior Authorization.
  • All review criteria is based upon World Professional Association for Transgender Health (WPATH) Standards of Care
• Medications prescribed to treat obesity
• Hormonal Reassignment therapy
  • Coverage requires meeting medical necessity criteria for Gender Affirmation treatment, and a primary care physician or endocrinologist’s letter describing the medical necessity for hormone therapy to establish eligibility for this benefit initially, then Pharmacy Department prior authorization of the specific hormone(s) requested.
  • Procedures considered investigational, based upon limited literature evidence for their use for transgender individuals
• Some prescription drugs require prior authorization from a Plan medical director and certain criteria to be met by the member. The member’s physician must contact the Plan to obtain prior authorization. To accord with changes in medical technology, the Plan maintains a list of pharmaceuticals that require prior authorization. The list is available to the member upon request. Failure to obtain prior authorization may result in the dispensing pharmacy requiring personal payment from the member.

At a Plan pharmacy per prescription unit or refill:

$0 Tier 1 (Preferred generic and Preventive drugs)

$10 Tier 2 (Non-Preferred Generic)

$40 Tier 3 (Preferred Brand drugs)

$140 Tier 4 (Non-Preferred Brand drugs)

For members on maintenance medication that choose to use the options of mail order or Retail 90^Rx, copayments are based on a 90-day supply. You pay 2.75 copayments for a 90-day supply:

$0.00 Tier 1

$27.50 Tier 2

$110.00 Tier 3

$385.00 Tier 4

Note: If there is no generic equivalent available, you will still have to pay the brand-name copayment.

Note: If the physician allows substitution and the member prefers a brand-name drug on the formulary instead of the generic (if available), the member pays $10 plus the difference in cost between the generic and the brand-name drug. If the physician does not allow substitutions, the member will pay the brand name copayment.

At an out of network pharmacy per prescription unit or refill:

50% coinsurance, deductible applies Tier 1 (mainly generic)

50% coinsurance, deductible applies Tier 2 (brand-name on formulary)

50% coinsurance, deductible applies Tier 3 (brand-name non-formulary)

Specialty Prescription Drugs

Specialty Prescription Drugs are available from a Specialty Pharmacy vendor. Coverage is subject to prior written order by your Physician and prior authorization by Health Alliance and can be verified by calling the Customer Service Department at 1-800-851-3379. To be consistent with changes in medical technology, Health Alliance will maintain a list of covered Specialty Prescription Drugs and the medical conditions for which they are approved for coverage. Examples of Specialty Prescription Drugs include: Interferons, Erythropoietin and granuloctye colony stimulating factor (G-CSF). Specialty

Tier 5 specialty drugs are the most clinically and cost effective, these are also known as Preferred Specialty Drugs.

Tier 6 specialty prescription drugs are at a higher cost then Tier 5 and usually have clinically comparable alternatives available at the Tier 5 level. These are also known as Non-Preferred Specialty drugs.

Growth hormone therapy (GHT) 

Note: We will only cover GHT when we preauthorize treatment. Call 1-800-851-3379 for prior authorization. We will ask you to submit information that established the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date you submit the information. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3 How to Get Care.

$200 copayment for Tier 5 Specialty Prescription Drugs

50% coinsurance for Tier 6 Specialty Prescription Drugs

50% coinsurance, deductible applies  Tier 4 Specialty Prescription Drugs

50% coinsurance, deductible applies Tier 5 Specialty Prescription Drugs

50% coinsurance, deductible applies Tier 6 Specialty Prescription Drugs

Prescription Contraceptives

Tier 1 prescription contraceptive pills, patches, the ring and the morning after pill will be covered at an in-network pharmacy under the preventative benefit.

Tier 2 , Tier 3 and Tier 4 prescription contraceptive pills, patches, ring and morning after pill are covered under the prescription drug benefit.

FDA approved over the counter contraceptive products (including but not limited to condoms, sponges, and spermicide) are also covered for women with a prescription at a preferred pharmacy under the preventative benefit with a $0 copayment. Coverage is limited to one package per month.

One type of contraceptive pharmacy product is covered per month.

You must have a prescription and coverage is limited to women only.

For Tier 1 you pay Nothing.


