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/insure/health 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 when you add or remove family members from your coverage for any reason, 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 is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2024 benefits of your old 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 assistance with enrolling in a conversion policy (a non-FEHB individual policy). 

If you are an enrollee and your divorce or annulment is final, your ex-spouse cannot remain covered as a family member under your Self Plus One or Self and Family enrollment. You must contact us to let us know the date of the divorce or annulment and have us remove your ex-spouse. We may ask for a copy of the divorce decree as proof.  In order to change enrollment type, you must contact your employing or retirement office. A change will not 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 to you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get information about your coverage choices. You can also visit OPM’s website at www.opm.gov/healthcare-insurance/healthcare/plan-information/ https://www.opm.gov/healthcare-insurance/life-events/memy-family/im-separated-or-im-getting-divorced/#url=Health. We may request that you verify the eligibility for any or all family members listed as covered under the enrollee's FEHB enrollment. 

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

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

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

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

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 855-236-7113 or visit our website at www.cdphp.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 (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 518-641-3140 or 877-269-2134 or write to us at 500 Patroon Creek Blvd., Albany, NY 12206. You may also request replacement cards through our website at www.cdphp.com.

You get care from “Plan providers” and “Plan facilities.” You will only pay copayments, deductibles, and/or coinsurance, if you use our point-of-service program, you can also get care from non-Plan providers but it will cost you more. If you use our Open Access program 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) providers agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount. If an in-network provider bills you for covered services over your normal cost share (deductible, copay, co-insurance) contact your Carrier to enforce the terms of its provider contract.

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

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 CDPHP UBI provider directory, which we update periodically. The list is also available at Find-A-Doc on our website at findadoc.cdphp.com.

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

This plan provides Care Managers for complex conditions that can be reached by contacting the CDPHP single source referral line at 1-888-94-CDPHP (23747) for assistance.

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. 

You are encouraged to select a personal doctor within the network to coordinate your care, but you are not required to notify us of your selection. Your primary care provider can be an internist, family practitioner, general practitioner, or pediatrician (for children).

Your primary care provider can be an internist, family practitioner, general practitioner, or pediatrician (for children). Your primary care provider will provide most of your healthcare or give you a referral to see a specialist.

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

• Participating specialists are listed in our CDPHP UBI directory and in Find-A-Doc at our website at findadoc.cdphp.com.
• No referral is necessary to visit a participating specialist.
• If you have a chronic and disabling condition and lose access to your specialist because we: 

          - Terminate our contract with your specialist for other than cause;

          - Drop out of the Federal Employees Health Benefits (FEHB) Program and 
             you enroll in another FEHB program Plan; or

         -  Reduce our service area and you enroll in another FEHB Plan,

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

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

Your primary care provider will refer you to a specialist for needed care.  When you receive a referral from your primary care provider, you must return to the primary care provider after the consultation, unless your primary care provider authorized a certain number of visits without additional referrals.  The primary care provider must provide or authorize all follow-up care.  Do not go to the specialist for return visits unless your primary care provider gives you a referral.  However, you may see.

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

·    If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care provider will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. 

Your primary care provider will create your treatment plan.  The provider 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;

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

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

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

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 518-641-3140 or 877-269-2134. 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; 
• 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.

How to get approval for...

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.

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

• Transplants
• Skilled Nursing Facility (including cardiac and pulmonary rehab)
• Inpatient rehabilitation or facility services
• Inpatient residential treatment
• Gender dysphoria therapy
• Genetic testing
• Hormone therapy (including growth hormone therapy)
• Durable Medical Equipment (DME) over $1,000
• Prosthetics and Orthotics (P & O) over $1,000
• Certain prescription drugs and supplies
• Non-emergent care for full-time students out of the area
• Reconstructive surgery
• Accidental dental services
• Sleep studies (facility based)
• Non-emergency ambulance
• Autologous blood banking
• Clinical trials
• Infusion therapy
• Certain provider administered drugs
• Second opinions
• Assistive communication devices for Austism spectrum disorder 

First, your physician, your hospital, you, or your representative, must call us at 800-274-2332 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 medication.

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 518-641-3140 or 877-269-2134. You may also call OPM’s FEHB 2 at 202-606-3818 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care,  call us at 518-641-3140 or 877-269-2134. 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

Gender dysphoria therapy surgery and related services, determined to be medically necessary, will be covered under the enrollee’s medical benefit unless such services are specifically identified as a contract exclusion. Preauthorization and medical review must be obtained in advance in order for gender dysphoria therapy services to be covered. A specific list of genital reconstruction procedures the plan will cover include but are not limited to:  mastectomy, reduction mammoplasty,  hysterectomy, salpingo-oophorectomy, colpectomy (removal of the vagina) and metoidioplasty (construction of a penis) include vaginoplasty, penile inversion to create a vagina and clitoris, penectomy, colovaginoplasty (creation of vagina from sigmoid colon), orchiectomy, clitoroplasty, and labiaplasty. 

Note: Refer to Section 5(b) for a list of gender dysphoria therapy surgical exclusions.

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.

If no one contacts us, we will decide whether the service was medically necessary. If we determine that the service was medically  necessary, we will reduce our normal allowance by 50 percent, not to exceed $500 for each service. If we determine that  it was not medically necessary, we will not pay benefits.

Within the exception of emergency care, you must obtain prior authorization for providers and facilities that do not participate with us if you enroll in the Standard Option. The number to call is 800-274-2332.

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 518-641-3140 or 1-877-269-2134.

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.

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

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

Example: For the Standard Option when you see your primary care provider, you pay a copayment of $40 per office visit, and when you go in the hospital, you pay $500 per admission plus 20% of the plan allowance, after the annual deductible has been satisfied.

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

• The calendar year deductible is $350 per person under the Standard Option. 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 $350 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 $700 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 $700 under the Standard Option.

Note: If you change plans during Open Season, you do not have to start a new deductible under your old 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.

Coinsurance is the percentage of our allowance that you must pay for your care. For certain services, coinsurance does not begin until you have met your calendar year deductible.

Example: In our Standard Option Plan, you pay 50 percent of our allowance for durable medical equipment, after the annual deductible has been satisfied.

Network providers agree to accept our Plan allowance so if you use a network provider, you never have to worry about paying the difference between our Plan allowance and the billed amount for covered services.

Non-Network providers: If you use a non-network provider, you will have to pay the difference between our Plan allowance and the billed amount.

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.

On the Standard Option, after your deductible, copayments, and coinsurance total $8,550 for Self Only or $8,550 per person for Self Plus One, or $17,100 per Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. However, the following services do not count toward your catastrophic protection out-of-pocket maximum:

• Non-covered services
• Amounts that exceed our allowable charge for a covered service
• Precertification penalties

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 old 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 old 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 old 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 old plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

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

A surprise bill is an unexpected bill you receive for:

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

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

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

In addition, your health plan adopts and complies with the surprise billing laws of New York State and NSA. Financial Services Law Article 6 (Chapter 60 of the Laws of 2014).  23 NYCRR 400; 42 USC § 300gg–111; 42 USC § 300gg–131 42 USC § 300gg–132. This policy or contract form provides that the insured will be held harmless for any nonparticipating provider charges for a surprise bill that exceed an insured’s in-network deductibles, copayments and/or coinsurance.  The non-participating provider may only bill an insured for any in-network deductible, copayment and/or coinsurance. The policy or contract form also includes a description of the independent dispute resolution process.

