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

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

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

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

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

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

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

We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office. For information on your premium deductions, 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 26^th 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 are enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

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

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

Natural children, adopted children, and stepchildren

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

Foster children

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

Children incapable of self-support

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

Married children

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

Children with or eligible for employer-provided health insurance

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

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

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

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

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

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

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

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

The benefits in this brochure are effective January 1.  If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1.  If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2023 benefits of your prior plan or option.  If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option.  However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2023 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 Temporary Continuation of Coverage (TCC), or a conversion policy (a non-FEHB individual policy.)

If you are an enrollee, and your divorce or annulment is final, your ex-spouse cannot remain covered as a family member under your Self Plus One or Self and Family enrollment.

You must contact us to let us know the date of the divorce or annulment and have us remove your ex-spouse. We may ask for a copy of the divorce decree as proof. In order to change enrollment type, you must contact your employing or retirement office. A change will not automatically be made.

If you were married to an enrollee and your divorce or annulment is final, you may not remain covered as a family member under your former spouse's enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). 

If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices. You can also visit OPM's website at www.opm.gov/healthcare-insurance/healthcare/plan-information. 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 or 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 FEHBP coverage.

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

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

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

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions. When you contact us we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 800-279-1301 or visit our website at www.deancare.com. 

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

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 800-279-1301 or write to us at:

P.O. Box 56099, Madison WI 53705

You may also request replacement cards through our online member portal DeanConnect at www.deancare.com/deanconnect.

You get care from “Plan providers” and “Plan facilities.” You will only pay copayments, deductibles, and/or coinsurance, and you will not have to file claims. You can receive covered services from a participating provider without a required referral from your primary care provider or by another participating provider in the network.

FEHB Carriers must have clauses in their in-network (participating) provider agreements.  These clauses provide that, for a service that is a covered benefit in the plan brochure or for non-elective 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, copayment, co-insurance) contact your Carrier to enforce the terms of its provider contract.

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

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

We list Plan providers in the provider directory, which we update monthly. The list is also on our website at www.deancare.com.

The plan recognizes that transgender, non-binary, and other gender diverse members require health care delivered by healthcare providers experienced in gender affirming health. Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender.

This plan provides Care Coordinators for complex conditions and can be reached at 800-279-1301 or visit our website at www.deancare.com for assistance. 

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update daily. The provider directory can be found on our website at www.deancare.com/doctors.

It depends on the type of care you need. First, you and each family member must choose a primary care provider. This decision is important since your primary care provider provides or arranges for most of your health care. When you enroll, you (and your family members) must choose a primary care provider. Each member of your family may select a different primary care provider. A provider who specializes in only one area of medicine would not be able to treat all of your basic health care needs.

Primary care providers specialize in different areas, and each specialty has its own benefits. A basic summary might help you narrow your search:

• Family Medicine (with or without Obstetrics) focuses on healthcare for individuals and families of all ages.  This includes routine and preventive care, treatment of acute and chronic illness, and coordination of your overall care. Some Family Medicine physicians also include Obstetrics (the care of women during pregnancy and childbirth).
• Internal Medicine focuses on adult patients and the aging process. Internists generally see patients over 18 years old. They also frequently care for patients with multiple ongoing health conditions. They provide preventative care, age-related screenings and health guidance.
• Pediatrics is a specialty which treats children from birth to their late teens. While pediatricians see healthy children for primary care, they also help children who have special or difficult health conditions. Pediatricians provide ongoing screenings, immunizations and preventative care throughout childhood.

You can also visit deancare.com/newmember for the most up-to-date listing of providers and view our Tips for Choosing a Primary Care Provider.

Dean Health Plan members are free to switch to a different primary care provider (PCP) at any time. If you are changing to another PCP within the same clinic, you may ask that clinic’s staff for assistance. Otherwise you may call the Customer Care Center at 800-279-1301.

Written referrals are not required when seeing a Dean Health Plan provider.

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

• 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. You may receive services from your current specialist until we can make arrangements for you to see someone else.
• If you have a chronic and disabling condition and lose access to your specialist because we:
  • terminate our contract with your specialist for other than cause; 
  • drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program plan; or
  • reduce our service area and you enroll in another FEHB plan;
• If you receive care from an Out-of-Network Provider that is not available from a Network Provider and have an approved Prior Authorization to see this Out-of-Network Provider, payment for covered charges will be based on the actual charges, and not the Maximum Allowable Fee. We have no liability or responsibility for the quality of care provided by an Out-of-Network Provider. Prior Authorization is required both to determine medical appropriateness and whether services can be provided by Network Providers.

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 third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.  Services provided by an Out-of-Network Provider require Prior Authorization.

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 Care Center immediately at 800-279-1301. 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 92^nd 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.

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

If you choose an out-of-network provider, it is up to you to secure a prior authorization.  Failure to do so may result in a penalty of 100% of cost. Your out-of-network provider must contact our Customer Care Center to submit a prior authorization request. Dean Health Plan will then review the request and provide a written decision to both you and your provider within 15 business days. Make sure you wait until you receive this approval before receiving the recommended services to avoid penalty.

A good rule to remember is that any time you seek services with an out-of-network or non-participating provider, you will need to obtain a prior authorization from an in-plan provider.

If you fail to obtain a Prior Authorization for any Medically Necessary covered service which requires an authorization, you, the Member, will be responsible for 100% of the total cost of services. It is the responsibility of the Member to ensure that Prior Authorization has been obtained for all services, including facility Confinements and/or surgery.

Your health care provider must get prior authorization from us before we will cover certain procedures or services. Examples of procedures and services that need prior authorization are listed below. This is not an all-inclusive list. You should contact the Customer Care Center at 800-279-1301 or TTY 711 to verify whether a procedure or service needs prior authorization.

Examples of Procedures/Services Requiring Prior Authorization:

• Certain organ and blood and marrow transplant services – this Prior Authorization must be obtained before the transplant workup is initiated
• In-network benefits for services from non-network providers, with the exception of emergency services
• Certain reconstructive or restorative surgery procedures
• Certain drugs, biologics and biosimilars
• Certain home health care services
• Certain durable medical equipment
• Certain outpatient surgical procedures
• Certain imaging services
• Non-emergency licensed air ambulance transportation
• Skilled nursing facility services

The Process for Obtaining Prior Authorization:

If your health care provider recommends that you have a service or procedure that needs prior authorization, your health care provider should submit a prior authorization request form to Us. It is the member’s responsibility to make sure that your health care provider requests prior authorization. We must receive the prior authorization request at least 15 business days before the date of your service or procedure. We will notify you in writing of our decision.

Your health care provider may decide that it is medically necessary for you to 1) get additional services beyond what we originally authorized, or 2) receive care for longer than the length of time we originally authorized. If this happens, your health care provider must contact Us to request an extension of the original authorization. You and your health care provider will be notified of whether we approve or deny your extension request.

Prior authorization does not guarantee coverage and/or payment if you have already reached a benefit maximum or your coverage has been terminated.

Professionally Administered Drugs - Covered Expenses:

• Medically Necessary Professionally Administered Drugs that are administered, in conjunction with a covered benefit such as an office visit or home health care visit, by a physician acting within the scope of the provider’s license, on an outpatient basis in a hospital, physician’s office or in your home.
• Prior Authorization (approval in advance) is required before you receive certain biologics, biosimilars and professionally administered drugs. Certain biologics, biosimilars and Professionally Administered Drugs may be subject to Step Therapy. In certain cases, it is possible to get an exception to Step Therapy requirements. To obtain more information about the Step Therapy exception process call Customer Care Center at the number on the back of your ID card.
• If you require certain Professionally Administered Drugs, We may direct you to a designated Health Care Provider with whom We have an arrangement to provide those certain Professionally Administered Drugs. Such designated Health Care Providers may include an outpatient pharmacy, specialty pharmacy, home health care agency, home infusion provider, hospital-affiliated pharmacy or hemophilia treatment center contracted pharmacy.  If you or your provider administering the Professionally Administered Drugs are directed to a designated Health Care Provider and you or your provider choose not to obtain your Professionally Administered Drug from that designated Health Care Provider, benefits may not available under this Policy for that professionally administered drug.

 Non-Covered Professionally Administered Drug  Expenses:

• Professionally Administered Drugs provided by an Out-of-Network Network Provider.

First, your physician, your hospital, you, or your representative, must call us at 800-279-1301 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

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

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

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

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

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

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

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM.  Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 800-279-1301.  You may also call OPM's FEHB 3 at 202-606-0755 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us at 800-279-1301.  If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

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

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

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

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

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

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

Failure to Obtain Authorization for Non-Plan Providers:  If you fail to obtain Prior Authorization for any service requiring such an authorization, you, the Member, will be responsible for 100% of the total cost of services received from any Non-Plan Provider. It is the responsibility of the Member to ensure that Prior Authorization has been obtained for all services.

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 800-279-1301.

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

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

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

1. Precertify your hospital stay or, if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply; or
2. Ask you or your provider for more information.
   • You or your provider must send the information so that we receive it within 60 days of our request.  We will then decide within 30 more days.
   • If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due.  We will base our decision on the information we already have.  We will write to you with our decision.
3. Write to you and maintain our denial.

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

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

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.

Coinsurance is the percentage of covered expenses that a member is required to pay each time covered services are provided, subject to any maximums specified in this brochure.  Coinsurance amounts are applied toward the catastrophic protection out-of-pocket maximum expense in most circumstances.  Coinsurance does not begin until you have met your calendar year deductible.

The calendar year coinsurance limit under the High Option is $500 Self Only enrollment or $1,000 Self Plus One and Self and Family enrollment.

The calendar year coinsurance limit under the Standard Option is $4,500 Self Only enrollment or $9,000 Self Plus One and Self and Family enrollment.

Example:

High Option Plan: For most services you pay 10% coinsurance of actual charges up to your coinsurance limit. 

Standard Plan:  For most services you pay 10% coinsurance of actual charges after your deductible has been met up to your Deductible & Coinsurance limits.

A copayment is a specified dollar amount that you may be required to pay each time covered services are provided, subject to any maximums specified in this policy. 

Copayment amounts are applied to our contracted fee or Maximum Allowable Fee, and apply at the benefit level.

Copayment amounts are applied toward the out-of-pocket expense maximum.

Example:

Primary Care Physician Copayment:  When you see your primary care provider or chiropractor you pay a copayment of $20 per office visit.

Specialist Provider Copayment:  When you see a specialty provider you pay a copayment of $40 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 High Option plan does not have a deductible.

The Standard Option plan has a calendar year deductible of $500 per person.  Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $500 under the Standard Option.  Under a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $1,000 under the Standard Option.  Under a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $1,000 under the Standard Option.

Under a Self Plus One or Self and Family enrollment, no one member will ever be required to satisfy more than the Self Only deductible amount of $500.

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.

The maximum amount payable based upon the average charge for the same service provided.

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.

After your out-of-pocket expenses, including any applicable deductibles, copayments and coinsurance total $5,000 for Self Only, or $10,000 for a Self Plus One or Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. The maximum annual limitation on cost sharing listed under Self Only of $5,000 applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

Example Scenario:  Your plan has a $5,000 Self Only maximum out-of-pocket limit and a $10,000 Self Plus One or Self and Family maximum out-of-pocket limit.   If you or one of your eligible family members has out-of-pocket qualified medical expenses of $5,000 or more for the calendar year, any remaining qualified medical expenses for that individual will be covered fully by your health plan.  With a Self and Family enrollment out-of-pocket maximum of $10,000, a second family member, or an aggregate of other eligible family members, will continue to accrue out-of-pocket qualified medical expenses up to a maximum of $5,000 for the calendar year before their qualified medical expenses will begin to be covered in full. 

However, copayments and coinsurance, if applicable for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments and coinsurance for these services:

• Premiums
• Non-Covered Services
• Benefit Reduction Amounts
• Services provided by out-of-network providers that have not been prior authorized

Be sure to keep accurate records and receipts of your copayments and coinsurance to ensure the plan’s calculation of your out-of-pocket maximum is reflected accurately.