For Tier 2, Tier 3 and Tier 4 are subject to the Tier 2, Tier 3 or Tier 4 prescription drug copayment


For FDA approved over the counter contraceptives you pay nothing.

For Tier 1 you pay 50% coinsurance, deductible applies


For Tier 2 and Tier 3 you pay 50% coinsurance, deductible applies

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 availabe without cost sharing on the formulary can be accessed through the process below.

• Over-the-counter and prescription drugs approved by the FDA to prevent unintended pregnancy.
• Most FDA-approved contraceptive modalities are available on the formulary with no prior authorization or exception request required. Certain brand name products which have an equivalent generic alternative already available under the $0 preventive benefit will incur the regular copay. To have this copay waived, a provider may submit an exception request stating that the brand name contraceptive is medically necessary. The provider can indicate that the request is urgent and it will be reviewed within 24 hours.  
• Coverage will be provided for prescription Contraceptives or their substitutable generic equivalent when prescribed for the purpose of preventing conception, and which are approved by the U.S. Food and Drug Administration (FDA).
• Generic drugs may be placed on any formulary tier. This includes specialty tiers if the drug meets the definition of a specialty drug. The majority of generic drugs are covered under the Tier 1 and Tier 2 benefit when they exist and are available and allowable by applicable state or federal law.
• If you or your Physician requests a brand-name drug when a generic exists, you pay the Tier 3 or Tier 4 Deductible, Copayment or Coinsurance, plus a 100% Coinsurance for the difference in cost between the brand-name drug and the generic drug. This price difference is applied to your Deductible and Out-of-Pocket Maximum. In no instance will the total cost you are charged for the drug exceed the actual cost of the drug.
• If a Tier 3 or Tier 4 drug is prescribed and a generic does not exist, you pay the Tier 3 or Tier 4 Deductible, Copayment or Coinsurance.
• If a higher-tiered drug is determined to be Medically Necessary by your Physician and Health Alliance, you may qualify to pay a reduced-tier copay. To determine if you would qualify, call our Customer Service Department at 1-800-851-3379.
• Contact our Customer Service Department at 1-800-851-3379 for information on how to submit your claim for reimbursement of over-the-counter contraceptives.
• Reimbursement for covered over-the-counter contraceptives can be submitted in accordance with Section 7.

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

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

For Tier 1 you pay Nothing.


For Tier 2, Tier 3 and Tier 4 are subject to the Tier 2, Tier 3 or Tier 4 prescription drug copayment


For FDA approved over the counter contraceptives you pay nothing.

For Tier 1 you pay 50% coinsurance, deductible applies


For Tier 2 and Tier 3 you pay 50% coinsurance, deductible applies

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).

See Tobacco Cessation Educational Classes and Programs in Section 5(a).

See Tobacco Cessation Educational Classes and Programs in Section 5(a).

Not covered

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• 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
• Non-prescription medications unless specifically indicated elsewhere
• Drugs for which there is a non-prescription equivalent available
• Medical supplies, such as dressings & antiseptics

All charges.

All charges.

Opioid rescue agents such as naloxone are covered under this Plan with no cost sharing when obtained from an in 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.

For Tier 1 you pay 50% coinsurance, deductible applies


For Tier 2 and Tier 3 you pay 50% coinsurance, deductible applies

Medications to promote better health as recommended by ACA.

The following drugs and supplements are covered without cost-share, even if over-the-counter, are prescribed by a healthcare professional and filled at a network pharmacy.

• Aspirin (81 mg) for men age 45-79 and women age 55-79 and women of childbearing age
• Folic acid supplements for women of childbearing age 400 & 800 mcg
• Pre-natal vitamins for pregnant women
• Flouride tablets, solution (not toothpaste, rinses) for children 0-6
• 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. 

Not covered:

• Drugs and supplies for cosmetic purposes
• Nonprescription medications

50% coinsurance, deductible applies

25% coinsurance, deductible applies

50% coinsurance, deductible applies

All charges.

All charges.

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

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

TTY 711 or 1-800-526-0844 (Illinois Relay)

The Plan offers a reciprocity program for family members living temporarily away from home in an area serviced by the Plan. Under this program, family members living away can receive coverage for medically necessary routine care. For additional information on this program, or to enroll a family member, call the Customer Service Department at 1-800-851-3379.