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.cdphp.com or contact the health plan at (518) 641-3140 or 1-877-269-2134. TTY/TDD users may call 711.

• 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 a physician's office

$40 per visit for primary care 

$60 per visit for specialist

Professional services of physicians

• Chronic heart failure walk-in visits

Nothing if you receive these services at a preferred facility; otherwise, $60 per office visit.

Professional services of physicians

• In an urgent care center

$60 per visit

• During a hospital stay
• In a skilled nursing facility

20% of the Plan allowance for inpatient services (calendar year deductible applies)

• Office medical consultations
• Second surgical opinion/inpatient consultation

$40 per office visit

$60 per visit for specialist

$40 per visit

Advance care planning

$40 per visit for primary care
$60 per visit for specialist

Not covered:

• Surgery primarily for cosmetic purposes
• Homemaker services

Telehealth services must be provided through an interactive audio and video telecommunications system that permits real-time communication between the practitioner at the distant site and the patient at the originating site. Providers performing telehealth services must be participating with CDPHP UBI. 

In addition to providing covered services via Telehealth, we cover online internet consultations between you and providers who participate in our Telemedicine program for medical conditions that are not an emergency condition. Our Telemedicine program, Doctor on Demand, as a preferred telehealth provider allows members to communicate with providers through two-way video and can be easily accessed through our website at www.cdphp.com or by going directly to  www.doctorondemand.com.

CDPHP® has partnered with aptihealth as a preferred telehealth provider to expand our network of mental health care providers, offering members 18 years+ quick, affordable access to mental health and substance use services from a video-enabled smartphone, laptop, or tablet. The 90 day program has proven success in decreased ER department visits/admissions and costs. For more information or to sign up, visit www.aptihealth.com/CDPHP.

CDPHP® has partnered with Valera Health to offer increased access to mental health through telemedicine visits. Telemedicine appointments are available with a behavioral health coach, licensed clinical social worker, licensed mental health counselor, nurse practitioner, psychiatrist, or psychologist. To get started, visit www.valerawellness.com to request a free consultation with a Valera Health coach.

Nothing for services provided by the preferred telehealth providers Doctor on Demand, Aptihealth, and MovN. 

All other telehealth services will be subject to an office visit copay of $40 per PCP visit or $60 per specialist visit.

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap test
• Pathology
• X-ray
• CT/CAT Scan (other than breast MRI)
• MRI
• Ultrasounds (other than breast ultrasound)

Nothing if you receive these services at a preferred facility; otherwise, $60 per office visit

• Non-routine mammograms
• Breast MRI
• Breast ultrasound
• Digital breast tomosynthesis (3D mammogram) when billed in conjunction with routine mammogram screening

Nothing

$60 per provider visit

Lung cancer screening – Note: Annual low dose computed tomography in adults ages 50 to 80 years who have a 30 pack per year smoking history and currently smoke or have quit within the past 15 years

• Routine physical every calendar year

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

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/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

Routine mammogram - covered

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

• Tetanus-diphtheria (Td) booster - once every 10 years, ages 19 and over (except as provided for under childhood immunizations)
• Influenza vaccine, annually
• Pneumococcal vaccine, age 65 and older

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, and 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.

Not covered:

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

• Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
• Immunizations such as DTaP/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
• You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations

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

Complete maternity (obstetrical) care, such as:

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

Doulas empower birthing persons to advocate for their health care preferences, facilitate communication with providers. Most doulas provide services such as: at home visits during the prenatal period, attending prenatal visits with you and your health care provider, 24/7 availability via text/e-mail, continuous in-person support for the duration of labor and birth, postpartum follow up visits, breastfeeding education sessions and lactation support postpartum, and support for navigating new family dynamics in the postpartum period.

$40 office visit for the initial diagnosis. You pay nothing thereafter for prenatal care or the first postpartum care visit; $40 per office visit for all postpartum care visits thereafter.

Eligible members who pay for and use the services of a certified doula are eligible for a once, per pregnancy, reimbursement of up to $1,500 for out-of-pocket costs. The reimbursement is only allowed once per Plan Year. Members must utilize a certified doula and pay for their services.

• Breastfeeding support, supplies, and counseling for each birth

Note: Here are some things to keep in mind:

• You do not need to precertify your vaginal delivery.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery.  We will extend your inpatient stay if medically necessary.
• We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

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

Contraceptive counseling on an annual basis

A range of voluntary family planning services, limited to:

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

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

The following prenatal screening and diagnostic testing may be performed during pregnancy to identify fetuses at increased risk for or affected with genetic conditions and birth defects.

• Screening with ultrasound and maternal serum markers is routinely offered.
• Prenatal diagnosis by chorionic villus sampling or amniocentesis for chromosome abnormalities is available to all women;
• However, it is offered specifically to those at higher risk due to maternal age, a positive screen result, abnormal ultrasound findings, or known risk of a genetic condition based on family history.
• Investigations for fetal infection and blood antigen incompatibility may also be performed in the prenatal period.
• Results of testing are used to guide reproductive decision-making, pregnancy management and anticipatory management of the infant at birth.

$40 per office visit

$60 per visit for specialist

Voluntary sterilization (See Surgical procedures Section 5 (b) including:

$40 per office visit

$60 per visit for specialist

Not covered:

• Reversal of voluntary surgical sterilization

Infertility is a disease or condition characterized by the incapacity to impregnate another person or to conceive, defined as the failure to establish a clinical pregnancy after 12 months of  unprotected sexual intercourse or therapeutic donor insemination, or after six months of unprotected sexual intercourse or therapeutic donor insemination for a female (or individual with female reproductive organs) 35 years of age or older. Infertility may also be established through an evaluation based on medical history and diagnostic testing.

Diagnosis and treatment of infertility specific to:

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

• Fertility drugs (see prescription drug benefit in section 5(f) for fertility drug coverage)

Artificial insemination (AI) services and associate fertility drugs:
- Enrollees are eligible for up to two procedures per cycle, for a maximum of six cycles of artificial insemination to achieve pregnancy.
- If pregnancy is not established after six cycles of artificial insemination, no further coverage is available.

Iatrogenic Infertility: Standard fertility preservation services when a medical treatment directly or indirectly leads to iatrogenic infertility due to surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes. Standard fertility preservation services include the collecting, preservation, and storing of ova and sperm.

$60 per office visit

20% of the Plan allowance for inpatient services (calendar year deductible applies)

See prescription drug benefit in section 5(f) for fertility drug coverage

Not covered: (See Non-FEHB Benefits Available to Plan Members)

• Assisted reproductive technology (ART) procedures, such as:
  • In vitro fertilization (IVF) see Section 5(f). Prescription Drug Benefits. For coverage of IVF-related drugs up to three (3) cycles per year.
  • Embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
• Services and supplies related to ART procedures
• Fertility drugs (see prescription drug benefit in section 5(f) for fertility drug coverage details and limitations)

Not covered: 

• Cost of donor sperm
• Cost of donor egg
• Leuprolide Acetate when used for cessation of ovulation
• Cloning
• Procedures to reverse a previous voluntary sterilization procedure.
• Infertility treatment for a couple in which there has been a voluntary tubal ligation or vasectomy.
• Items such as ovulation predictor kits and home pregnancy kits
• IVIG when utilized for infertility or pregnancy loss

Infertility services must be rendered by a provider who is qualified to provide such services in accordance with the guidelines established and adopted by the American Society for Reproductive Medicine.