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 protections against “surprise billing” and “balance billing” for out-of-network emergency services; out-of-network non-emergency services provided with respect to a visit to a participating health care facility; and out-of-network air ambulance services. Plan providers are physicians and other healthcare professionals in our service area
that we contract with to provide covered services to our members.

A surprise bill is an unexpected bill you receive for

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

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

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

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.deancare.com/Members/No-surprises or contact the health plan at 800-279-1301.

Healthcare FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you, your tax dependents, and your adult children (through the end of the calendar year in which they turn 26).

FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans.  This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.

Professional services of physicians

• In physician's office
• Advance care planning

$20 copayment per visit - Primary Care Provider

$40 copayment per visit - Specialist

$20 copayment per visit - Primary Care Provider

$40 copayment per visit - Specialist

Professional services of physicians

• In an urgent care center
• Office medical consultation
• Second surgical opinion

$20 copayment per visit - Primary Care Provider

$40 copayment per visit - Specialist

$20 copayment per visit - Urgent Care Center

$20 copayment per visit - Primary Care Provider

$40 copayment per visit - Specialist

$20 copayment per visit - Urgent Care Center

• During a hospital stay
• In a skilled nursing facility

10% coinsurance

10% coinsurance after deductible

Telemedicine Services

• This term is the umbrella term that includes a wide range of technologies that support Telehealth and Virtual Care/Virtual Visits.
• Not all conditions may be available or appropriate for treatment by a Telehealth Services provider, and you may be referred to another more appropriate care setting.

Covered Expenses

• Telehealth; an interactive audio and/or video telecommunications system that permits real-time communication between the provider at the practice location and the Member at a different location.
  • Coverage of a service provided via Telehealth is subject to the same benefits and limitations as if the service is provided face-to-face (e.g., allowable providers, prior authorization, copayments, deductible, coinsurance).
• Virtual Care/Virtual Visit (member completes a computer based questionnaire and receives a treatment plan from a provider).
  • Complete an online health interview.  Answer a series of questions about how you are feeling and the symptoms you are experiencing - just as you would during an in-office visit.  A provider from SSM Health reviews your responses and creates a treatment plan, which may include a prescription if necessary.  You'll be notified when the results are available.  For more information, visit www.deancare.com/virtualvisit.

Non-Covered Telemedicine Services Expenses

• All other benefits not otherwise listed in the Policy.
• Virtual visit with a provider that is not contracted with Us will not be covered.

Please Note:

• Virtual visit with a provider that is not contracted with Us will not be covered.
• Not all conditions may be treated or appropriate for treatment through a virtual visit provider.  You may be referred to another more appropriate care setting.

Telehealth Visit

• $20 copayment per visit - Primary Care Provider
• $40 copayment per visit - Specialist

Virtual Visit

• Nothing

Telehealth Visit

• $20 copayment per visit - Primary Care Provider
• $40 copayment per visit - Specialist

Virtual Visit

• Nothing

Diagnostic services associated with an office visit or urgent care visit

• X-rays and readings
• Laboratory services and readings
• Hearing services
• Vision care services
• Readings - MRI/MRA, CT scans, PET scans

Nothing

Nothing

Other Diagnostic Services 

Covered Expenses:

• Electrocardiogram (EKG)
• Endoscopy
• Duplex scan
• Pulmonary stress test
• Sleep study
• Nerve conduction studies
• Neuropsychological testing
• Swallow study

• CT Scan
• MRI
• PET Scan

$50 copayment per visit (3 copayment maximum of $150 per member per year) 

Outpatient services only

10% coinsurance after deductible

Outpatient services only

Genetic Counseling and Testing

We cover genetic counseling, occurring in an office, clinic, or telephonically. Genetic testing services received in an office or outpatient hospital setting.

Covered Expenses:

• Genetic counseling, pre-test or post-test.
• Genetic testing.
  • When the test will directly affect treatment decisions or frequency of screening for a disease, or when results of the test will affect reproductive choices.

Nothing

Nothing

Not covered:

• Genetic counseling and testing services provided by an Out-of-Network provider.
• Genetic testing when performed in the absence of symptoms or high-risk factors for a heritable disease.
• Genetic testing when knowledge of genetic status will not affect treatment decisions, frequency of screening for the disease, or reproductive choices.
• Genetic testing that has been performed in response to direct to consumer marketing and not under the direction of your physician.

Note:  BRCA testing, if appropriate, is covered as a women’s preventive health service.

All charges

All charges

Routine physical once annually.

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

• Immunizations such as pneumococcal, influenza, shingles, tetanus/Tdap and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at 
  https://www.cdc.gov/vaccines/schedules/.
• Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV and colorectal cancer screening.  For a complete list of screenings go to the U.S Preventive Services Task Force (USPSTF) website at
   https://www.uspreventiveservicestaskforce.org/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.healthcare.gov/preventive-care-women.
• To build your personalized list of preventive services go to 
  https://health.gov/myhealthfinder.

Nothing

Nothing

Routine mammogram

Nothing

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

Note: Preventive services are defined as health care services that might include screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems. The Affordable Care Act (ACA) outlines preventive services which are offered at no cost sharing to the member.

Additionally, in order to be covered under the plan, preventive services must:

• Be performed by or ordered by a Primary Care Provider or Obstetrician/Gynecologist; and
• Be expenses for care to evaluate or assess health and wellbeing and screen for possible detection of unrevealed illness on a regular basis; and
• Be provided by a Plan Provider; and
• Not be performed for the primary reason of diagnosing or treating an illness or injury.

Dean Health Plan follows the United States Preventive Service's Task Force (USPSTF) recommendations for preventive services. We allow services that receive an "A" or "B" rating. We do cover certain services under the ACA (preventive services) related to pregnancy at no member cost share.

You may review the Health Resources and Services Administration (HRSA) guidelines available at www.hrsa.gov/womens-guidelines and related federal guidance for additional detail.

Laboratory and diagnostic studies may be subject to other plan benefits (diagnostic or treatment benefits) if determined not to be part of a preventive visit. When a Member has symptoms or a history of an illness or injury, laboratory and diagnostic studies relating to that illness or injury are no longer considered part of a preventive visit.

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.

• Medical Nutrition Therapy and Intensive Behavioral Therapy for the prevention of obesity related comorbidities as recommended under the U.S. Preventive Services Task Force (USPSTF) A and B recommendations.

Nothing

Nothing

Not covered:

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

All charges

All charges

Well-child visits, examinations and immunizations as described in the Bright Future Guidelines provided by the American Academy of Pediatrics.

Immunizations such as Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at
https://www.cdc.gov/vaccines/schedules/index.html.

Pediatric Vision (eye glasses) – One pair of eyeglasses per contract year.

Covered Pediatric Vision Expenses:

• Single vision, conventional (lined) bifocal, and conventional (lined) Bifocal lenses
• Polycarbonate lenses are covered for children  (monocular or patients with prescriptions > +/-6.00 diopters)
• Frame
• Scratch resistant coating
• Ultraviolet protective coating

Lenses include choice of glasses or plastic lenses. One pair of replacement glasses per year.

Non-Covered Pediatric Vision Expenses:

• Blended segment lenses
• Intermediate vision lenses
• Standard progressives
• Premium progressives (Varilux®, etc.)
• Photochromic glass lenses
• Plastic photosensitive lenses (Transitions®)
• Polarized lenses
• Standard anti-reflective (AR) coating
• Premium AR coating
• Contact lenses

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

You may also find a complete list of preventive care services recommended under the S. Preventive Services Task Force (USPSTF) online at https://shorturl.at/hovHM.

HHS: www.healthcare.gov/coverage/preventive-care-benefits/

CDC: www.cdc.gov/vaccines/schedules/index.html

Women's preventive services:
www.healthcare.gov/preventive-care-women/

For additional information:
www.health.gov/myhealthfinder

Note: For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to www.brightfutures.aap.org/Pages/default.aspx.

Nothing

Nothing

Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention.

Nothing

Nothing

Complete maternity (obstetrical) care, such as:

• Delivery
• Postnatal care

$20 copayment - Primary Care Provider or $40 copayment - Specialist per office visit*

10% coinsurance for inpatient professional delivery services

$20 copayment - Primary Care Provider or $40 copayment - Specialist per office visit*

10% coinsurance after deductible for inpatient professional delivery services.

• Prenatal and Postpartum care
• Screening for gestational diabetes 
• Breastfeeding support, supplies and counseling for each birth
  • The health plan covers the purchase of one covered breast pump per birth with no prior authorization required. The pump is covered at 100% per the women’s preventive benefit.
• Screening and counseling for prenatal and postpartum depression

Note: Here are some things to keep in mind:

• Hospital services are covered under Section 5(c).
• New members under this certificate who are in their third trimester as of their effective date and are seeing an out-of-network provider are allowed to continue receiving care with their Out-of-Network Provider for the duration of their pregnancy and until their first postpartum checkup. Services provided by an out-of-network provider require prior authorization.
• You do not need to precertify your vaginal delivery; see Section 3, How You Get Care for other circumstances, page (Applies to printed brochure only), 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, (you do not need to precertify the normal length of stay). We will extend your inpatient stay for you or your baby if medically necessary. See Section 3, How You Get Care, page (Applies to printed brochure only), for other circumstances.
• We cover routine nursery care of the newborn child during the covered portion of the mother maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Dean Health Plan follows the United States Preventive Service's Task Force (USPSTF) recommendations for preventive services. We allow services that receive an "A" or "B" rating. We do cover certain services under the ACA (preventive services) related to pregnancy at no member cost share.
• You may review the Health Resources and Services Administration (HRSA) guidelines available at www.hrsa.gov/womensguidelines/ and related federal guidance for additional detail.
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

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

Nothing

Nothing

Not covered:

• Amniocentesis, CVS (Chorionic Villi Sampling), or non-invasive pre-natal testing when performed exclusively for sex determination.
• Birthing classes (e.g. Lamaze).
• Elective abortions.
• Services, Drugs, or supplies related to abortions, except when:  1) an individual suffers from a physical disorder, physical injury, or physical illness that would place the individual in danger of death unless an abortion is performed; 2) the pregnancy is the result of an act of rape or incest.
• Home or intentional out of hospital deliveries (e.g. free standing birthing centers).
• Maternity services received outside the service area during the last 30 days of the pregnancy except for emergency and urgent care services.
• Treatment, services or supplies for a non-Member traditional surrogate or gestational carrier.

Contraceptive counseling on an annual basis

A range of voluntary family planning services, limited to:

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

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

Nothing

Nothing

• Vasectomy (in an office setting)

$20 copayment per visit - Primary Care Provider

$40 copayment per visit - Specialist

$20 copayment per visit - Primary Care Provider

$40 copayment per visit - Specialist

Not covered:

• Reversal of voluntary surgical sterilization

All charges

All charges

Diagnosis of infertility

See Section 5(a) for covered labs, diagnostic test and x-rays.

See Section 5(b) for covered surgical services.

See Section 5(f) for covered prescription drugs.

See Section 5(a) for covered labs, diagnostic test and x-rays.

See Section 5(b) for covered surgical services.

See Section 5(f) for covered prescription drugs.

Physician, hospital and ambulatory surgical center services for the treatment of infertility, such as:

• Artificial insemination up to six cycles annually:
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)
• Other Services, such as:
  • Chromotubation
  • Fimbrioplasty
  • Salpingostomy
  • Labs
  • Injectable drugs billed on medical claims
• Fertility drugs (See Prescription Drugs in Section 5(f))

Note:  Fertility Treatment is the treatment or procedure intended to assist conception, undergone as the result of infertility or for any other reason. 