See the Health Alliance website for information on Health and Wellness programs available to you as a member at https://www.healthalliance.org/health-and-wellness

Hally Health/Health Alliance offers a Care Coordination program for pregnant people experiencing risk factors that may complicate pregnancy. Risk factors could include but are not limited to comorbid physical or mental health conditions, stressors related to social determinants of health or environmental stressors. The program begins with a comprehensive, holistic assessment of the member’s individual strengths and opportunities for risk mitigation. Together, the care coordinator and the member identify and remove barriers to optimal health. Because each member’s needs are individual, goals are individualized and detailed to ensure the best outcome possible for the pregnancy. Support is offered as early as the first trimester and continues until approximately 6 weeks postpartum.

Our maternal health program includes assisting members in getting resources to better understand the importance of routine blood pressure monitoring in high risk pregnancies.

In most cases, providers and facilities file claims for you. Providers must file on the form CMS 1500, Health Insurance Claim Form. Your facility will file on the UB 04 form. For claims questions and assistance, contact us at 1-800-851-3379, or at our website at 
www.healthalliance.org.

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

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

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

Submit your claims to:

Health Alliance Medical Plans, Inc.

3310 Fields South Drive

Champaign, IL  61822

All Plan pharmacies will file your claim electronically with you only being responsible for your copayment. However, if for any reason you had to pay for your prescriptions out of pocket, please call the Customer Service Department at 1-800-851-3379 for information on submitting your claim.

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

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

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

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

If you live in a county where at least 10% of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language. You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services(such as phone customer assistance) , and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

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

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

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

b) Send your request to us at: Health Alliance Medical Plans, 3310 Fields South Drive, Champaign, IL  61822; and

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

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

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

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

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

a) Pay the claim or

b) Write to you and maintain our denial  or

c) Ask you or your provider for more information.

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

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

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

You must write to OPM within:

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

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

Send OPM the following information:

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

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

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

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

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

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

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

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

Note: If you have serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 1-800-851-3379. We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal. You may call OPM's FEHB 2 at 1-202-606-3818 between 8 a.m. and 5 p.m. Eastern Time.

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

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

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

When we are the primary payor, we will pay the benefits described in this brochure.

When we are the secondary payor, the primary payor will process the claim first, up to its plan limit. If the claim is paid in full by the primary payor, we will not pay anything. If the claim is not paid in fully by the primary payor, we will pay the claim based on the remaining charge, up to our allowance. We will not pay more than our allowance.

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

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

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

We do not cover services that:

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

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

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

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

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

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

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

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

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

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

Some FEHB plans already cover some dental and vision services. When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage. FEDVIP coverage pays secondary to that coverage. When you enroll in a dental and/or vision plan on www.BENEFEDS.com or by phone 1-877-888-3337 (TTY 1-877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.

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

If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:

• Routine care costs - costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient's condition, whether the patient is in a clinical trial or is receiving standard therapy. These costs are covered by this Plan.
• Extra care costs - costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient's routine care. This Plan covers some of these costs, providing the Plan determines the services are medically necessary. For more specific information see Organ/tissue transplants in Section 5(b) Surgical and Anesthesia Services Provided by Physicians and Other Healthcare Professionals. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.
• Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This Plan does not cover these costs.

For more detailed information on "What is Medicare?" and "Should I Enroll in Medicare?" please contact Medicare at 1-800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2018) or at www.medicare.gov.

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

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

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

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

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

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 1-800-851-3379 or see our website at www.healthalliance.org.

You can find more information about how our plan coordinates benefits with Medicare by calling the Customer Service Department at 1-800-851-3379.

We do not waive any costs if the Original Medicare Plan is your primary payor.

If you choose to enroll in the Health Alliance Medicare Advantage POS Rx plan, we will reduce the Part B premium that you pay to the Social Security Administration by $125 per month. If you pay your Part B premium monthly, you will see this amount credited in your Social Security check. If you pay your Part B premium quarterly, you will see an amount equaling three months of reductions credited on your quarterly Part B premium statement. Please note, it may take several months to see these reductions credited to either your Social Security check, or on your premium statement. You will be reimbursed for any credits you did not receive during this waiting period.