All charges

See prescription drug benefit in section 5(f) for fertility drug coverage

• Testing and treatment

$40 per office visit

$60 per visit for specialist

• 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 Organ/Tissue Transplants in Section 5(b).

• Respiratory and inhalation therapy

$40 per office visit for chemotherapy and radiation therapy

Dialysis – hemodialysis and peritoneal dialysis

$40 per office visit if received as an outpatient. Covered in full if part of home care.

Intravenous (IV)/infusion Therapy – home IV and antibiotic therapy

$60 per office visit if received as an outpatient. Covered in full if part of home care.

$40 per month

• Growth hormone therapy (GHT)

Note: Growth hormone medications are covered under the Prescription Drug Benefit.

Note: - We only cover GHT when we preauthorize the treatment.  We will ask you to submit information that establishes that the GHT is medically necessary.  Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services which are determined to be medically necessary based off of the criteria established in our Growth Hormone policy from the date you submit the information.  If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies.   Please refer to Section 5(f) for coverage for prescription drugs. See Services requiring prior approval in Section 3.

$60 per office visit

Applied behavior analysis (ABA) - Children with autism spectrum disorder

Note: Speech therapy and ABA therapy services that duplicate services already being provided by a Federal or State agency (i.e., Early intervention program) or by a school district (Individualized Educational Program), that are sufficient in meeting the needs of an individual, are excluded. 

$40 per office visit

60 visits for each of the following per calendar year:

• Qualified Physical therapists
• Occupational therapists
• Habilitative therapists

$60 per office visit

$60 per outpatient visit

20% of the Plan allowance for inpatient services (calendar year deductible applies)

• Pulmonary rehabilitation
• Cardiac rehabilitation following a qualifying event/condition is provided for up to 72 sessions.

Nothing per visit for pulmonary or cardiac rehabilitation

20% of the Plan allowance for inpatient services (calendar year deductible applies)

Note: We only cover therapy when a physician:

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

These services require prior approval. See Section 3.

Not covered:

• Long-term rehabilitative therapy
• Exercise programs
• Continuous ECG monitoring and Thallium stress tests
• Services for chronic or maintenance phase of cardiac rehabilitation

Speech therapy is limited to up to 60 visits for each specific diagnosis and related conditions per calendar year. 

Note: Please refer to Section 3 for services requiring prior approval. Speech therapy and ABA therapy services that duplicate services already being provided by a Federal or State agency (i.e., Early intervention program) or by a school district (Individualized Educational Program), that are sufficient in meeting the needs of an individual, are excluded. 

$60 per office visit

$60 per outpatient visit

20% of the Plan allowance for inpatient services (calendar year deductible applies)

Not covered:

• Care beyond treatment period.

• Hearing examinations and testing for  treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist.

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

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

Note: For benefits for the devices, see Section5(a) Orthopedic and prosthetic devices.

$60 per office visit

Not covered:

• Hearing services that  are not shown as covered

• Eye glasses or contact lenses necessitated by certain medical conditions such as aphakia, keratoconus, or endocrine exophthalmos or following intraocular surgery. Replacement reviewed based on medical necessity.

50% of the Plan allowance (calendar year deductible applies)

• Routine eye exam and eye refractions once every 24 months
• Eye exercises and orthoptics when approved

$60 per office visit

Not covered:

• Eye glasses or contact lenses
• Radial keratotomy and other refractive surgery

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 for primary care office visit

$60 per visit for specialist

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
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy

50% of the Plan allowance. Must be preauthorized if cost is over $1,000. (calendar year deductible applies)

• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants
• External hearing aid obtained through Hearing Care Solutions  including:
  • Choose between two technology levels of hearing aids and get two hearing aids for a low, fixed copay each.
  • Comprehensive hearing exam, evaluation, and hearing aid fitting* at no charge.**
  • Three-year supply of batteries (up to 192 cells per ear for non-rechargeable devices).
  • Three-year warranty, including loss, damage, and repair (a deductible applies to all warranties).
  • One year of follow-up care at no charge†, including routine visits and in-office repairs.

* When purchased through Hearing Care Solutions.

** Ear molds are excluded from coverage.

† Routine services during 1st year are with original provider. Any services during the 1st year that are not administered by the original provider are subject to charges at the provider’s discretion. 

One covered hearing aid per ear per benefit year for a fixed copay each unless hearing needs change.

Go to www.hearingcaresolutions.com/cdphp for more information or contact 1-855-460-5422 to schedule your hearing exam.

$60 per office visit

Implanted hearing device - 50% of the Plan allowance. Must be preauthorized if cost is over $1,000. (Calendar year deductible applies)

Per external hearing aid device through Hearing Care Solutions - $599 Premium hearing aid / $899 Premier hearing aid

• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy.

 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.

• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
• Approved lumbosacral supports

50% of the Plan allowance. Must be preauthorized if cost is over $1,000. (Calendar year deductible applies)

Hair prosthesis. CDPHP UBI provides benefits for the purchase of one medically necessary cranial prosthesis, wig, or toupee per lifetime, per member for replacement of hair loss as a result of injury, disease, or treatment of a disease. Coverage is limited to a maximum amount of $400 per prosthesis, wig, or toupee. This limitation is applied to the balance remaining after the member’s payment of the coinsurance.

50% of the Plan allowance (Calendar year deductible applies)

Not covered:

• Prosthetic sleeve or sock
• Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
• Corsets, trusses, elastic stockings, support hose, and other supportive devices

Prosthetic replacements provided less than three years after the last one we covered unless medically indicated

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include, but are not limited to:

• Oxygen
• Hospital beds
• Wheelchairs
• Crutches
• Walkers

50% of the Plan allowance. Must be preauthorized if cost is over $1,000 or item is rented. (Calendar year deductible applies)

• Blood glucose monitors and test strips (see Note below)
• Insulin pumps

Note: Blood glucose monitors and test strips are covered only when obtained from the CDPHP UBI designated manufacturer of diabetic equipment or supplies.  If you require a different glucose monitor or test strip that is not available from the CDPHP UBI designated diabetic equipment or supply manufacturer, you or your physician must submit a request for a medical exception by calling our Member Services department at 518-641-3140 or 877-269-2134. A CDPHP medical director will review the need for an exception and make the determination.

Your Plan physician will call us for authorization of this equipment. We will arrange with a healthcare provider to rent or sell you durable medical equipment. Note: See “Services requiring our prior approval” in Section 3.

$40 per item

50% of plan allowance (calendar year deductible applies)

• Home healthcare ordered by a Plan physician, approved by the Plan’s medical director, and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide. Some services include: home infusion therapy, medical supplies, drugs and medications. Please refer to Section 3, “Services requiring our prior approval.”

• Oxygen therapy

50% of the Plan allowance (calendar year deductible applies)

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient’s family;
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative;
• Rest cures

• Medically necessary care for spinal manipulation

$60 per office visit

Acupuncture – by a doctor of medicine or osteopathy, or licensed or certified acupuncture practitioner (10 visits per plan year)

Note: Acupuncture visits for the following three conditions are unlimited, and do not count towards the limit of 10 visits per calendar year:

• Emesis developing after surgery in adults
• Emesis developing after chemotherapy in adults
• Persistent nausea associated with pregnancy

$60 per office visit

Not covered:

• Naturopathic services
• Hypnotherapy
• Biofeedback

All charges

CDPHP UBI offers a variety of innovative wellness classes and disease management programs.  Programs and classes are also available to address childhood obesity.  Please refer to Section 5, Non-FEHB Benefits Available to Members.