Infertility is a disease of the reproductive system defined by the failure to achieve a pregnancy by any means including artificial insemination after 12 months or more of attempts to conceive for individuals under age 35; and 6 months for individuals age 35 and older. Infertility may also be established through evidence of medical history and diagnostic testing.

The diagnosis of infertility and certain services for fertility treatment in connection with the voluntary planning of conceiving a child are covered. Coverage includes benefits for professional, hospital and ambulatory surgical center services. Services for the diagnosis of infertility and fertility treatment must be received from or under the direction of a physician. All services, supplies, drugs and associated expenses for fertility treatment are not covered. See Section 5(f). Prescription Drug Benefits for coverage of fertility treatment drugs.

Prior authorization (approval in advance) is required before you receive certain biologics, biosimilars and professionally administered drugs. Certain biologics, biosimilars and professionally administered drugs may be subject to step therapy. In certain cases, it is possible to get an exception to step therapy requirements. To obtain more information about the step therapy exception process, call the Dean Health Plan Customer Care Center at the number listed on the front of this certificate.

To determine if Dean Health Plan requires prior authorization for a particular service or treatment, please call the Dean Health Plan Customer Care Center at the number listed on the front of this certificate. Please see Section 3. How You Get Care for more information about prior authorization requirements and processes.

50% of the allowed amount of covered services.

Member pays 100% of all artificial insemination charges that exceed the six cycle annual limit.

50% of the allowed amount of covered services.

Member pays 100% of all artificial insemination charges that exceed the six cycle annual limit.

Not covered:

• Consultation, treatment, or procedures for Assisted Reproductive Technology (ART).

Assisted Reproductive Technology (ART): All treatments or procedures that include the handling of human eggs, sperm, and/or embryos to help an individual become pregnant. ART includes, but is not limited to, gamete intrafallopian transfer (GIFT), uterine embryo lavage, embryo transfer, in vitro fertilization (IVF), pronuclear state transfer (PROST), tubal embryo transfer (TET), zygote intrafallopian transfer (ZIFT), low tubal ovum transfer, intracytoplasmic sperm injection, cryopreservation (e.g., egg, embryo, sperm), and other third party-assisted ART methods (e.g., sperm donation, egg donation, Traditional Surrogates and Gestational Carriers, embryo donation).

All charges

All charges

Testing and treatment

$20 copayment per visit - Primary Care Provider

$40 copayment per visit - Specialist

10% coinsurance after deductible

• Allergy injections
• Allergy serum

Nothing

Not covered:

• Provocative food testing
• 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 Section 5(b), Organ/Tissue Transplants, page (Applies to printed brochure only).

• Respiratory and inhalation therapy
• Cardiac and pulmonary rehabilitation services for cardiac disease and lung disease as medically necessary. Phase II treatment must begin within 90 days of surgery.
• Dialysis - hemodialysis and peritoneal dialysis
• Intravenous (IV)/infusion therapy - home IV and antibiotic therapy

Note: Growth hormone therapy (GHT) is covered under the prescription drug benefit.

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.

Nothing

10% coinsurance after deductible

• Applied behavior analysis (ABA) therapy for autism spectrum disorder

$20 copayment per day per therapy type

Autism

Please contact our Customer Care Center for coordination of care assistance.

Covered Expenses:

• Services specifically related to a primary verified diagnosis of autism spectrum disorder, which includes autism disorder, Asperger's syndrome and pervasive development disorder not otherwise specified. Verified diagnosis must be conducted by a provider skilled in testing and in the use of empirically validated tools specific for autism spectrum disorders. For the diagnosis to be valid, the evidence must meet the criteria for autism spectrum disorder in the most recent Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. These services include:
  • Diagnostic testing, if testing tool is appropriate to the age of the Member and determined through the use of empirically validated tools specific for autism spectrum disorders. Dean Health Plan reserves the right to require a second opinion with a provider mutually agreeable to the Member and Dean Health Plan.
  • Intensive level services. The Member is eligible for 4 years of intensive level services. Any previous intensive-level services received by the Member will be counted against this requirement under this Policy, regardless of payor.

Intensive level services must be consistent with the following:

• Evidence based
• Provided by a qualified provider as defined by state law
• Based on a treatment plan developed by a qualified provider or professional as defined by state law that includes an average of 20 or more hours per week over a six-month period of time with specific cognitive, social, communicative, self-care or behavioral goals that are clearly defined, directly observed and continually measured. Treatment plans shall require that the Member be present and engaged in the intervention.
• Provided in an environment most conducive to achieving the goals of the Members treatment plan
• Includes training and consultation, participation in team meetings and active involvement of the Member's family and treatment team for implementation of the therapeutic goals developed by the team.
• Commences after an insured is 2 years of age and before the insured is 9 years of age.
• Services must be assessed for progress and documented throughout the course of treatment.
• The Member must be directly observed by the qualified provider at least once every two months.

Non-intensive level services. The Member is eligible for non-intensive level services, including direct or consultative services, that are evidence-based and are provided by a qualified provider or qualified paraprofessional if one of following conditions apply:

• After the completion of intensive level services and designed to sustain and maximize gains made during intensive-level treatment.
• To a Member who has not and will not receive intensive-level but for whom non-intensive level services will improve the member's condition.

Non-intensive level services must be consistent with the following:

• The services are based upon a treatment plan and includes specific therapy goals that are clearly defined, directly observed and continually measured and that address the characteristics of autism spectrum disorders. Treatment plans shall require that the Member be present and engaged in the intervention.
• Implemented by qualified providers, qualified supervising providers, qualified professionals, qualified therapists or qualified paraprofessionals as defined by state law.
• Provides treatment and services in an environment most conducive to achieving the goals of the Member’s treatment plan.
• Provides training and consultation, participation in team meetings and active involvement of the Member’s family in order to implement therapeutic goals developed by the team
• Provides supervision for qualified professionals and paraprofessionals in the treatment team.
• Services must be assessed for progress and documented throughout the course of treatment.

$20 office visit copayment per visit will apply where applicable (i.e. Autism intensive/non-intensive physician and facility charges)

$20 office visit copayment per visit will apply where applicable (i.e. Autism intensive/non-intensive physician and facility charges)

10% coinsurance after deductible for all other related services

Not covered Autism Expenses*:

• Animal-based therapy including hippotherapy
• Auditory integration training
• Chelation therapy
• Child care fees
• Cost for the facility or location of for the use of the facility or location when treatment, therapy or services are provided outside a Member’s home.
• Cranial sacral therapy
• Custodial or respite care
• Hyperbaric oxygen therapy
• Provider travel expenses
• Special diets and supplements
• Therapy, treatment or services to a Member residing in a residential treatment center, inpatient treatment or day treatment facilities
• Prescription drugs and durable medical equipment**

   *Please also see General Exclusions

**These items may be covered under the normal terms and conditions of the policy and are not covered under the Autism benefit. Please see Section 5(f). Prescription drug benefits, if applicable, and/or Section 5(a). Medical services and supplies provided by physician and other health care professionals (Durable Medical Equipment) for more information.

All charges

Outpatient visits if significant improvement can be expected within two months for the services of each of the following:

• Qualified physical therapists
• Occupational therapists

Note: We only cover therapy when a provider:

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

Occupational therapy is limited to services that assist the member to achieve and maintain self-care and improved functioning in other activities of daily living.

$40 copayment per day per therapy type

$40 copayment per day per therapy type

Biofeedback when prior authorization is obtained.

$40 copayment per day per therapy type

$40 copayment per day per therapy type

Habilitative Services

• Physical therapy, occupational therapy and speech therapy.
• Counseling.
• Behavioral health services.
• Habilitative services for Developmental delay.
• Cover health care services and devices that help a person keep, learn, or improve skills and functioning for daily living (habilitative services). Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

Note: Certain services require Prior Authorization. Please contact the Customer Care Center for a current list of services that require Prior Authorization.

Not covered:

• Custodial care
• Daycare
• Recreational care
• Respite care
• Vocational training
• Exercise programs

Outpatient visits when medically necessary

Note: Inpatient speech therapy is billed by the hospital and included under the inpatient hospital service/authorization.

$40 copayment per day per therapy type

$40 copayment per day per therapy type

• Hearing services to determine if correction is needed
• Treatment related to illness or injury, including diagnostic hearing tests performed by an M.D.,
  D.O., or audiologist

Nothing

• One hearing aid per ear every 36 months
• One adult hearing aid per ear, including repairs, ear molds and hearing aid dispensing fees. The hearing aid must be repaired by/purchased from SSM Health Dean Medical Group, or other authorized providers. Please contact the Customer Care Center with questions regarding authorized providers, or reference our website at www.deancare.com.
• Infants and children through age 18 who are certified as deaf or hearing impaired by a physician or audiologist are eligible for bilateral hearing aids. Benefits are available per benefit period. The benefit period is 36 consecutive months from the date the benefit is first used.
• Cochlear implants for children and adults, including procedures for implantation and post-cochlear implant aural therapy.  For therapy benefits please refer to Section 5(a) Orthopedic and prosthetic devices for benefits for devices. 

Note:

• For routine hearing screening performed during a child's preventive care visit, see Section 5(a) Preventive care, children.

Not covered:

• Batteries and chargers for hearing aids
• Hearing aids that are available over-the-counter

All charges

• Routine vision exam (limited to one per contract year)
• Non-routine vision exam
• Vision care services
  • An initial lens (eyeglass lens or contact lens) following surgical repair of the eye.
    • For the purposes of this benefit, reasons for surgical repair include treatment for cataracts or diseases of the cornea surface.
  • Therapeutic contact lenses for the treatment of the following diseases of the ocular surface, when these contact lenses will result in significantly better visual and/or improved binocular function when compared to eyeglasses, such as the following conditions:
    • Keratoconus;
    • Pathological myopia;
    • Aphakia;
    • Anisometropia;
    • Aniridia;
    • Corneal disorders;
    • Post-traumatic disorder;
    • Irregular astigmatism;
    • High ametropia;
    • Bullous keratopathy
• Diagnostic vision services

Exam and Testing - $20 copayment per visit with primary care provider; $40 copayment per visit with specialist

Vision Treatment or Supplies - Nothing

Exam and Testing - $20 copayment per visit with primary care provider; $40 copayment per visit with specialist

Vision Treatment or Supplies - Nothing

Not covered:

• Eyeglasses, contact lenses or fitting of contact lenses
• Radial keratotomy and other refractive surgery

All charges

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

Note: See orthopedic and prosthetic devices for information on podiatric shoe inserts.

$40 copayment per visit

Not covered:

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

• Artificial limbs and eyes
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy
• Lenses following cataract removal; or therapeutic contact lenses/bandages as well as the fitting as determined by Us.
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants
• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy.
• Prescription support stockings.

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

Durable medical equipment may require prior authorization as stated in our medical policies.  Your plan doctor will obtain the prior authorization.  Bone anchored hearing aids do not require a prior authorization.  

10% coinsurance

10% coinsurance after deductible

Not covered:

• Orthopedic and corrective shoes
• Arch supports
• Foot orthotics (that are not custom made)
• Heel pads and heel cups
• Lumbosacral supports
• Non-prescription elastic support or anti-embolism stockings
• Prosthetic replacements provided less than 3 years after the last one we covered

Durable medical equipment may require prior authorization as stated in our medical policies. Your plan doctor will obtain the prior authorization.

Rental of a ventilator or other mechanical equipment or purchase of such equipment at the option of Dean Health Plan.  