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048) or at www.medicare.gov.

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

This Plan and our Medicare Advantage plan: We offer a Medicare Advantage plan only for our Federal Employee members known as Health Alliance Advantage POS Rx. This plan enhances your FEHB coverage by lowering cost sharing for some services and/or adding benefits, such as reducing your Part B premium at no additional cost. If you live in our FEHB service area and you have Medicare parts A and B, or Medicare part B only, you may enroll in our Health Alliance Medicare Advantage POS Rx plan. Enrolling in our Health Alliance Medicare Advantage POS Rx plan does not change your FEHB premium. Your enrollment in the Health Alliance Medicare Advantage POS Rx plan is in addition to your FEHB plan enrollment. You will continue to pay your FEHB premium. Your benefits with the Health Alliance Medicare Advantage POS Rx plan are subject to Medicare rules. If you are considering enrolling in Health Alliance Medicare Advantage POS Rx, call us at 1-855-291-9335 (TTY 711) 8 a.m. to 8 p.m. CST. Voicemail is used on holidays and weekends April 1st to September 30th. You may also visit our website at 
https://healthalliance.org/federal

With your Health Alliance Medicare Advantage POS Rx plan, you receive additional coverage such as lower cost sharing and additional benefits. Below is a summary for comparison.

Benefit Description: Deductible 

You pay with or without Medicare: $750

You pay with Health Alliance Medicare Advantage POS Rx: $0



Benefit Description: Out-of-Pocket Maximum 

You pay with or without Medicare: $7,350 for self only or $7,350 per person for Self Plus One or $14,700 for Self and Family
 
You pay with Health Alliance Medicare Advantage POS Rx: $2,000 per person 



Benefit Description: Primary Care Provider 
 
You pay with or without Medicare: $30 copayment 

You pay with Health Alliance Medicare Advantage POS Rx: $0

Benefit Description: Specialist  

You pay with or without Medicare: $60 copayment 

You pay with Health Alliance Medicare Advantage POS Rx: $0



Benefit Description: Labs 

You pay with or without Medicare: 25% coinsurance 

You pay with Health Alliance Medicare Advantage POS Rx: $0


Benefit Description: Inpatient Hospital 

You pay with or without Medicare: 25% coinsurance 

You pay with Health Alliance Medicare Advantage POS Rx: $0 



Benefit Description: Outpatient Surgery 

You pay with or without Medicare: 25% coinsurance 

You pay with Health Alliance Medicare Advantage POS Rx: $150

Additional benefits included in the Health Alliance Medicare Advantage POS Rx plan include:

• Fitness allowance for fitness activities
• Hearing aid coverage
• In-Home Support Companion Benefit
• Travel assistance services
• Over the counter product mail order discounts

This is a summary of the key benefits and features of the Health Alliance Medicare Advantage POS Rx plan. As a member of this Medicare Advantage plan, ou are still entitled to coverage under the FEHB program. All benefits are subject to the definitions, limitations and exclusions set for this FEHB brochure and the Health Alliance Medicare Advantage POS Rx Evidence of Coverage.

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

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

If you are enrolled in Medicare, and are not enrolled in a Medicare Advantage Plan (Part C), you have the opportunity to enroll in the Medicare Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP). The PDP EGWP is a prescription drug benefit for FEHB covered annuitants and their FEHB covered family members who are eligible for Medicare. This allows you to receive benefits that will never be less than your coverage that is availabe to members with only FEHB but more oftern you will receive benefits that are better than members with only FEHB.

If you choose to enroll in our Health Alliance Mediare Advantage POS Rx plan, you will continue to remain enrolled in our FEHB Plan. You will receive all of the benefits of Medicare Part D plus additional drug benefits covered under this FEHB plan. Participation in the PDP EGWP is voluntary and you have the choice to opt out of PDP EGWP enrollment at any time.

In the case of those with higher incomes you may have a separate premium payment for your PDP EGWP benefit. Please refer to the Part D-IRMAA section of the Medicare website: https://www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/monthly-premium-for-drug-plans to see if you would be subject to an additional premium.