• Tobacco and nicotine cessation programs, including individual, group, phone counseling, and for physician prescribed over the counter (OTC) and prescription drugs approved by the FDA to quit smoking (vaping) or other nicotine use. 

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

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

• Tobacco and nicotine use interventions for children and adolescents, including education or brief counseling, to prevent initiation of tobacco and nicotine use in school-aged children and adolescents.

Nothing

• Multicomponent, family centered programs focused on childhood obesity that are part of intensive behavioral interventions (behavior change counseling for healthy diet and physical activity)

Nothing

• Screening and diagnosis of Austism spectrum disorder

$60 per office visit

• Applied behavioral analysis associated with Autism spectrum disorder

$60 per office visit

• Speech therapy, physical therapy, and occupational therapy associated with Autism spectrum disorder

$60 per office visit

• Assistive communication devices associated with Autism spectrum disorder

Note:
Please see Section 5(f) for Prescription Drug Coverage associated with Autism spectrum disorder. 

Speech therapy and ABA therapy services that duplicate services already being provided by a Federal or State agency (i.e., Early intervention program) or by a school district (Individualized Educational Program), that are sufficient in meeting the needs of an individual, are excluded. 

$40 copay per device

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Surgical treatment (bariatric surgery) of severe obesity, a condition in which you weigh 100 pounds or 100% over your normal weight according to current underwriting standards; there is documented failure of a non-surgical attempt; and your body mass index is 40 or higher (or 35 or higher and you have severe co-morbidities). Note: This procedure requires preauthorization. Please call the Plan at 877-269-2134 for further information.
• Insertion of internal prosthetic devices. See 5(a), Orthopedic and prosthetic devices for device coverage information. Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done.
• Voluntary sterilization (e.g., Tubal ligation, Vasectomy)
• Surgically implanted contraceptive and intrauterine devices (IUDs). Note: Devices are covered under 5(f) Prescription drug coverage.
• Treatment of burns
• Gender affirming surgery and related services, determined to be medically necessary, are covered under the enrollee's medical benefit unless such services are specifically identified as a contract exclusion. Once medically necessary criteria have been met, and gender affirming surgery is approved, the enrollee must undergo a complete physical examination by the physician performing the surgery. Note: Transgender affirming surgery and related services require precertification. Please call the Plan at 877-269-2134 for further information. (see Section 3. How you get care)

$40 per primary care office visit

$60 per visit for specialist care

Nothing at outpatient facility

20% of the Plan allowance for inpatient services (calendar year deductible applies)

Not covered:

• Routine treatment of conditions of the foot (see Foot care)
• Reversal of any procedure resulting in sterilization
• Reversal of genital and/or breast surgery
• Reversal of surgery to revise secondary sex characteristics
• The following services related to gender affirming surgery are considered cosmetic in nature and are not covered or limited to unless justification of medical necessity for treatment of the member’s gender dysphoria is provided and prior authorization is received: · Abdominoplasty, blepharoplasty, neck tightening, or removal of redundant skin · Breast augmentation · Breast, brow, face, or forehead lifts · Calf, cheek, chin, nose, or pectoral implants · Collagen injections · Drugs to promote hair growth or loss · Electrolysis, unless required for vaginoplasty or phalloplasty · Facial bone reconstruction, reduction, or sculpturing, including jaw shortening and Rhinoplasty · Gluteal augmentation · Hair transplantation · Lip reduction · Liposuction · Thyroid chondroplasty · Voice surgery

• Surgery to correct a functional defect
• Surgery to correct a condition caused by illness or injury if:
  • the condition produced a major effect on the member's appearance and
  • the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers and toes.
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • surgery to produce a symmetrical appearance of breasts;
  • treatment of any physical complications, such as lymphedemas;
  • breast prostheses and surgical bras and replacements (see Prosthetic devices)

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

• Gender Affirming Surgery (see Section 3. How you get care)

$60 per office visit

Nothing at outpatient facility

20% of the Plan allowance for inpatient services (calendar year deductible applies)

Not covered:

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

Oral surgical procedures, limited to:

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

$60 per office visit

Nothing at outpatient facility

20% of the Plan allowance for inpatient services (calendar year deductible applies)

Not covered:

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

These solid organ transplants are covered. These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. See Other services under You need prior Plan approval for certain services in Section 3 How You Get Care.  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

$60 per office visit

Nothing at outpatient facility

20% of the Plan allowance for inpatient services (calendar year deductible applies)

Blood or marrow stem cell transplants

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

The Plan extends coverage for the diagnoses as indicated below.

• Allogeneic transplants for
  
  • Acute lymphocytic or non-lymphocytic (i.e., myelogeneous) 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)
  • Hemoglobinopathy
  • Infantile malignant osteopetrosis
  • Kostmann's syndrome
  • Leukocyte adhesion deficiencies
  • Marrow failure and related disorders (i.e., Fanconi's, Paraxysmal 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 transplant for

• Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
• Advanced Hodgkin’s lymphoma with recurrence (relapsed)
• Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
• Advanced neuroblastoma
• Ependymoblastoma
• Ewing’s sarcoma
• Medulloblastoma
• Pineoblastoma

Autologous tandem transplants for recurrent germ cell tumors (including testicular cancer)

Allogeneic blood or marrow stem cell transplants for

• Advanced forms of myelodysplastic syndromes
• Advanced neuroblastoma
• Infantile malignant osteopetrosis
• Kostmann’s syndrome
• Leukocyte adhesion deficiencies
• Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
• Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s syndrome, Sanfilippo’s syndrome, Maroteaux-Lamy syndrome variants)
• Myeloproliferative disorders
• Phagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome
• Sickle cell anemia
• Thalassemia major (homozygous beta-thalassemia)
• X-linked lymphoproliferative syndrome

$60 per office visit

Nothing at outpatient facility

20% of the Plan allowance for inpatient services (calendar year deductible applies)

Autologous blood or marrow stem cell transplants for

• Multiple myeloma
• Testicular, mediastinal, retroperitoneal, and ovarian germ cell tumors
• Breast cancer
• Epithelial ovarian cancer
• Amyloidosis
• Ewing’s sarcoma
• Medulloblastoma

Allogeneic transplants for

• Chronic lymphocytic leukemia
• Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
• Multiple myeloma

Nonmyeloablative allogeneic transplants for

• Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
• Advanced forms of myelodysplastic syndromes
• Advanced Hodgkin’s lymphoma
• Advanced non-Hodgkin’s lymphoma
• Chronic lymphocytic leukemia
• Chronic myelogenous leukemia
• Colon cancer
• Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
• Chronic lymphocytic leukemia/small lymphocytic lymphoma
• Multiple myeloma
• Multiple sclerosis
• Myeloproliferative disorders
• Non-small cell lung cancer
• Ovarian cancer
• Prostate cancer
• Renal cell carcinoma
• Sarcomas
• Sickle Cell Disease

$60 per office visit

Nothing at outpatient facility

20% of the Plan allowance for inpatient services (calendar year deductible applies)

Autologous transplants for

• Chronic lymphocytic leukemia
• Chronic myelogenous leukemia
• Early state (indolent or non-advanced) small cell lymphocytic lymphoma

$60 per office visit

Nothing at outpatient facility

20% of the Plan allowance for inpatient services (calendar year deductible applies)

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

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

Allogeneic transplants for

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

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

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

Autologous Transplants for

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

$60 per office visit

Nothing at outpatient facility

20% of the Plan allowance for inpatient services (calendar year deductible applies)

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
• Advanced Hodgkin’s lymphoma with recurrence (relapsed)
• Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
• Acute myeloid leukemia
• Advanced Myeloproliferative disorders (MPDs)
• Amyloidosis
• Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
• Hemoglobinopathy
• Marrow failure and related disorders (i.e., Fanconi’s, PNH, Pure Red Cell Aplasia)
• Myeloproliferative disorder (MDDs)
• Paroxysmal nocturnal nemoglobinuria
• 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

$60 per office visit

Nothing at outpatient facility

20% of the Plan allowance for inpatient services (calendar year deductible applies)

National Transplant Program (NTP) – CDPHP UBI facilitates organ transplants at a CDPHP UBI approved transplant center.