• Oxygen
• Dialysis equipment
• Hospital beds
• Wheelchairs
• Crutches, splints, trusses, orthopedic braces and appliances
• Walkers
• Insulin pumps
• TENS unit
• Oxygen therapy and other inhalation therapy and related items for home use
• Speech generating devices

Not covered:

• Repairs and replacement of durable medical equipment/supplies unless they are prior authorized by Us.
• Non-prescription elastic support or anti-embolism stockings
• Shoes or orthotics that are not custom made and can be purchased over the counter.
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative.
• Medical supplies and durable medical equipment for comfort, personal hygiene, and convenience, regardless of the Medical Necessity of such items.  Examples include, but are not limited to: air conditioners, air cleaners, humidifiers, physical fitness equipment, Health Care Provider equipment except as covered by our Medical policy, disposable supplies, alternative communication devices, and self-help devices not medical in nature.
• Home testing and monitoring supplies and related equipment except those used in connection with the treatment of diabetes,
• Equipment, models or devices that have features over and above that which is medically necessary. Coverage will be limited to the standard model as determined by Us.
• Any durable medical equipment or supplies used for work, athletic or job enhancement.

All charges

All charges

Medical Foods and Enteral Therapy

Durable medical equipment may require prior authorization as stated in Our medical policies. Your plan doctor will obtain the prior authorization.

• Medical foods to be covered without regard to age, mode of administration (oral vs. nasogastric tube), narrow arbitrary limitations to specific diseases (e.g., PKU), or whether it is the sole source of nutrition for that individual for those members with diagnosis of cystic fibrosis, amino acid, organic acid, fatty acid, metabolic and absorption disorders as well as other conditions when prescribed to treat the member’s condition and as described in Our medical policy.
• Amino acid based elemental formula is covered up to five (5) years of age for members with with IgE mediated allergies to food proteins, food protein-induced enterocolitis syndrome, eosinophilic esophagitis and other conditions when prescribed to treat the member’s condition and as described in Our medical policy.
• Synthetic or semi-synthetic enteral feeding is covered with Prior Authorization for members when this feeding supplies the member’s sole source of nutrition, is to be delivered via naso-gastric, jejunostomy or gastrostomy tube, and criteria are met as described in Our medical policy.

Note: Medical supplies and equipment are covered when prescribed by your plan physician for treatment of a diagnosed illness or injury. The supplies or equipment must be purchased from a plan durable medical equipment provider.

Oral nutrition is covered when mandated by law or covered under Our medical policy for a specific condition. Items available at grocery stores are not considered medical foods and therefore are not covered.

10% coinsurance

10% coinsurance after deductible

Not covered:

• Oral nutrition is not considered a medical item. We do not cover nutritional support that is taken orally (i.e., by mouth), unless mandated by law or covered under Our medical policy for a specific condition. Examples include, but are not limited to, over-the-counter nutritional supplements, infant formula and donor breast milk.

All charges

All charges

• Home healthcare ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide.
• Services include oxygen therapy, intravenous therapy and medications.

10% coinsurance

10% coinsurance after deductible

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient's family
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative
• Services primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship, or giving oral medication
• Private duty nursing or nursing aide

• Manipulation of the spine and extremities
• Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

$20 copayment per visit

Not covered:

• Maintenance and long term therapies.

Acupuncture - by a doctor of medicine or osteopathy, or licensed or certified acupuncture practitioner.

Note: Limited to 10 visits per member per contract period.  

Please visit our website at www.deancare.com for a list of participating acupuncturists.

$20 copayment per visit

$20 copayment per visit

Not covered:

• All other forms of alternative medicine not otherwise listed in the policy.

Tobacco cessation

As part of your health benefits, Dean Health Plan provides coverage of tobacco cessation medications. You can receive any of the tobacco cessation medications listed on the drug formulary with no member cost-sharing. To take advantage of this benefit you must obtain a prescription from your doctor and may enroll in the Dean Health Plan Quit for Life^® program.

The Quit For Life^® Program is completely free to Dean Health Plan commercial members 18 years and older. Using a mix of medication and phone-based coaching, it can help you down the path to quit smoking and overcome physical, psychological and behavioral addictions to nicotine dependence.

A highly trained Quit Coach^® helps you gain the knowledge, skills and behavioral strategies to quit for life.

Free of Cost - the program includes:

• up to five outbound coaching calls and unlimited access to a Quit Coach for the duration of the program;
• a printed workbook that helps guide you through the quitting process;
• an opportunity to receive twelve weeks of the NRT patch or gum at no cost, mailed directly to your home.

The Quit For Life^® Program uses four essential practices to quit:

1. Quit At Your Own Pace: Quit on your own terms, but get the help you need, when you need it.
2. Conquer Your Urges to Smoke: Gain the skills you need to control cravings, urges and situations involving alcohol.
3. Use Medications So They Really Work: Learn how to supercharge your quit attempt with the proper use of nicotine substitutes or medications.
4. Don't Just Quit, Become a Nonsmoker: Once you've stopped using tobacco, learn to never again have that "first" cigarette.

Enroll Now!

Enrollment in The Quit for Life^® Program is easy!

Call 866-QUIT4LIFE (866-784-8454) or enroll online at www.deancare.com/quitforlife. 

Diabetic Education

• Diabetic education
• Diabetic self-management training classes

Nothing

Nothing

Not covered:

• Educational services, except for diabetic education
• Group counseling

All charges

All charges

Nutritional Counseling and Education Visits

Nutritional counseling services by a registered dietitian when both of the following are true:

• Patient self-management is an important component of the treatment for a disease
• There exists a knowledge deficit regarding the disease which requires the intervention of a trained health professional.

$40 copayment per visit

$40 copayment per visit

Not covered:

• Food or medical food formulated to be consumed or administered internally under the supervision of a physician intended for specific dietary management.
• Nutritional supplements or vitamins.

All charges

All charges

A comprehensive range of services, such as:

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

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.

10% coinsurance

Not covered:

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

All charges

Services listed in this subsection will not be paid unless you:

1. Obtain Prior Authorization to participate in the Dean Comprehensive Weight Management Program ("Program"); and
2. Meet the criteria listed within the appropriate Dean Health Plan Medical Policy. Please contact Our Customer Care Center at 800-279-1301 (TTY: 711) for the criteria.

Prior Authorization may only be granted after you have consulted with a Program provider. Only certain Dean Health Plan providers qualify as Program providers.  Contact our Customer Care Center at 800-279-1301 (TTY: 711) for a listing of plan providers.

Any surgery must be performed at SSM Health St. Mary’s Hospital - Madison or the SSM Health Surgery Center in Madison, Wisconsin.

Covered Expenses:

• Medical weight management services received through the Program.
• Surgical treatment of severe obesity (bariatric surgery).
• Follow-up care services.

10% coinsurance

10% coinsurance after deductible

Not covered:

• Treatments, services or procedures that are not Medically Necessary nor approved by Us.
• Diet supplements.
• Low-calorie foods and beverages.
• Weight loss books and materials obtained through the Program or other outside sources.
• Body sculpting procedures related to weight loss.

All charges

All charges

We adhere to WPATH Standards for gender affirming care and services, including facial feminization.  There are no exclusions for WPATH Standards.

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:  
  • the condition produced a major effect on the member’s appearance and 
  • the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers and toes.
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • surgery to produce a symmetrical appearance of breasts
  • treatment of any physical complications, such as lymphedemas
  • breast prostheses and surgical bras and replacements (see Prosthetic devices)
• Gender Affirming Surgeries.  Gender transitions surgeries include, but are not limited to, the following surgeries with prior authorization:
  • For female to male transition:  surgeries and procedures such as:  Mastectomy, Hysterectomy, Vaginectomy, Salpingo-Oophorectomy, Breast reduction, Nipple – Areola Reconstruction, Metoidioplasty, Phalloplasty, Urethroplasty/Urethromeatoplasty, Scrotoplasty, Placement of Testicular and Penile (erectile) Prosthesis, secondary sex characteristics
  • For male to female transition:  surgeries and procedures such as:  Penectomy, Orchiectomy, Breast Augmentation Mammoplasty and Implants, Repair of Introitus, Coloproctostomy, Vaginoplasty, Colovaginoplasty, Clitoroplasty, Labiaplasty, secondary sex characteristics

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.

10% coinsurance

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

• Surgery consult and/or evaluation.
• Surgical procedures as follows:
  • Removal of impacted teeth
  • Removal of tumors and cysts that are not related to non-bony impacted teeth.
  • Treatment for accidental injuries of the jaw, cheeks, lips, tongue, roof, and floor of mouth.
  • Apicoectomy.
  • Removal of exostoses of the jaw and hard palate when not performed to facilitate denture placement.
  • Treatment of fractured facial bones.
  • External/ internal incision and drainage of facial abscess of soft tissues.
  • Cutting of accessory sinuses, salivary glands or ducts.
  • Reducing dislocations; alveoloplasty.
  • Lingual frenectomy.
  • Vestibuloplasty.
  • Residual root removal.

Medically Necessary Anesthesia and Facility Charges for Dental Procedures

Charges for medical facilities (e.g. hospital, ambulatory surgery center (ASC)) and general anesthesia services for dental care  will be covered if the Member is a child under the age of five. Charges for medical facilities and general anesthesia services will also be covered in the ASC or hospital location if the Member is five years and older if any of the following applies:

• The Member has a chronic disability that;
• Is attributable to a behavioral or physical impairment or combination of behavioral and physical impairments;
• Is likely to continue indefinitely; and
• Results in substantial functional limitations in self-care, language, learning, mobility, capacity for independent living or economic self-sufficiency; or
• The Member has a medical condition requiring hospitalization or general anesthesia for dental care.

Temporomandibular Joint Disorders (TMJ)

Coverage is limited to diagnostic procedures, including diagnostic casts, diagnostic study models and bite adjustments, and Medically Necessary surgical or non-surgical treatment for the correction of temporomandibular disorders (TMJ), if the following apply:

• Under the accepted standards of the profession of the Health Care Provider rendering the service, the procedure or device is reasonable and appropriate for the diagnosis or treatment of this condition.
• The purpose of the procedure or device is to control or eliminate infection, pain, disease or dysfunction.
• Orthognathic surgery only for the treatment of TMJ, when prior authorized by Us.

$40 copayment per visit (surgery consult and/or evaluation)

10% coinsurance (all other services)

$40 copayment per visit (surgery consult and/or evaluation)

10% coinsurance after deductible (all other services)

Not covered Expenses for Oral Surgery:

• All charges or costs exceeding a benefit maximum.
• All dental services, except those listed as covered in Section 5(g). Dental Benefits subsection.
• Surgery performed to correct functional deformities of the mandible or maxilla.
• Correction of malocclusion.
• Orthognathic surgery; except for the treatment of TMJ.
• Orthodontic care, periodontic care, or general dental care.
• Restoration. Examples include but are not limited to crowns and root canals.
• Tooth damage due to eating, chewing or biting.

Not covered Expenses for Hospitalization for Dental Procedures:

• Hospitalization costs for services not listed in this Section, except those listed in the Hospital & Surgical Services and Dental Services subsections, for which Prior Authorization is required.
• Any non-hospital or non-ambulatory surgery center facility charges.
• Any charges related to dental procedures unless listed as a Covered Expense elsewhere in this Certificate.

Not covered Expenses for Temporomandibular Joint Disorders (TMJ):

• All dental services, except those listed as covered in this TMJ subsection.

All charges

All charges

These solid organ transplants are covered.  These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan.  See Section 3, page (Applies to printed brochure only) for prior approval. Solid organ transplants are limited to:

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

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)

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below.