• You have FEHB coverage on your own or through your spouse who is also an active employee

• You have FEHB coverage through your spouse who is an annuitant

• It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)

• It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD

• This Plan was the primary payor before eligibility due to ESRD (for 30-month coordination period)

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

• Medicare based on ESRD (for the 30-month coordination period)

• Medicare based on ESRD (after the 30-month coordination period)

The introduction of sperm into a woman's vagina or uterus by non-coital methods, for the purpose of conception.

An authorization by you (the enrollee or covered family member) that is approved by us (the Carrier), for us to issue payment of benefits directly to the provider.

• We reserve the right to pay you directly for all covered services. Benefits payable under the contract are not assignable by you to any person without express written approval from us, and in the absence of such approval, any assignemnt shall be void.
• Your specific written consent for a designated authorized representative to act on your behalf to request reconsideration of a claim decision (or, for an urgent claim, for a representative to act on your behalf without designation) does not constitute an Assignment.
• OPM's contract with us, based on federal statute and regulation, gives you a right to seek judicial review of OPM's final action of the denial of a health benefits claim but it does not provide you with authority to assign your right to file such a lawsuit to any other person or entity. Any agreement you enter into with another person or entity (such as a provider, or other individual or entity) authorizing that person or entity to bring a lawsuit against OPM, whether or not acting on your behalf, does not constitute an Assignment, is not a valid authorization under this contract, and is void.

All fertility treatments in which either eggs or embryos are handled. In general, ART procedures involve surgically removing eggs from a woman’s ovaries, combining them with sperm in the laboratory, and returning them to the woman’s body or donating them to another woman. They do not include treatments in which only sperm are handled (i.e., intrauterine—or artificial—insemination) or procedures in which a woman takes medicine only to stimulate egg production without the intention of having eggs retrieved.

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

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

The percentage of our negotiated fee that you must pay for your care. Coinsurance does not begin until you have met your calendar year deductible.

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

The general term used to refer to your out-of-pocket costs (e.g. deductible, coinsurance and copayments) for the covered care you receive.

An oocyte donor or sperm donor.

A fertilized egg that has begun cell division and has completed the pre- embryonic stage.

An ART cycle produces 3 or more embryos for transfer, each of which are at least 6 to 8 cells (for day 3 transfers) of reasonable quality (grade B or equivalent) with less than 50% fragmentation.

The placement of the pre-embryo into the uterus or, in the case of zygote intrafallopian tube transfer, into the fallopian tube.

Less than 50% fertilization

A reproductive cell. In a man, the gametes are sperm; in a woman, they are eggs or ova.

The direct transfer of a sperm/egg mixture into the fallopian tube. Fertilization takes place inside the tube.

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

A failure to establish a pregnancy or to carry a pregnancy to live birth after 12 months of unprotected sexual intercourse if the individual with female reproductive organs is 35 years of age or younger (on or prior to 35th birthday), or after 6 months of unprotected sexual intercourse if the individual with female reproductive organs is over 35 years of age (after 35th birthday).

For individuals with female reproductive organs without male partners and no regular exposure to sperm, to demonstrate a diagnosis of infertility Intrauterine Insemination (IUI) treatment is required (coverage of donor sperm is included). 

A process in which an egg and sperm are combined in a laboratory dish where fertilization occurs. The fertilized and dividing egg is transferred into the woman's uterus.

Women with male partners and exposure to sperm meeting the definition of infertility above and who fail initial infertility treatments are eligible for 3 or more IUI cycles.  Donor sperm is covered if medically necessary. Drugs related to IUI treatment are covered as above. If 3 cycles of IUI are failed, the woman may seek prior authorization for IVF treatment.

For women without male partners and no regular exposure to sperm, to demonstrate a diagnosis of infertility 3 cycles of IUI treatment are required (coverage of donor sperm is included). Drugs related to IUI treatment are covered as above. If the 3 cycles of IUI fail, the member may seek prior authorization for IVF treatment.  

Transgender individuals, taking into consideration anatomic sexual reproductive capabilities, may seek prior authorization for medically necessary infertility services.

The procedure in which oocytes are transferred past a blocked or damaged section of the fallopian tube to an area closer to the uterus.