Limited Benefits – Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may be provided in a National Cancer Institute – or National Institutes of Health-approved clinical trial at a Plan-designated center of excellence.

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

Note: Please see Section 3 for “Services requiring our prior approval.”

$60 per office visit

Nothing at outpatient facility

20% of the Plan allowance for inpatient services (calendar year deductible applies)

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)

20% of the Plan allowance for inpatient services (calendar year deductible applies)

• Hospital outpatient department

Nothing

• Skilled nursing facility

20% of the Plan allowance for inpatient services (calendar year deductible applies)

• Ambulatory surgical center
• Office

Room and board, such as

• ward, semiprivate, or intensive care accommodations
• general nursing care
• meals and special diets

$500 per admission plus 20% of the Plan allowance. (calendar year deductible applies)

For individual coverage, inpatient copays are limited to two per calendar year. For family coverage, inpatient copays are limited to three per calendar year. The copayment does not apply to hospital inpatient charges for newborn nursery care.

Other hospital services and supplies, such as:

• operating, recovery, maternity, and other treatment rooms
• prescribed drugs and medications
• diagnostic laboratory tests and X-rays
• administration of blood and blood products
• blood or blood plasma, if not donated or replaced
• dressings, splints, casts, and sterile tray services
• medical supplies and equipment, including oxygen
• anesthetics, including nurse anesthetist services
• take-home items
• medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

20% of the Plan allowance (calendar year deductible applies)

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 except when medically necessary in the hospital when ordered and approved by a CDPHP UBI participating physician

• 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 biologics
• 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.

$100 per visit (calendar year deductible applies)

Services not associated with a medical procedure being done on the same day: Outpatient hospital diagnostic x-ray and laboratory tests.

Nothing if you receive these services at a preferred facility; otherwise, $60 per visit 

$500 per admission plus 20% of the Plan allowance (calendar year deductible applies)

Nothing

This Plan covers end of life care, regardless of age, including coverage for:

• Medical services and supplies provided by physicians and other health care professionals
• Diagnostic and treatment services
• Professional services of physicians
• Hospice care (210 days combined inpatient and outpatient)

$40 per visit for primary care

$60 per visit for specialty

Nothing for hospice

$100 per trip (calendar year deductible applies)

• Emergency care at a doctor’s office

$40 per primary care visit

$60 per visit for specialist 

• Emergency care at an urgent care center

$60 per visit

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

$150 per visit (calendar year deductible applies)

All charges

• Emergency care at a doctor’s office

Refer to Other services in Section 3 for prior authorization procedures

$40 per visit primary care 

$60 per visit for specialist 

• Emergency care at an urgent care center

$60 per visit 

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

$150 per visit (calendar year deductible applies)

• Local professional ambulance service when medically appropriate
• Air ambulance if medically appropriate and approved.

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

$100 per trip (calendar year deductible applies)

We cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders. Services include:

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

$40 per visit        

• Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment practitioner
• Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility

$40 per visit or test

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

20% of the Plan allowance (calendar year deductible applies)

• Inpatient services provided and billed by a hospital or other covered facility
• Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services
• Services approved in alternate care settings such as residential treatment

$500 per admission plus 20% of the Plan allowance. For individual coverage inpatient copays are limited to two per calendar year. For family coverage, inpatient copays are limited to three per calendar year (calendar year deductible applies).

• Outpatient services provided and billed by a hospital or other covered facility
• Services in approved treatment programs, such as partial hospitalization, full-day hospitalization, or facility-based intensive outpatient treatment

$40 per visit or test

• Services not provided and billed by a licensed mental health or substance use disorder treatment provider
• Services not provided by a participating provider
• Conversion therapy

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.
• Self-administered injectable drugs
• Drugs for sexual dysfunction within applicable limits. Please call the Plan for information.
• Infertility prescriptions available for members between 21 and 44 years of age, up to six cycles per pregnancy attempt for Artificial Insemination.
  • If pregnancy is not established after six cycles of artificial insemination, no further coverage is available.
•  Infertility prescriptions available for members between 21 and 44 years of age, up to three cycles per year for IVF.

(see Section 3. How you get care) Please note: Most infertility drugs require prior authorization. Prior authorization must be obtained from the CDPHP UBI pharmacy department.

• Nutritional formulas for the treatment of phenylketonuria, branched-chain ketonuria, galactosemia and homocystinuria.

• Prescription or non-prescription enteral formulas for home use, whether administered orally or via tube feeding, for which a Physician or other licensed Provider has issued a written order. The written order must state that the enteral formula is Medically Necessary and has been proven effective as a disease-specific treatment regimen. Specific diseases and disorders include but are not limited to: inherited diseases of amino acid or organic acid metabolism; Crohn’s disease; gastroesophageal reflux; gastroesophageal motility such as chronic intestinal pseudo-obstruction; and multiple severe food allergies. Multiple food allergies include, but are not limited to: immunoglobulin E and nonimmunoglobulin E-mediated allergies to multiple food proteins; severe food protein induced enterocolitis syndrome; eosinophilic disorders and impaired absorption of nutrients caused by disorders affecting the absorptive surface, function, length, and motility of the gastrointestinal tract.

• Modified solid food products that are low in protein, contain modified protein, or are amino acid based to treat certain inherited diseases of amino acid and organic acid metabolism and severe protein allergic conditions.
• Prescription Drugs for the treatment of Autism spectrum disorder.
• Hormone Therapy (see Section 3. How you get care) Please note: Some hormone therapies require prior authorization. Prior authorization must be obtained from the CDPHP UBI pharmacy department. The prior authorization request must include a treatment plan for the use of the requested hormonal medication.
• Drugs to treat gender dysphoria
  • CDPHP will provide coverage for medically necessary hormone therapy, whether or not in preparation for gender affirming surgery, for treatment of gender dysphoria. See Hormone Therapy in this section.

Tier 1 drugs - $10 copayment (2.5 copayments will apply for 90-day supplies of maintenance medications obtained by mail order)

Tier 2 drugs - 50% of the Plan allowance with a $400 per prescription maximum, up to a 30-day supply.

Tier 3 drugs - 50% of the Plan allowance with a $600 per prescription maximum, up to a 30-day supply.

Member pharmacy cost share will apply toward the annual out-of-pocket maximum.

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. 