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced neuroblastoma
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hematopoietic Stem Cell Transplant (HSCT)
  • Hemoglobinopathy
  • Infantile malignant osteopetrosis
  • Kostmann's syndrome
  • Leukocyte adhesion deficiencies
  • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Mucolipidosis (e.g., Gaucher's disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  • Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s syndrome, Sanfillippo’s syndrome, Maroteaux-Lamy syndrome variants)
  • Myelodysplasia/Myelodysplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell anemia
  • X-linked lymphoproliferative syndrome
• Autologous transplants for
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Breast Cancer
  • Ependymoblastoma
  • Epithelial ovarian cancer
  • Ewing's sarcoma
  • Hematopoietic Stem Cell Transplant (HSCT)
  • Medulloblastoma
  • Multiple myeloma
  • Neuroblastoma
  • Pineoblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

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

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

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

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

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

• Allogeneic transplants for
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Beta Thalassemia Major
  • Chronic inflammatory demyelination polyneuropathy (CIDP) 
  • Multiple myeloma
  • Multiple sclerosis
  • Sickle Cell anemia

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

• Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
• Advanced Hodgkin’s lymphoma
• Advanced non-Hodgkin’s lymphoma
• Chronic lymphocytic leukemia
• Chronic myelogenous leukemia
• Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
• Multiple myeloma
• Multiple sclerosis
• Myelodysplasia/Myelodysplastic Syndromes
• Myeloproliferative disorders (MSDs)
• 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 lymphomas
  • Breast Cancer
  • Childhood rhabdomyosarcoma 
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Epithelial Ovarian Cancer
  • Mantle Cell (Non-Hodgkin lymphoma)
  • Multiple sclerosis
  • Systemic lupus erythematosus
  • Systemic sclerosis

Note:  Coverage for organ-procurement costs is limited to costs directly related to the procurement of an organ from a cadaver or compatible living donor. Organ-procurement costs include the following: organ transportation, compatibility testing, hospitalization, and surgery (when a live donor is involved).

Nothing

Nothing

10% coinsurance after deductible

Not covered:

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

Professional services provided in –

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

Nothing

Room and board, such as

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

10% coinsurance

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
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

10% coinsurance

Note:  Inpatient dental procedures – limited benefit. Hospitalization for certain procedures is covered when a Plan doctor determines there is a need for hospitalization for reasons totally unrelated to the dental procedure; the Plan will cover the hospitalization, but not the cost of the professional dental services. Conditions for which hospitalization would be covered include hemophilia and heart disease; the need for anesthesia, by itself, is not a condition. The Plan will not cover the cost of the professional dental services.

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

10% coinsurance

Not covered:

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

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests, X-rays , and pathology services
• Administration of blood, blood plasma, and other biologicals
• Blood and blood plasma, if not donated or replaced
• Pre-surgical testing
• Dressings, casts, and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service

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

10% coinsurance

Extended care benefit: The plan provides a comprehensive range of benefits for up to 120 days per confinement when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan.

All necessary services are covered, including:

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

10% coinsurance

Hospice Care

• Inpatient hospice
• Hospice services while at a skilled nursing facility
• Home-based hospice
• Respite care is a form of hospice services that give your uncompensated primary caregivers (i.e., family members or friends) rest or relief when necessary to maintain a terminally ill Member at home.
• Respite care is limited to five consecutive days per plan year.
• Respite care is available once per plan year.
• Respite services managed through credentialed hospice provider.

Nothing

Not covered:

• Independent nursing, homemaker services
• Respite care for more than five consecutive days

Dean Health Plan partners with Vital Decisions Living Well Program, offering telephonic health care counseling to individuals and their families who are experiencing serious illness. The phone counseling is offered at no cost to the member and can be extremely beneficial by supporting participants in making important health decisions.  The Living Well Program, which is a voluntary, patient-centered service, will: help individuals identify their quality of life preferences and values; assist patients in actively and effectively communicating their priorities to family and physicians and ensure that more effective shared decision making occurs.

Nothing

Nothing

Palliative Care

• Palliative care is specialized medical care ordered by a palliative care provider for people living with an advanced life-limiting illness, focused on providing relief from the symptoms and stress of the illness.
• Palliative care team may include providers such as doctors, nurses, or social workers.
• These services are coordinated by a palliative care provider and must be Medically Necessary.
• Prior Authorization may be required for in-home palliative care services.  Please contact the Customer Care Center for information on which services require prior authorization.

 Covered Expenses:

• Outpatient visits with palliative care providers.
• In-home visits with a palliative care provider or team member for member-facing issues associated with advanced life-limiting illnesses. Must be prior authorized.
• Licensed skilled nursing.
• Licensed medical social worker.

Nothing

Nothing

 Non-Covered Expenses for Palliative Care:

• Custodial Care or any service that is not required to be provided by a skilled/licensed provider.
• Services provided by volunteers.
• Residential Care.
• Housekeeping or homemaking services.
• Home care services provided by a family member or someone that resides with the Member.

All charges

All charges

Ambulance

• Ambulance transportation must be provided by an established state-licensed ambulance service and comply with all local and federal laws.
• Out-of-network air ambulance services are covered at the in-network level.

Ground Ambulance Services

• Ground ambulance transportation to or from a hospital in urgent or emergency situations when medical attention is required along the way.
• Non-urgent or non-emergency ground ambulance transportation situations in the following circumstances:
  • The Member needs to be transported from one acute inpatient facility setting to another inpatient facility care setting.
  • The Member is transported from an acute facility to another acute care site because Medically Necessary services are not available in the hospital the Member was admitted. The Member will be transported back to the original facility upon completion of services.
  • The Member is a mother whose baby requires transfer to a higher level of care, and the mother requires an inpatient level of post-partum care and has been accepted for admission at the receiving facility.
  • Other non-urgent or non-emergency ground ambulance transportation involving transport between higher level of care to lower level of care or transport between lower levels of care, when the Member requires medical care en route, may require Prior Authorization.
  • Please contact Our Customer Care Center about services that require Prior Authorization.
• Ground ambulance services when transportation is not provided, in the following circumstances:
  • Transportation is unplanned;
  • Services are provided by qualified medical professionals from the ambulance provider; and
  • Services are deemed Medically Necessary to treat the injury or medical condition that prompted the call for the ambulance.

Air and Water Ambulance Transportation

• Ambulance transportation to transfer a Member to a hospital or from one hospital to another hospital is covered if all of the following requirements are met:
  • The Member needs to be transported due to an emergency situation and requires medical attention along the way;
  • Using any other method of transportation, including ground ambulance transportation, would endanger the Member’s health;
  • The transferring hospital cannot provide the hospital or skilled nursing care the Member’s illness or injury requires; and
  • The facility which receives the transported Member is the nearest one with appropriate facilities.

10% coinsurance

Not covered:

• Non-emergency or non-urgent ground or air ambulance services or transportation, unless the transportation or service is listed as a Covered Expense under Ground Ambulance Transportation in the Section or is Prior Authorized by Us.
• Charges for, or in connection with, any other form of travel, unless otherwise stated in this Section.
• Member’s condition does not meet medical criteria for ambulance services or transportation.
• Any ambulance transportation or services initiated for convenience or non-medical reasons.

All charges

All charges

Emergency care at a doctor's office

• With primary care provider

$20 copayment per visit

$20 copayment per visit

Emergency care at a doctor's office

• With specialist

$40 copayment per visit

$40 copayment per visit

Emergency care at a doctor's office

• Related services

Note:  See Section 5(a) Lab, X-Ray and Other Diagnostic Tests for services covered without member cost share when associated with an office visit or urgent care visit.

10% coinsurance*

10% coinsurance after deductible*

Emergency care at an urgent care center

• With primary care provider or specialist

$20 copayment per visit

$20 copayment per visit

Emergency care at an urgent care center

• Related services

Note:  See Section 5(a) Lab, X-Ray and Other Diagnostic Tests for services covered without member cost share when associated with an office visit or urgent care visit.

10% coinsurance*

10% coinsurance after deductible*

Emergency care as an outpatient at a hospital; including doctors' services

Note:  The ER copayment is waived if admitted for observation or inpatient directly from the emergency visit (High Option).

*Other charges will result from services rendered by other providers who treated you during your urgent care or emergency room visit. These charges include, but are not limited to; diagnostic services, procedures/treatments and various medical supplies.

$100 copayment per hospital emergency room visit and 10% coinsurance for related services*

10% coinsurance after deductible per hospital emergency room visit*

Emergency care at a doctor’s office

• With primary care provider

$20 copayment per visit

$20 copayment per visit

Emergency care at a doctor’s office

• With specialist

$40 copayment per visit

$40 copayment per visit

Emergency care at a doctor’s office

• Related services

10% coinsurance*

10% coinsurance after deductible*

Emergency care at an urgent care center

• With primary care provider or specialist

$20 copayment per visit

$20 copayment per visit

Emergency care at an urgent care center

• Related services

10% coinsurance*

10% coinsurance after deductible*

Emergency care as an outpatient at a hospital; including doctors' services

Note:  The ER copayment is waived if admitted for observation or inpatient directly from the emergency visit (High Option).

*Other charges will result from services rendered by other providers who treated you during your urgent care or emergency room visit. These charges include, but are not limited to; diagnostic services, procedures/treatments and various medical supplies.

$100 copayment per hopsital emergency room visit and 10% coinsurance for related services*

10% coinsurance after deductible per hospital emergency room visit*

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 (ground or air).

Note: See 5(c) for non-emergency service.  Non-transport service is covered if medically appropriate.

10% coinsurance

10% coinsurance after deductible

When part of a treatment plan we approve, we cover professional services by licensed professional behavioral 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, behavioral health illness, or behavioral health 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

$20 copayment per visit (Outpatient)/Includes Telehealth Visits

10% coinsurance (Inpatient)

$20 copayment per visit (Outpatient)/Includes Telehealth Visits

10% coinsurance after deductible (Inpatient)

• Outpatient diagnostic tests provided and billed by a licensed behavioral 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

$20 copayment per visit (Outpatient)

10% coinsurance (Inpatient)

$20 copayment per visit (Outpatient)

10% coinsurance after deductible (Inpatient)

Inpatient behavioral health services means medically oriented treatment, psychotherapy and other behavioral health services provided by a licensed professional in a state licensed or certified hospital or behavioral health residential facility on a 24 hour per day basis to enable a person with a behavioral health disorder or a behavioral health disorder in combination with other impairments to function successfully.

• Medically Necessary services provided at an in- network inpatient, behavioral health inpatient/residential facility.
• Medically Necessary services at a substance use disorder residential/inpatient treatment programs for alcohol and/or drug dependent persons services provided by a licensed professional in a state licensed or certified facility.
• Medically Necessary inpatient detoxification services are considered medical and, therefore, are NOT applied to this benefit. Please see the “Detoxification Services” provision under the “Hospital & Surgical Services” subsection for more information on this coverage.

10% coinsurance

Partial hospitalization or day treatment programs are more intensive than outpatient services and less intensive than inpatient services. The services must be in a licensed behavioral health or substance use disorder partial hospitalization or day treatment facility with services by a licensed behavioral health or substance use disorder treatment services provider.

• Medically Necessary outpatient services, including group, family and individual therapy in an office or clinic setting with a behavioral health or substance use disorder treatment in-network Provider.

For Full-Time Students attending school in Wisconsin, but outside the service area:

• A clinical assessment by an Out-of-Network Provider and 5 visits for outpatient behavioral health or substance use disorder treatment with an approved Prior Authorization. We retain the right to choose the provider. Further treatment may be approved upon review of Our Quality and Care Management division.

Medically Necessary and prior authorized services for the following treatments and programs:

• Behavioral health or substance use disorder treatment for adults, adolescents, and children in a partial hospitalization or day treatment program.
• Services for persons with chronic behavioral health illness provided through a community program. These programs provide services to people with chronic behavioral health illnesses that, due to history or prognosis, require repeated acute treatment or prolonged periods of inpatient care. Benefits are payable only for charges directly related to treatment of behavioral health illness.
• Intensive outpatient programs for the treatment of drug and alcohol use disorders. Treatment must be provided by specialists in addiction medicine.
• Intensive outpatient programs for the treatment of behavioral health disorders.
• Coordinated emergency behavioral health services for persons who are experiencing a behavioral health crisis or who are in a situation likely to turn into a behavioral health crisis if support is not provided. Services are provided by a program certified for the period of time the person is experiencing a behavioral health crisis until the person is stabilized or referred to other providers for stabilization. Certified emergency behavioral health service plans shall provide timely notice to Us to facilitate coordination of services for persons who are experiencing, or are in a situation likely to turn into, a behavioral health crisis.