A service or supply that is required to identify or treat a condition and is:

• Appropriate and necessary for, and consistent with, the symptom or diagnosis and treatment or distinct improvement of an illness or injury.
• Adequate and essential for the evaluation or treatment of a disease, condition or illness.
• Can reasonably be expected to improve the member’s condition or level of functioning.
• Conforms with standards of good medical practice, uniformly recognized and professionally endorsed by the general medical community at the time it is provided.
• Not mainly for the convenience of the member, a physician or other provider.
• The most appropriate medical service, supply or level of care that can safely be provided. When applied to inpatient care, it further means that your medical symptoms or condition require that the services cannot be safely provided to you as an outpatient.

Natural menopause is defined as “the time when a woman naturally stop having menstrual periods. Menopause happens when the ovaries stop making estrogen. Menopause marks the end of the reproductive years, as defined by the American College of Obstetrics and Gynecology(ACOG).

The female egg or ovum, formed in an ovary.

A woman determined by a physician to be capable of donating eggs in accordance with the standards recommended by the American Society for Reproductive Medicine.

The procedure by which eggs are obtained by inserting a needle into the ovarian follicle and removing the fluid and the egg by suction. Also called ova aspiration.

Three or more follicles develop and estrogen levels are >500 mIU/mL following ovarian hyperstimulation with gonadotropins. Diminished reserve is indicated by peak estrogen levels less than 500 mIU/mL or <3 mature follicles are available at the time of stimulation and retrieval.

Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways. We determine our allowance based on Maximum Allowable Charge (MAC). Plan providers accept the Plan allowance as payment in full.

You should also see Important Notice About Surprise Billing - Know Your Rights in Section 4 Your Cost For Covered Services that describes your protections against surprise billings under the No Surprises Act.

Benefits that cover any related medical condition that may be associated with pregnancy, including complications of pregnancy.

For males: 39 million total sperm per ejaculation; 40% total motility (progressive and non-progressive); 30% progressive motility and 4% or more normal forms using Kruger strict mophology.

For females: At least one unobstructed tube as evidenced by hystersalpingogram.

Individuals who have at least 10 million Total Motile Sperm Count (TMSC) in cases of male factor infertility are required to perform at least three artificial insemination cycles prior to IVF.

An unexpected bill you receive for

• emergency care - when you have little or no say in the facility or provider form 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.

Sexual union between a male and a female, without the use of any process, device or method that prevents conception, including but not limited to oral contraceptives, chemicals, physical or barrier contraceptives, natural abstinence or voluntary permanent surgical procedures.

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:

• Waiting could seriously jeopardize your life or health;
• Waiting could seriously jeopardize your ability to regain maximum function; or
• In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care of treatment that is the subject of the claim.

Urgent care claims usually involve pre-service claims and not post-service claims. We will determine whether or not a claim is an urgent care claim by applying the judgement of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at 1-800-851-3379. You may also prove that your claim is an urgent care claims by providing evidence that a physician with knowledge of  your medical condition has determined that your claim involves urgent care.

A procedure by which the uterus is flushed to recover a pre-implantation embryo.

A woman who carries a pregnancy for an individual who meets infertility coverage criteria.

A fertilized egg before cell division begins.

A procedure by which an egg is fertilized in vitro and the zygote is transferred to the fallopian tube at the pronuclear stage before cell division takes place. The eggs are harvested and fertilized on one day and the embryo is transferred at a later time.

Office visit copayment: $30 primary care: $60 specialist. No deductible.

25% coinsurance for lab, X-ray or other diagnostic tests, deductible applies

30

*25% coinsurance, deductible applies

54

*25% coinsurance, deductible applies

55

$60 urgent care visit/$300 hospital ER. No deductible.

58

$60 urgent care visit/$300 hospital ER. No deductible.

58

Regular cost-sharing

59

$0/$10/$40/$140 No deductible.

63

$27.50/$110/$385 No deductible.

63

No benefit

70

$30 copayment for primary care physician office visit. No deductible.

$60 copayment for specialist office visit. No deductible.

39

• Flexible benefits option
• Services for deaf and hearing impaired
• Reciprocity benefits

71

Nothing after $7,350/Self Only or $14,700/Family enrollment per year

25