• A member or their authorized representative (usually their prescribing provider) can initiate a formulary exception request either in writing, by fax, verbally or initiated on our web site. When a provider indicates a medical reason for a non-formulary contraceptive drug, exceptions are approved within 72 hours from the submission of the request for standard requests, and 24 hours for an urgent request. This time frame includes the decision and notification of the member and provider through telephone and the determination letter.
• Our formulary includes coverage for over the counter contraceptives when ordered by a provider. These claims can be processed at a pharmacy in the same manner a prescription contraceptive would be. If a member purchased an over the counter contraceptive, they can submit a direct member reimbursement request to Capital Rx. Direct member reimbursement forms may be obtained via the member portal or by calling member services. Once complete, mail or email the form back along with the pharmacy receipt to:

  Capital Rx – Attn. Claims Dept.
  9450 SW Gemini Dr., #87234
  Beaverton, O.R. 97008

Breast Cancer Preventive Medication- Note: For women who are at an increased risk for breast cancer and at a low risk for adverse medication effects.

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

Not covered

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies

Nonprescription medications unless specifically indicated elsewhere

Nothing

Oral chemotherapy prescriptions

Nothing

Tobacco and nicotine cessation prescriptions

Note: Physician prescribed over-the-counter and prescription drugs approved by the FDA to treat tobacco and nicotine dependence are covered under the Tobacco and nicotine cessation benefit. (See Section 5(a) under Educational Classes and programs.)

Durable medical equipment for insulin dependent persons

$40 per item

Insulin, oral agents to control blood sugar, needles, test strips, lancets, and visual reading and urine test strips.

$40 per item

Non-insulin disposable needles and syringes for the administration of covered medication. 

Note: Blood glucose monitors and test strips are covered only when obtained from a CDPHP UBI designated manufacturer of diabetic equipment or supplies. If you require a different glucose monitor or test strip that is not available from a CDPHP designated diabetic equipment or supply manufacturer, you or your physician must submit a request for a medical exception by calling our Member Services department at 518-641-3140 or 877-269-2134. A CDPHP medical director will review the need for an exception and make the determination. 

50% of the Plan allowance (calendar year deductible applies)

Medications to promote better health as recommended by ACA. 

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

• Aspirin (81 mg) for men age 45-79 and women age 55-79 and women of childbearing age
• Folic acid supplements containing 0.4 to 0.8 mg of folic acid for women who are planning or capable of pregnancy
• Statin preventive medication for adults ages 40-75 years with no history of cardiovascular disease (CVD), one or more CVD risk factors, and a calculated 10-year CVD event risk of 10% or greater
• Liquid iron supplements for children age 0-1 year
• Vitamin D supplements (prescription strength) (400 & 1000 units) for members 65 or older
• Pre-natal vitamins for pregnant women
• Flouride tablets, solution (not toothpaste, rinses) for children age 0-6

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

Nothing

Not covered:

• Drugs and supplies for cosmetic purposes
• Vitamins, nutrients, and food supplements not listed as a covered benefit even if a physician prescribes or administers them.
• Nonprescription medications except for any over-the-counter products listed on our formulary and as stated above
• Weight loss prescriptions
• Drugs to enhance athletic performance
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
• Fertility drugs

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco and nicotine dependence are covered under the tobacco and nicotine cessation benefit (See Section 5(a) under Educational Classes and programs.).

All charges

$60 per visit

Dental benefits

• Prevention of dental caries in children from birth through age 5 years: Primary care clinicians can apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption.
• Prevention of dental caries in children from birth through age 5 years: Primary care clinicians can prescribe oral fluoride supplementation starting at 6 months for children whose water supply is deficient in fluoride.

Easy-to-use internet-based tools to help you manage your own health and make smarter decisions that may reduce health care costs. These programs are available to members through www.cdphp.com.

Secure Member Site - Log in at www.cdphp.com to view your claim history, specific plan benefits, copayments, coinsurance, and more.

Visit Us On Social Media

• Keep up with CDPHP via Facebook, Twitter, or LinkedIn! 
• Wellness – Get started on your path to better health by visiting the CDPHP Health Hub, powered by Virgin Pulse. We’ll help you make small, everyday changes focused on the areas you want to improve the most. With daily engagement, you’ll build healthy habits and experience the lifelong rewards of better health. The CDPHP Health Hub can help you reach your goals by learning how to eat for energy, move more, sleep better, manage stress, and more. Visit your secure online member account for more information.

Finding A Doctor Has Never Been Easier

• Find-A-Doc - Online search tool that offers details on CDPHP network physicians including name, specialty, location, and doctors that are certified by the Bridges to Excellence Program. The enhanced site provides Google maps and ZIP code radius searches to help you locate CDPHP participating physicians in your area.
• My CDPHP Mobile App - Be sure to download My CDPHP Mobile to your smartphone. It’s convenient, free, and easy to use! Now, in addition to showing provider network listings, it allows you to log in securely to access personal benefit details and view, email, or fax your member ID card.

Rx Corner - Get more information on your prescription drug coverage.

CDPHP ConnectRx, On the Go - This pharmacy cost transparently tool will enable you to:

• View your current medication list and alert you to potential savings opportunities
• See if you’re eligible for additional savings using a CDPHP Rx for Less pharmacy
• Request a medication or pharmacy switch 
• View how much a medication will cost based on your CDPHP plan 
• Get alerts about screenings or appointments you may need to keep you healthy

CDPHP ConnectRx, On the Go is now available in the App Store or Google Play.

Get a Price Check - CDPHP Price Check is designed to create cost transparency by giving you estimated costs on a range of health care services before you choose a provider. Armed with this information, you’ll have more control over your health care as you compare prices and plan for expenses in advance of a service rather than when you receive the bill.

• Check out the costs of a wide variety of procedures and services – with more being added all the time!
• Find provider and cost information by location
• Review how expenses could affect your deductible and out-of-pocket costs

Log in to your member account to get started. Price Check is also available in the My CDPHP app!

Personalized Online Help
Send a secure message to a health professional; receive an answer confidentially within 24 hours. For members that would like to make lifestyle changes to improve their health, CDPHP can help with personalized, web-based support. Through our Took Kits for Good Health, members can find helpful information related to many different chronic conditions and health issues. Visit www.cdphp.com/members/wellness-treatment/get-health-support/health-guides. >

Single-Source Referral Line - Looking for wellness support and advice? CDPHP has a variety of programs that might help. Call our single-source referral line at 888-94-CDPHP (23747) and leave a confidential message about your health concern. An expert professional will call you back with suggestions for CDPHP programs that can help fulfill your unique needs.

CDPHP Behavioral Health Access Center - Call 888-320-9584 if you have questions about your behavioral health benefits or need help finding a provider of care. If calling after hours you may press “1” to be connected with the CONTACT Lifeline where you can speak with a licensed mental health professional.

Diabetes Prevention Program - CDPHP supports members at-risk for developing diabetes through coverage of the Diabetes Prevention Program (DPP). This evidence-based program provides members with the opportunity to meet with a trained coach over the course of 12 months to learn ways to reduce the risk of developing diabetes, from healthy eating and physical activity to problem-solving and coping skills. Community-based and online programs are available:

• CDPHP offers coverage of in-person DPP programs through a reimbursement benefit. Members are directed to www.cdc.gov to find local programs. They are also encouraged to talk with their doctor to find out if this program is appropriate.
• CDPHP offers coverage of an online Diabetes Prevention Program called VP Transform for Prediabetes. VP Transform is a year-long, CDC recognized, digital lifestyle change and weight loss intervention that combines software, connected hardware and remote health coaching. The program is structured in two phases. Phase 1: “Transform Core” is an intensive sixteen (16) week intervention that delivers the evidence-based curriculum, health coaching, social support and tracking tools to initiate and sustain changes to behavior.
  Phase 2: “Transform for Life,” consists of eight (8) months of maintenance programming, with all the program features of phase 1 in place, with the only difference being a reduction in frequency of coaching sessions and lessons. With digital coaching, dynamic behavioral goal setting, planning, and tracking, participants have the resources available to lead to a meaningful lifestyle change.