Note:  To qualify for coverage under behavioral health and substance use disorder treatment care, the care must be Medically Necessary and prior authorized by Us.

• Medical Necessity will be reviewed by our Quality and Care Management division. To qualify, the treatment program must be staffed by a multi-disciplinary team, which should include registered nurses, occupational therapists, social workers, psychologists, physicians or other health care professionals. The treatment must be provided by substance use disorder treatment or behavioral health credentialed professionals and the treatment program must include a quality assurance program to review quality of care.
• Prior Authorization will be approved if Our Quality and Care Management division determines that the Member requires more intensive treatment than is available through outpatient services and that the care is the most appropriate level of care for the Member. Prior Authorization does not guarantee payment if the services would not otherwise be covered according to the provisions of this Certificate.

$20 copayment per visit

Not covered:

• Biofeedback.
• Family counseling for non-medical reasons.
• Wilderness and camp programs, boarding school, academy-vocational programs and group homes.
• Halfway houses.
• Hypnotherapy.
• Long-term or maintenance therapy.
• Marriage counseling.
• Phototherapy.

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

• Drugs and medications that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered
• Insulin, with a copayment applied to each vial
• Diabetes care.  We cover the following drugs and supplies related to diabetes care:
  • Insulin, disposable supplies and any prescription medication used to treat diabetes. Disposable supplies include: blood or urine glucose strips, control solutions for blood glucose monitors, finger stick devices, lancets and syringes. Single-packaged items such as blood glucose testing strips are limited to two items per cost-sharing amount.
  • Infusion pumps and related equipment and supplies are covered under the medical benefit as required by Wis. Stat. § 632.895(6) from a network durable medical equipment provider.
  • Continuous glucose monitoring equipment and related supplies.
• Growth hormones (prior authorization required)
• Drugs to treat gender dysphoria.  Drug therapy for patients with gender dysphoria is established by the treating provider. Members should review their drug formulary for coverage information.

Note:  See Section 5(a) and 5(b) for intravenous fluids and medication for home use.  Zyban is covered through the Tobacco Cessation benefit with no member cost share (see Tobacco cessation found in Section 5(a) - Educational classes and programs).

Tier 1 (Generics) $10 copayment*

Tier 2 (Preferred brands and select generics) 30% co-insurance of the allowed amount (maximum $75 copayment per prescription, up to a $1,500 out-of-pocket maximum per contract year, $10 copayment applies thereafter.)*

Tier 3 (Non-preferred brands and select generics) 50% co-insurance of the allowed amount (minimum $50 copayment and a maximum $150 copayment per prescription)*

Tier 4 (Specialty drugs) $100 copayment*

*Regardless of the tier your oral chemotherapy falls into you will never pay more than $100 for a 30 day supply, in compliance with the Wisconsin law governing coverage of oral chemotherapy drugs.

Note: If there is no Tier 1 generic equivalent available, you will be required to pay the higher Tier 2 or Tier 3 copayment.

Tier 1 (Generics) $10 copayment*

Tier 2 (Preferred brands and select generics) 30% co-insurance of the allowed amount (maximum $75 copayment per prescription, up to a $1,500 out-of-pocket maximum per contract year, $10 copayment applies thereafter.)*

Tier 3 (Non-preferred brands and select generics) 50% co-insurance of the allowed amount (minimum $50 copayment and a maximum $150 copayment per prescription)*

Tier 4 (Specialty drugs) $100 copayment*

*Regardless of the tier your oral chemotherapy falls into you will never pay more than $100 for a 30 day supply, in compliance with the Wisconsin law governing coverage of oral chemotherapy drugs.

Note: If there is no Tier 1 generic equivalent available, you will be required to pay the higher Tier 2 or Tier 3 copayment.

6 for $6

Select unique generic medications for conditions such as diabetes, high blood pressure, mood disorders and bone health available to members for $6 for a 6-month supply at all participating in-network SSM Health retail pharmacies and Costco retail pharmacy.  Refer to your drug formulary for the most current listing of eligible medications.

$6 for a 6 month supply

$6 for a 6 month supply

Mail Order Prescription Drug Benefit

• 90-day supply for the cost of a 60-day supply (Tiers 1 and 2 only)
• 90-day supply at mail order for 3 copayments (Tier 3)
• Specialty drugs not available at mail order (Tier 4)

Tier 1 (Generics) - $20 copayment

Tier 2 (Preferred brands and select generics) - 30% coinsurance of the allowed amount (maximum $150 copayment per prescription, up to a $1,500 out-of-pocket maximum per contract year; $20 copayment applies thereafter

Tier 3 (Non-preferred brands and select generics) - 50% coinsurance of the allowed amount (minimum $150; maximum $450)

Tier 1 (Generics) - $20 copayment

Tier 2 (Preferred brands and select generics) - 30% coinsurance of the allowed amount (maximum $150 copayment per prescription, up to a $1,500 out-of-pocket maximum per contract year; $20 copayment applies thereafter

Tier 3 (Non-preferred brands and select generics) - 50% coinsurance of the allowed amount (minimum $150; maximum $450)

Contraceptive drugs and devices as listed in the ACA/HRSA site.

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

• Over-the-counter contraceptives are a covered benefit with a prescription. 

• To obtain a non-formulary contraceptive for a member, the provider should fill out an Exception to Coverage form and send to the PBM. The PBM will approve the request if the provider notes that the non-formulary contraceptive product is medically necessary.  

Drugs to treat sexual dysfunction are limited to Viagra and Cialis.  Contact the plan for dose limits.

50% copayment per unit or refill

50% copayment per unit or refill

• Outpatient Infertility drugs

Self-Injectable and Oral medications for the diagnosis and treatment of infertility, except as described below under not covered.

Dean Health Plan’s drug formulary covers all related drug categories of fertility drugs, including IVF medications with an approved prior authorization when Prescribed by a Reproductive Specialist AND Member has a primary diagnosis of infertility AND this medication is NOT prescribed for assisted reproductive technology.

The outpatient infertility pharmacy benefit allows for up to three IVF cycles annually (5 months of medications).

Note:  See formulary for covered drugs at https://www.deancare.com/getmedia/95ae4b9f-4408-4462-a504-f82063259610/Traditional-4-Tier-Formulary.pdf

See formulary management procedures at https://www.deancare.com/members/pharmacy-benefits/formulary-management-procedures

50% copayment of the allowed amount per unit or refill regardless of the tier the covered formulary drug is on.

50% copayment of the allowed amount per unit or refill regardless of the tier the covered formulary drug is on.

Not covered:

• Drugs to enhance athletic performance
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
• Nonprescription medications unless specifically indicated elsewhere
• Infertility drugs, including, but not limited to, those administered by a medical provider for the purpose of Assisted Reproductive Technology (ART).
• Drugs prescribed by a provider who is not acting within their scope of licensure.
• New to market Drugs. Products recently approved by the FDA and introduced into the market will not be covered until they are reviewed and considered for placement on Our Drug List.
• New to market biologics, biosimilars and professionally administered drugs. Biologics, biosimilars and professionally administered drugs recently approved by the FDA (including approval for a new indication) will not be covered until they are reviewed and approved for coverage by Us.
• If you fail to provide your prescription coverage information to the pharmacy, you will be responsible for any amount above what We would have paid for your prescription under this policy.
• Products that are duplicative to, or are in the same class and category as, products on Our Drug list.
• Drugs, supplies, biologics and biosimilars that have not been approved by the U.S. Food and Drug Administration (FDA).
• Professionally administered drugs that do not meet both of the following requirements: (a) administered in conjunction with a covered benefit and (b) administered by a physician acting within the scope of the provider’s license.
• Any form, mixture or preparation of cannabis for medical or therapeutic use and any device or supplies related to its administration.
• Services or drugs used to treat conditions that are cosmetic in nature, unless otherwise determined to be reconstructive.

Note:  Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco and nicotine dependence are covered under the Tobacco cessation benefit.  (Section 5(a), Educational classes and programs, page (Applies to printed brochure only).)

All charges

All charges

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.

• Select preventive medications from the drug formulary within the following categories:  Antihypertensives, Antihyperlipidemics, Antidiabetics, Anticoagulants, Antiplatelets, Osteoporosis, Antiasthmatics/Bronchodilators and mental health medications
• 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)
• Liquid iron supplements for children age 0-1 year
• Prescription strength vitamin D supplements for members age 65 or older (400 & 1000 units)
• Pre-natal vitamins for pregnant individuals
• Fluoride tablets, solution (not toothpaste, rinses) for children age 0-6 years

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

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

Nothing

Nothing

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Fertility drugs that are not approved by the plan
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
• Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them; except as required by ACA (except for Vitamin D for adults age 65 and older)
• Nonprescription medications unless specifically indicated elsewhere

Note: Over-the-counter and prescription drugs approved by the FDA to treat tobacco and nicotine dependence are covered under the Tobacco cessation benefit. (Section 5(a), Educational classes and programs, page (Applies to printed brochure only).)

All charges

All charges

Mandatory 90-Day Generic Maintenance Drug Fill

For Tier 1 generic maintenance Drugs as defined by Us, a retail provider must dispense a 90-day supply. This requirement will apply after you have received three consecutive 30-day supplies.

• Tier 1 (Generics) maintenance drugs will be required to be filled at a 90-day supply.
• For newly written prescriptions for a Tier 1 generic maintenance drug and new to taking this drug you will be allowed three 30-day fills of the drug before being required to fill at a 90-day supply.
• Brand maintenance drugs are NOT mandatory to fill with a 90-day supply, but is optional if you wish to do so.
• You will experience a lower out-of-pocket cost using our Costco mail order pharmacy (90-day supply for 2 copayments) vs. retail pharmacy (90-day supply for 3 copayments).

Note:  You may request an exception to this requirement to continue filling your Tier 1 (Generic) maintenance drug with a 30-day supply by either: 1) asking the retail pharmacy provider to contact Our pharmacy benefit manager (Navitus Health Solutions), or 2) contacting Our Customer Care Center at 800-279-1301.

Retail Tier 1 (Generics) - $30 copayment

Mail Order Tier 1 (Generics) - $20 copayment

Retail Tier 1 (Generics) - $30 copayment

Mail Order Tier 1 (Generics) - $20 copayment

• Tooth extractions, initial repair, and/or replacement with artificial teeth, because of an accidental injury.

Dental, Extraction of Natural Teeth, and Replacement with Artificial Teeth due to an accidental injury.

To be eligible for coverage:

• The services must be Medically Necessary while you are enrolled under this Policy.
• The tooth must meet the definition of “sound, natural tooth”.
• A “sound, natural tooth” is a tooth (including supporting structures) that is free from disease that would prevent continual function of the tooth for at least one year. In the case of primary (baby) teeth, the tooth must have a life expectancy of one year.

The term "injured" does not include conditions resulting from eating, chewing or biting.

• Medically Necessary hospital or ambulatory surgery center charges incurred, and anesthetics provided in connection with dental care that is provided to a Member in a hospital or ambulatory surgery center may require prior authorization. Please contact our Customer Care Center for a current list of services that require Prior Authorization.

24/7 Access to your Health Care Information

Member Portal

Visit www.deancare.com/login and use your member number located on your ID card to activate your account.

• View insurance plan details
• Request member ID cards or download a digital copy
• Change your primary care clinic
• Review past claim details and more

MyChart

Visit www.deancare.com/mychart to activate your account.

• Send and receive secure messages with your primary care provider
• Schedule appointments
• Get lab results
• View and pay your medical bill
• Request prescription refills and more

Behavioral Health Case Management

Behavioral Health Resources are available at www.deancare.com/behavioralhealth.

If you are a Dean Health Plan member and have a mental health and/or substance use condition, you may benefit from free case management. Through case management, you’ll be connected with a behavioral health registered nurse or social worker who serves as your resource. Your case manager works with you, your health care provider and other members of your health care team to establish the best plan of care for you.