Cardiac Rehabilitation - The MovN program offers CDPHP® members a convenient alternative to traditional center-based cardiac rehab programs, which are often difficult for members to access. MovN uses a digital app, remote monitoring tools, a 1:1 dedicated coach, and a personalized treatment plan to help members improve their cardiac health and live longer.

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 are subject to our ongoing review.
• By approving an alternative benefit, we do not guarantee you will continue to receive it.
• The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits.
• If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8).

The phone system also includes a TDD system. Members may call 711 for services.

Maternal Health Education Reimbursement: CDPHP UBI will reimburse out-of-pocket costs related to in-person or digital maternal health educational classes. Reimbursements can be made up to $75 total per contract in a benefit year. Example educational classes include childbirth preparation, parenting, infant care, or infant CPR. To receive reimbursement after completing an eligible class, sign into your member portal and complete the Maternal Health Education Reimbursement Form (proof of payment is required).

Ovia Health: provides support and education to members to help them achieve their personal and family health goals. Ovia provides clinically validated education, resources, and reminders that are personalized to a member’s unique situation that help to keep them on track with their preventive care. Members have unlimited access to Ovia’s health coaching team to receive support and clinically-validated responses to common questions, as well as to be connected to a CDPHP Care Manager if the member is identified as high-risk. Custom content within the app will allow members to learn about and utilize their relevant health plan benefits specific to their plan type. Members can choose between three different smartphone apps to engage with Ovia depending on where they are in their family health journey; including family planning or pregnancy prevention, pregnancy support, parenting and menopause support.

High Risk Pregnancies: Describe maternal health program and if program provides self-measured blood pressure cuffs (validated blood pressure monitors) and clinical support when using the blood pressure monitors/cuffs.

CDPHP has a robust quality management program devoted to improving the care and service our members receive. Click on “Commitment to Quality” in the lower right-hand corner of any page at www.cdphp.com for details. You can review survey results regarding members’ satisfaction with their primary care providers, and data on the quality and safety of the hospitals in our network.

In most cases, providers and facilities file claims for you. Provider must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, contact us at 518-641-3140 or 877-269-2134 or at our website at www.cdphp.com.    

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

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

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

Submit your claims to:

CDPHP Universal Benefits,^® Inc.
500 Patroon Creek Blvd.
Albany, NY 12206

518-641-3140 or 877-269-2134

www.cdphp.com

If you have an Urgent care claim, please contact our member services department at 518-641-3140 or 877-269-2134.

Urgent care claims must meet the definition found in Section 10 of this brochure, and most urgent care claims will be claims for access to care rather than claims for care already received.

We will notify you of our decision not later than 24 hours after we receive the claim as long as you provide us with sufficient information to decide the claim.  If you or your authorized representative fails to provide sufficient information we will inform you or your authorized representative of the specific information necessary to complete the claim not later than 24 hours after we receive the claim and a time frame for our receipt of this information.  We will decide the claim within 48 hours of (i) receiving the information or (ii) the end of the time frame, whichever is earlier.

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 as an appealable decision.  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. 

As indicated in Section 3, certain care requires Plan approval in advance. We will notify you of our decision within 15 days after the 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 before the expiration 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 fail to follow these pre-service claim procedures, then we will notify you of your failure to follow these procedures as long as (1) your request is made to our customer service department and (2) your request names you, your medical condition or symptom, and the specific treatment, service, procedure, or product requested.  We will provide this notice within five days following the failure or 24 hours if your pre-service claim is for urgent care.  Notification may be oral, unless you request written correspondence.

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

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

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

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, a healthcare professional with knowledge of your medical condition will be permitted to act as your authorized representative without your express consent.   For the purposes of this section, we are also referring to your authorized representative when we refer to you.

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

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

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

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

b) Send your request to us at: CDPHP UBI, 500 Patroon Creek Blvd., Albany, NY 12206; and

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

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

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

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

a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or precertify your hospital stay or grant your request for prior approval for a service, drug, or supply); or

b) Write to you and maintain our denial - go to step 4; or

c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of our request—go to step 3.

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.

In the case of an appeal of an urgent care claim, we will notify you of our decision not later than 72 hours after receipt of your reconsideration request.  We will hasten 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.

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, FEHB 2, 1900 E Street, NW, Washington, DC 20415-3620.

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
• Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim; 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.cdphp.com.

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

When we are the secondary payor, we will determine our allowance. After the primary plan 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 the program.

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 assigness receive payment form 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, judgement, or otherwise. 

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

Reimbursement to 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 jusgement, 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. 

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

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

• Routine care costs – costs for routine services such as doctor visits, lab tests, x-rays and scans, and hospitalizations related to treating the patient’s condition, whether the patient is in a clinical trial or is receiving standard therapy.  These costs are covered by this plan.
• Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care. This plan covers some of these costs, as long as the test is a covered benefit.  We encourage you to contact the plan to discuss specific services if you participate in a clinical trial.    
• Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes.  These costs are generally covered by the clinical trials.  This plan does not cover these costs. (See Section 6 General Exclusions)

For more detailed information on “What is Medicare?” and “Should I Enroll in Medicare?” please contact Medicare at 1- 800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048) or at www.medicare.gov.

The Original Medicare Plan (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, such as preauthorization for inpatient hospital stays.

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 518-641-3140 or 877-269-2134 or see our website at www.cdphp.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.

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 then we waive some costs because Medicare will be the primary payor. 

We offer reduced costs, Medicare Part B reimbursement, and value added benefits if you enroll in the CDPHP Medicare Advantage Extra Plan in addition to your Standard Plan enrollment. See bullet titled Medicare Advantage (Part C) in Section 9. Coordinating Benefits with Medicare and Other Coverage for coverage information. See also www.cdphp.com/federalemployees for detailed plan and enrollment information.

Benefit Description: Deductible
Standard Option You Pay without Medicare: $350 Self Only/$700 Self Plus One or Self and Family
Standard Option You Pay With Medicare Part B: $350 Self Only/$700 Self Plus One or Self and Family

Benefit Description: Catastrophic Protection Out-of-Pocket Maximum
Standard Option You Pay without Medicare: $8,550 Self Only/$17,100 Self Plus One or Self and Family
Standard Option You Pay With Medicare Part B: $8,550 Self Only/$17,100 Self Plus One or Self and Family

Benefit Description: Part B Premium Reimbursement Offered
Standard Option You Pay without Medicare: N/A
Standard Option You Pay With Medicare Part B: N/A

Benefit Description: Primary Care Physician
Standard Option You Pay without Medicare: $40 copay
Standard Option You Pay With Medicare Part B: Nothing

Benefit Description: Specialist
Standard Option You Pay without Medicare: $60 copay
Standard Option You Pay With Medicare Part B: Nothing

Benefit Description: Inpatient Hospital
Standard Option You Pay without Medicare: $500 copay per admission plus 20% of the plan allowance (calendar year deductible applies)
Standard Option You Pay With Medicare Part B: $500 copay per admission plus 20% of the plan allowance (calendar year deductible applies). The deductible and/or coinsurance may be waived under your CDPHP plan if applied by Medicare.