You can request behavioral health case management services by calling the Dean Health Plan Customer Care Center at 800-279-1301 or online at www.deancare.com/caremanagement.

Care Management Programs

Our care management team combines registered nurses, licensed social workers and program outreach specialist – all available to help you manage your health care needs. Through in-person and phone outreach, our team works closely with you to navigate health care and community resources to help you be the healthiest you can be.

Care management services are a free benefit from Dean Health Plan. Our services include:

• Behavioral health and substance use
• Complex case management, care coordination
• Maternal and child health
• Social work
• Transplant case management
• Advance care planning

 Visit www.deancare.com/caremanagement.

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

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

Health Care Support

Nurse Advice Line is there whenever you have a health question.  You can connect with an experienced registered nurse by calling 800-576-8773.  For additional information, visit DeanCare.com/DeanOnCall.

The Nurse Advice Line is available after-clinic hours from 5 pm - 8 pm and 24/7 on weekends and holidays to serve patient triage needs.

NOTE:  Due to licensing restrictions Nurse Advice Line's triage services are only available to residents of Wisconsin.

Maternal and Child Health

Dean Health Plan’s Care Management department offers outreach and education to pregnant women enrolled in our www.deancare.com/wellness/pregnancy, obstetric (OB) case management for high-risk pregnant women and pediatric case management for our youngest members with complex medical conditions.

Our team of nurses, social workers, and program outreach specialists can help you navigate the health care system, locate community resources and services, and coordinate care to ensure your, and your child’s, individual needs are met to achieve an optimal health outcome. Our certified lactation counselors can provide you with the support you need to be successful with breastfeeding and pumping. Case management begins with an assessment of your, or your child’s, needs to develop an individual care plan with personalized goals. 

Your OB case manager or program outreach specialist can help you:

• Choose a doctor for yourself and your child
• Receive support with any health concerns or chronic conditions you may have
• Make healthy changes – like quitting tobacco
• Care for yourself and your baby before and after birth
• Connect with local resources and find pregnancy education classes
• Get support with breastfeeding and find information about breast pumps
• Transition into the Well Child Program

Your pediatric case manager can help you:

• Understand your child’s medical condition, treatment, medications, and home health care needs
• Advocate for your child during the discharge planning process
• Coordinate outpatient care, specialty services, and community resources to manage chronic medical conditions and provide support for families
• Identify community resources that provide emotional support
• Understand your individual health care plan including how to maximize your benefits
• Get support with breastfeeding

Enrollment is voluntary. Sign up and one of our team members will contact you.

Nicotine Cessation

We offer two nicotine cessation programs:

• Freedom From Smoking
• Quit for Life

Freedom From Smoking

Dean Health Plan offers both an on-site and virtual no-cost tobacco program, Freedom from Smoking. This small group program includes eight one-hour sessions led by a certified Freedom from Smoking facilitator.

The program features a step-by-step plan for quitting tobacco. Each session is designed to help tobacco users understand their triggers and urges, and develop coping strategies to stay committed to quitting. This engaging program uses a variety of evidence-based techniques to personalize and address individual needs along with the benefits of support from the group.

For the schedule of upcoming dates and locations visit www.deancare.com/quitnow.

Quit for Life^®

Dean Health Plan offers the Quit For Life^® Program, at no cost to members 18 years and older. The program can help you quit tobacco use and overcome physical, psychological and behavioral addictions using a seamlessly integrated mix of medication, one-on-one coaching, group video sessions and digital tools for support.

A highly trained Quit Coach® can help you gain the knowledge, skills and behavioral strategies to quit for life. All complimentary, you’ll receive three coaching interactions (call, text or chat), two group video sessions, plus 24/7 support through unlimited access to a Quit Coach® for the duration of the program.

Call 866-QUIT4LIFE (866-784-8454) or enroll online at www.deancare.com/quitnow.

Notables is a bi-annual magazine for members featuring articles about living a healthy and active life, specialty wellness offerings from Dean Health Plan, benefit updates and more.

Nutritional Resources

• Eating healthy made simple. Get personalized nutrition guidance and make building healthy habits easy.
• Nutritional resources are available through the WebMD Living Healthy Portal, and an array of helpful offerings, all free on  deancare.com/Nutrition.

Partner Perks

Dean Health Plan has partnered with businesses in the area to offer you membership, service, and product discounts that support your overall well-being. To take advantage of these perks, just show your Dean Health Plan member ID card at participating locations. Visit www.deancare.com/wellness for more information.

Pharmacy Concierge Services

Dean Health Plan Pharmacy team offers direct consultation. 

• Benefits navigation
• Formulary
• Prior authorization
• Step therapy
• Enhanced onboarding support for new members (especially those with complex needs).
• Navigate to the “Contact Us” section at the bottom of www.deancare.com.
  • Click on “contact information”.
  • Click email Customer Care button.
  • Complete form and when Pharmacy Services is selected for “question regarding” inquiry will route to a Dean Health Plan pharmacist for review and response.

Wellness Events Calendar

Access live monthly webinars, book club discussions and more that cover the eight dimensions of wellness, held virtually for you to attend from anywhere. Learn more at www.deancare.com/events.

Wellness Programs and Features

Health Assessment

• Based on your individual questionnaire results, WebMD provides recommendations for each lifestyle category. A variety of interactive self-management tools are customized to your needs.

Health Coach

• Get expert support if you have diabetes, COPD, asthma, heart failure or coronary artery disease.*

Case Management

• Provides support through complex health situations.

Partner Perks

• Discounts for gyms, spas, golfing, devices, equipment, nutrition and more.

Tobacco Cessation

• Tobacco cessation and vape free programs for families. Free medications may be available.

R.E.A.L. Goals (Realistic, Easy, Attainable, Life Goals)

• Preset goals covering all eight dimensions along with tips and trackers to help you achieve success.

Wellness Webinars

• Covering all eight dimensions, available 24/7.

*Dean Health Plan shares secure claims information with WebMD. This data is only shared for the purpose of identifying health coaching opportunities through WebMD Condition Management program.

Visit www.deancare.com/wellness.

If you or a family member is not eligible under the FEHB Plan benefits, Dean Health Plan offers a variety of individual and family health insurance plans.

For more information, visit our website at deancare.com/shop-plans/individual-family-plans.

Whether you are eligible for Medicare coverage now, or will be soon, Dean Health Plan is here to help you understand more about Medicare. For more information, visit our website at deancare.com/medicare/shop-advantage-plans.  If you are turning 65 and need current year plan information, call one of our Dean Medicare Representatives directly at 877-234-0126 (TTY:  711).

Dean Medicare Advantage offers several free events where you can learn more about eligibility, enrollment periods and coverage options. See if you live in a participating county by visiting www.deancare.com/medicare/shop-medicare-advantage-plans/service-area.

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, call us at 800-279-1301, or at our website at
www.deancare.com.

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

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

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

Submit your claims to: Dean Health Plan, P.O. Box 56099, Madison WI 53705

If you receive prescription drugs from a non-network pharmacy in an emergency or urgent situation, please submit your receipts along with a Prescription Drug Claim Form found on our website at www.deancare.com/members/pharmacy-benefits under "Forms" and then selecting Reimbursement Form.

If you receive services from a Health Care Provider that require you to submit the claim to us for reimbursement, you must obtain an itemized bill and submit it to:

Dean Health Plan
Attention: Claims Department
P.O. Box 56099
Madison, WI 53705

Send us all of the documents for your claim as soon as possible.  You must submit the claim by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.

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 country 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: P.O. Box 56099, Madison, WI  53705 ; and

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

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

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

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

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

a) Pay the claim or  

b) Write to you and maintain our denial or.

c) Ask you or your provider for more information

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

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

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

You must write to OPM within:

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

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 3, 1900 E Street, NW, Washington, DC 20415-3630.

Send OPM the following information:

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

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request. However, for urgent care claims, a 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 file a lawsuit. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

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

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

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 our website at
www.deancare.com/federalemployee.

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

When we are the secondary payor, we will determine our allowance. After the primary plan processes the benefit, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance.

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

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

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

We do not cover services that:

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

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

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

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

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

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

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

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

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

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

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

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

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

• Routine care costs (as mandated by state) – 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 – This plan does not cover these costs.
• Research costs – This plan does not cover these costs.

For more detailed information on "What is Medicare?" and "Should I Enroll in Medicare?" please contact Medicare at 800-MEDICARE (800-633-4227), (TTY 877-486-2048) or at www.medicare.gov.

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

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

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

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

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

When Original Medicare is the primary payor, Medicare processes your claim first.  In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges.  To find out if you need to do something to file your claim, call us at 800-279-1301 or see our website at www.deancare.com.

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

• Medical services and supplies provided by physicians and other healthcare professionals.
• Standard member cost-share will apply for services not covered by Medicare (i.e. oral surgery).

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

High Option

Benefit Description: Deductible
High Option You pay without Medicare: N/A
High Option You pay with Medicare Part B: N/A

Benefit Description: Coinsurance
High Option You pay without Medicare: 10%
High Option You pay with Medicare Part B: Nothing

Benefit Description: Coinsurance Limit
High Option You pay without Medicare: $500 (Self Only), $1,000 (Self +1), $1,000 (Self + Family)
High Option You pay with Medicare Part B: N/A

Benefit Description: Out-of-Pocket Maximum
High Option You pay without Medicare: $5,000 (Self Only), $10,000 (Self + 1), $10,000 (Self + Family)
High Option You pay with Medicare Part B: $5,000 (Self Only), $10,000 (Self + 1), $10,000 (Self + Family)

Benefit Description: Primary Care Provider
High Option You pay without Medicare: $20 copayment
High Option You pay with Medicare Part B: Nothing

Benefit Description: Specialist
High Option You pay without Medicare: $40 copayment
High Option You pay with Medicare Part B: Nothing

Benefit Description: Inpatient Hospital
High Option You pay without Medicare: 10% coinsurance
High Option You pay with Medicare Part B: Nothing

Benefit Description: Outpatient Hospital
High Option You pay without Medicare: 10% coinsurance
High Option You pay with Medicare Part B: Nothing

You can find more information on how our plan coordinates benefits with Medicare by calling our Customer Care Center at 800-279-1301.

www.deancare.com/employers/resources/medicare

www.deancare.com/employers/resources/claims

Standard Option

Benefit Description: Deductible
Standard Option You pay without Medicare: $500 (Self Only), $1,000 (Self +1), $1,000 (Self + Family)
Standard Option You pay with Medicare Part B: Nothing

Benefit Description: Coinsurance
Standard Option You pay without Medicare: 10%
Standard Option You pay with Medicare Part B: Nothing

Benefit Description: Coinsurance Limit
Standard Option You pay without Medicare: $4,500 (Self Only), $9,000 (Self +1), $9,000 (Self + Family)
Standard Option You pay with Medicare Part B: N/A

Benefit Description: Out-of-Pocket Maximum
Standard Option You pay without Medicare: $5,000 (Self Only), $10,000 (Self +1), $10,000 (Self + Family)
Standard Option You pay with Medicare Part B: $5,000 (Self Only), $10,000 (Self +1), $10,000 (Self + Family)

Benefit Description: Primary Care Provider
Standard Option You pay without Medicare: $20 copayment
Standard Option You pay with Medicare Part B: Nothing

Benefit Description: Specialist
Standard Option You pay without Medicare: $40 copayment
Standard Option You pay with Medicare Part B: Nothing

Benefit Description: Inpatient Hospital
Standard Option You pay without Medicare: 10% coinsurance after deductible
Standard Option You pay with Medicare Part B: Nothing

Benefit Description: Outpatient Hospital
Standard Option You pay without Medicare: 10% coinsurance after deductible
Standard Option You pay with Medicare Part B: Nothing

You can find more information on how our plan coordinates benefits with Medicare by calling our Customer Care Center at 800-279-1301.

www.deancare.com/employers/resources/medicare

www.deancare.com/employers/resources/claims

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan.  These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country. 

To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (800-633-4227), (TTY 877-486-2048) or at www.medicare.gov.

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

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

However, we will not waive any of our copayments, coinsurance, or deductibles.  If you enroll in a Medicare Advantage plan, tell us.  We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

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

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

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

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

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

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

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

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

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

An 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 assignment 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 care 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 on 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 treatments or procedures that include the handling of human eggs, sperm, and/or embryos to help an individual become pregnant. ART includes, but is not limited to, gamete intrafallopian transfer (GIFT), uterine embryo lavage, embryo transfer, in vitro fertilization (IVF), pronuclear state transfer (PROST), tubal embryo transfer (TET), zygote intrafallopian transfer (ZIFT), low tubal ovum transfer, intracytoplasmic sperm injection, cryopreservation (e.g., egg, embryo, sperm), and other third party-assisted ART methods (e.g., sperm donation, egg donation, Traditional Surrogates and Gestational Carriers, embryo donation).

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

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

If you are a participant in a clinical trail, 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 trail 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 trail 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 trails. This plan does not cover these costs.

See Section 4, Your Cost For Covered Services, page (Applies to printed brochure only).

Includes Coinsurance amounts for certain medical expenses that a Member is required to pay when a covered service is provided. Pharmacy expenses and certain medical expenses are not included in the Coinsurance Limit. The Coinsurance amounts also apply toward the Out-of-Pocket Expense Maximum. No other out-of-pocket expenses apply toward the Coinsurance Limit.

a) The period of time between admission to and discharge from an inpatient or outpatient hospital, AODA residential center, skilled nursing facility, or licensed ambulatory surgical center on the advice of your physician, and discharge there from; or b) the time spent in a hospital receiving emergency care for illness or injury. Hospital swing bed Confinement is considered the same as Confinement in a skilled nursing facility. If the Member is transferred to another facility for continued treatment of the same or related condition, it is one Confinement.

Specific to a skilled nursing facility (SNF), an inpatient stay begins on the day of admission into a skilled nursing facility.  The 120 day SNF benefit renews when you haven't received any inpatient hospital care or skilled care in a skilled nursing facility for the same or a similar diagnosis for 60 days in a row.  If you go into a hospital or a skilled nursing facility after one SNF benefit period has ended, a new benefit period begins. There is no limit to the number of SNF Inpatient benefit periods.  However, an additional 120 days is not available until skilled care has not been required for at least 60 consecutive days. 

See Section 4, Your Cost For Covered Services, page (Applies to printed brochure only).

Services and procedures that improve physical appearance but do not correct or improve a physiological function and that are not Medically Necessary unless the service or procedure meets the definition of Reconstructive Surgery.

See Section 4, Your Cost For Covered Services,  page (Applies to printed brochure only).

Care we provide benefits for, as described in this brochure.

The type of care given when the basic goal is to help a person in the activities of daily life. This includes help in walking, getting in and out of bed, bathing, dressing, eating, using the toilet, preparing special diets, taking medications properly and 24 hour supervision for potentially unsafe behavior. Such care is custodial when it does not require continued attention by trained medical personnel. Such care is custodial even if provided by registered nurses, licensed practical nurses, or other trained medical personnel. Custodial care that lasts 90 days or more is sometimes known as Long Term Care.

See Section 4, Your Cost For Covered Services, page (Applies to printed brochure only).

We regularly evaluate new medical devices, new techniques, and new uses for older existing procedures. This process is both proactive and reactive. Health care experts in the Dean organization, including physician, and specialty providers, review and evaluate all pertinent information. If new technology is approved, procedures and policies are revised or established to implement this decision.

Treatment or procedure intended to assist conception, undergone as the result of infertility or for any other reason.

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

Infertility is a disease of the reproductive system defined by the failure to achieve a pregnancy by any means including artificial insemination after 12 months or more of attempts to conceive for individuals under age 35; and 6 months for individuals age 35 and older.  Infertility may also be established through evidence of medical history and diagnostic testing.

Maximum Allowable Fee is the maximum amount We allow for a given service/procedure with an Out-of-Network Provider.

This amount may be based on:

• Geographic location;
• Provider specialty;
• Training and experience of provider;
• Date of service;
• Complexity of treatment; or
• Degree of skill required of provider.

If there is a difference between the Maximum Allowable Fee and the amount billed by an Out-of-Network Provider, the Member will be responsible for the difference.

When you are seeking care with an Out-of-Network Provider, you can obtain information about Maximum Allowable Fees prior to receiving care. You need to contact your Out-of-Network Provider for the procedure code(s) and the amount(s) the provider intends to charge. Then provide this information to Our Customer Care Center in order for Us to determine the Maximum Allowable Fee for the service(s) in question. Within 5 business days of receiving your request for Maximum Allowable Fee details, We will notify you as to whether the service is covered and if it is subject to the Maximum Allowable Fee or any other Policy provisions (e.g. Deductibles or Copayments).

The services or supplies provided by a hospital, or plan provider (or a non-plan provider if there is an authorized referral requested or in an emergency or urgent care situation) that are required to identify or treat a member’s illness or injury as which, as determined by the Utilization Management Department, are: (a) consistent with the illness or injury; (b) in accordance with generally accepted standards of acceptable medical practice; (c) not solely for the convenience of a member, hospital, plan provider, or other provider; and (d) the most appropriate supply or level of services that can be safely provided to the member.

Plan allowance is the amount we use to determine our payment and your coinsurance for covered services.

We determine our Plan allowance as follows: Covered charges will be paid based on the contract agreement between the plan and the plan provider (subject to any coinsurance and copayment provisions outlined in this Certificate). If there is a difference between our contracted amount and the amount that the provider bills us, you will not be responsible for that amount.

You should also see Important Notice About Surprise Billing – Know Your Rights in Section 4 that describes your protections against surprise billing under the No Surprises Act.

Any claims that are not pre-service claims.  In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits.

We use providers in a specific geographic area. Being a Member of Dean Health Plan means you agree to use providers who are part of our provider network (Network Providers). Any care you need should be provided by Network Providers, including doctors and hospitals.

When you enroll as a Member you will choose a physician or clinic from our network of providers to be responsible for managing your health care.  This is your primary care provider (PCP) and is the provider you contact first whenever you need health care services. Your PCP evaluates your total health needs and provides personal medical care in one or more medical fields. If you choose a clinic rather than a physician, you may see any PCP in that clinic. When medically needed, your PCP preserves the continuity of care.  Your PCP is also in charge of coordinating other provider health services.

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

Professionally Administered Drugs must be, as determined by Us, typically administered or directly supervised by a qualified provider or a licensed/certified health professional. We generally consider Drugs that require intravenous infusion or injection, intrathecal infusion or injection, intramuscular injection or intraocular injection, as well as Drugs that, according to the manufacturer’s recommendations, must typically be administered by a Health Care Provider, to be Professionally Administered Drugs.

Certain covered Drugs have limits on the maximum quantity allowed per prescription over a specific time period. The medications subject to Quantity Limits are shown on Our Drug List with the abbreviation “QL.”  Some Quantity Limits are based on the manufacturer’s packaging, FDA labeling or clinical guidelines.

Surgery to rebuild or correct a:

1. Body part when such surgery is incidental to or following surgery resulting from injury, sickness, or disease of the involved body part; or
2. Congenital disease or anomaly which has resulted in a functional defect as determined by your Health Care Provider.

In the case of mastectomy, surgery to reconstruct the breast on which the mastectomy was performed and surgery and reconstruction of the other breast to produce a symmetrical appearance shall be considered reconstructive. Surgery that is cosmetic is not reconstructive.

Surgery to rebuild or correct a physical defect that has a direct adverse effect on the physical health of a body part, and for which the restoration or correction is Medically Necessary.

Process that involves trying an alternative covered Drug first before moving to another covered Drug for treatment of the same medical condition. The medications subject to Step Therapy are shown on the Drug list with the abbreviation “ST.”  You must meet applicable Step Therapy requirements before We will cover these preferred brand or non-preferred brand drugs.

An unexpected bill you receive for

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

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

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

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

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

If you believe your claim qualifies as an urgent care claim, please contact our Customer Care Center at 800-279-1301. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Nothing

(Applies to printed brochure only)

The calendar year coinsurance limit is $500 Self Only enrollment or $1,000 Self Plus One and Self and Family enrollment.

(Applies to printed brochure only)

$5,000 Self Only enrollment or $10,000 Self Plus One and Self and Family enrollment

(Applies to printed brochure only)

$20 office visit copayment (Primary Care Provider)
$40 office visit copayment (Specialist)

(Applies to printed brochure only)

Nothing

(Applies to printed brochure only)

10% coinsurance

(Applies to printed brochure only), (Applies to printed brochure only)

$100 copayment per emergency room visit (waived if direct admit to inpatient)

$20 copayment per urgent care visit

10% coinsurance for related services

(Applies to printed brochure only)

$100 copayment per emergency room visit (waived if direct admit to inpatient)

$20 copayment per urgent care visit

10% coinsurance for related services

(Applies to printed brochure only)

$20 copayment per visit (outpatient)

10% coinsurance (inpatient)

(Applies to printed brochure only)

Tier 1 (Generics) $10 copayment

Tier 1 (Select Generics) $6/6 month supply

Tier 2 (Preferred Brands and select Generics) 30% coinsurance, maximum $75 copayment per prescription ($1,500 out-of-pocket maximum per contract year; $10 copayment applies thereafter)

Tier 3 (Non-Preferred Brands and select Generics) 50% coinsurance with a minimum $50 copayment and a maximum $150 copayment per prescription.

Tier 4 (Specialty Drugs) $100 copayment

(Applies to printed brochure only)

90-day supply (maintenance medications)

• Tier 1 - $20 copayment (90-day supply)
• Tier 2 - 30% coinsurance of the cost for a 2-month supply (90-day supply)
• Tier 3 - 50% coinsurance (minimum $150; Maximum $450)

(Applies to printed brochure only)

The calendar year deductible is $500 Self Only Enrollment or $1,000 Self Plus One and Self and Family enrollment.  The calendar year deductible applies to most all benefits.

(Applies to printed brochure only)

The calendar year coinsurance limit is $4,500 Self Only Enrollment or $9,000 Self Plus One and Self and Family enrollment

(Applies to printed brochure only)

$5,000 Self Only Enrollment or $10,000 Self Plus One and Self and Family enrollment

(Applies to printed brochure only)

$20 office visit copayment (Primary Care Provider)
$40 office visit copayment (Specialist)
10% coinsurance after deductible for related services*

(Applies to printed brochure only)

Nothing

(Applies to printed brochure only)

10% coinsurance after deductible*

(Applies to printed brochure only)

10% coinsurance after deductible*

$20 copayment per urgent care visit

(Applies to printed brochure only)

10% coinsurance after deductible*

$20 copayment per urgent care visit

(Applies to printed brochure only)

Outpatient Services:  $20 copayment per visit

Inpatient Services:  10% coinsurance after deductible*

(Applies to printed brochure only)

Tier 1 (Generics) $10 copayment

Tier 1 (Select Generics) $6/6 month supply

Tier 2 (Preferred Brands and select Generics) 30% coinsurance, maximum $75 copayment per prescription ($1,500 out-of-pocket maximum per contract year; $10 copayment applies thereafter)

Tier 3 (Non-Preferred Brands and select Generics) 50% coinsurance with a minimum $50 copayment and a maximum $150 copayment per prescription.

Tier 4 (Specialty Drugs) $100 copayment

(Applies to printed brochure only)

90-day supply (maintenance medications)

• Tier 1 - $20 copayment (90-day supply)
• Tier 2 - 30% coinsurance of the cost for a 2-month supply (90-day supply)
• Tier 3 - 50% coinsurance (minimum $150; Maximum $450)

(Applies to printed brochure only)