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 our Medicare Advantage plan: We offer a Medicare Advantage plan known as • CDPHP Medicare Advantage Extra. CDPHP Medicare Advantage Extra enhances your FEHB coverage by lowering cost-sharing for some services and/or adding benefits. Standard Option members can choose to enroll in the CDPHP Medicare Advantage Extra if they continue to be covered under the CDPHP Standard Option. If you live in our CDPHP Medicare Advantage service area and you have Medicare Parts A and B, you can enroll in CDPHP Medicare Advantage Extra. Enrolling in CDPHP Medicare Advantage Extra does not change your FEHB premium. Your enrollment is in addition to your FEHB Standard Option enrollment: however, your benefits will be provided under the CDPHP Medicare Advantage Extra plan and are subject to Medicare rules. If you are already a member of CDPHP Medicare Advantage Extra and would like to understand your additional benefits in more detail, please refer to your CDPHP Medicare Advantage Extra Evidence of Coverage. If you are considering enrolling in CDPHP Medicare Advantage Extra, please call us at 1-877-480-3328 (TTY:711). 8 a.m. - 8 p.m. seven days a week from October 1 - March 31. From April 1 - September 30, Monday – Friday, our hours are 8 a.m. - 8 p.m. or visit our website at www.cdphp.com/federalmedicare.

With CDPHP Medicare Advantage Extra, you will get more coverage, such as lower cost sharing and additional benefits. This 2024 benefit summary allows you to make a comparison of your choices:

Benefit Description: Deductible
Standard Option without Medicare you pay: $350/$700
Standard Option with CDPHP Medicare Advantage Extra: None

Benefit Description: Primary Care
Standard Option without Medicare you pay: $40
Standard Option with CDPHP Medicare Advantage Extra: $15

Benefit Description: Specialty Care
Standard Option without Medicare you pay: $60
Standard Option with CDPHP Medicare Advantage Extra: $20

Benefit Description: Outpatient Surgery
Standard Option without Medicare you pay: $100 *
Standard Option with CDPHP Medicare Advantage Extra: $75

Benefit Description: Inpatient Hospital Care
Standard Option without Medicare you pay: $500+20% coinsurance *
Standard Option with CDPHP Medicare Advantage Extra: $250 per admission, maximum of 2 payments per plan year.

Benefit Description: Retail Pharmacy
Standard Option without Medicare you pay: Tier 1-$10 copayment; Tier 2-50% coinsurance, $400 per prescription max per 30-day supply; Tier 3-50% coinsurance, $600 per prescription max per 30 day supply.
Standard Option with CDPHP Medicare Advantage Extra: Tier 1-$0 copayment, Tier 2-$10 copayment, Tier 3-$30 copayment, Tier 4-$50 copayment, Tier 5-$55 copayment, Tier 6-$0 copayment.

Benefit Description: Additional Benefits Offered
Standard Option without Medicare: Weight loss $75 reimbursement.
Standard Option with CDPHP Medicare Advantage Extra: Weight loss $100 reimbursement. Senior Fit (Silver Sneakers), Papa Pals, Meals after hospital discharge.

Benefit Description: Out-of-pocket
Standard Option without Medicare: $8,550/$17,100
Standard Option with CDPHP Medicare Advantage Extra: $3,850 IN/$5,750 OON

Benefit Description: Out of Network (OON) Coverage
Standard Option without Medicare: N/A
Standard Option with CDPHP Medicare Advantage Extra: 30% coinsurance, must accept Medicare assignment.

Benefit Description: Part B Premium reimbursement
Standard Option without Medicare: $0
Standard Option with CDPHP Medicare Advantage Extra: Up to $165 monthly 

*You pay the deductible, then cost-sharing.

Medicare Part B premium reimbursement

We offer a plan designed to help Standard Option members with their Medicare Part B premium. For each month you are enrolled in CDPHP FEHB Standard Plan, have Medicare Part B and are enrolled in CDPHP Medicare Advantage Extra, you will be reimbursed up to $165 of the Medicare Part B monthly premium you pay, including any amount added to your Part B premium for the Part B late enrollment penalty (LEP) or Income Related Monthly Adjustment Amount (IRMAA). In addition to reimbursing you for the Part B monthly premium, we will cover additional benefits, including lower office visit copayments, urgent care and emergency care, plus additional coverage for benefits, such as the Senior Fit program.

You may be eligible for this reimbursement if:

• You enroll CDPHP Medicare Advantage Extra and maintain coverage in the plan's Standard Option simultaneously.
• The FEHB subscriber must complete an additional application for enrollment in CDPHP Medicare Advantage Extra.
• You live in our Medicare Advantage Service Area including the following counties: Albany, Broome, Chenango, Clinton, Columbia, Delaware, Dutchess, Essex, Franklin, Fulton, Greene, Hamilton, Herkimer, Jefferson, Lewis, Madison, Montgomery, Oneida, Orange, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, St. Lawrence, Tioga, Ulster, Warren, and Washington counties
• You have Medicare Parts A and B

For more information on how to obtain reimbursement, please visit www.cdphp.com/federalmedicare, or call 1-877-480-3328 (TTY:711).

• 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.

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

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

See Section 4, page 20.

See Section 4, page 20.

See Section 4, page 20.

See Section 4, page 20.

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

The total amount of applicable copayments and/or coinsurance that you must satisfy, before which CDPHP UBI will pay one hundred percent (100%) of the allowed amount for covered benefits. All amounts you pay for copayments and/or coinsurances are applicable toward the out-of-pocket maximum. 

Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways. We determine our allowance by the average community charges. Our providers accept the allowances as payment in full.

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.

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.

Us and We refer to CDPHP Universal Benefits,^® Inc., an affiliate of Capital District Physicians’ Health Plan, Inc. (CDPHP).

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
• 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 medication.

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at 518-641-3140 or 877-269-2134.  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.

Office visit copay: $40 primary care; $60 specialist

25

$500 copay per admission plus 20% of the Plan allowance.* For individual coverage, inpatient copays are limited to two per calendar year. For family coverage, inpatient copays are limited to three per calendar year.

49

$60 per visit

$100 for outpatient surgery*

50

$150  per visit to hospital emergency room;* $60 per visit to urgent care center

53

$150 per visit to hospital emergency room*

53

Regular cost-sharing

54

Tier 1 drugs - $10 copayment (2.5 copayments will apply for 90-day supplies of maintenance medications obtained by mail order).
Tier 2 drugs - 50% of the Plan allowance with a $400 per prescription maximum, up to a 30-day supply.
Tier 3 drugs - 50% of the Plan allowance with a $600 per prescription maximum, up to a 30-day supply.

57

$60 per visit for accidental injury benefit

61

$60 per visit for one refraction every 24 months

34

On-line tools, Flexible benefits option, Non-emergency medical care for full-time students attending school out of the area, Services for the deaf and hearing impaired, Maternal Health Education Reimbursement, Centers of Excellence for transplants/heart surgery

62

Nothing after $8,550/Self Only or $17,100/Self Plus One or Self and Family enrollment per year for medical and pharmacy combined qualified services.

20