Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

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

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

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

Also, your employing or retirement office can answer your questions, give you other plan's 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;
• When your enrollment ends; and
• When the next Open Season for enrollment begins.

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

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

Self Only coverage is only for the enrollee.  Self Plus One coverage is for the enrollee and one eligible family member.  Self and Family coverage is for the enrollee, and one or more eligible family member.  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 carrier to add a family member when there is already family Coverage.

Contact your employing or retirement office if you are changing from Self to Self Plus One or Self and Family or to add a family member if you currently have a Self Only plan. 

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, nor will we. Please tell us immediately of changes in family member status including your marriage, divorce, annulment, or when your child reaches age 26.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2023 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2022 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 by 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.

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

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

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

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

If you are divorced from a Federal employee, Tribal employee, or an annuitant, you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage 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/. 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.

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

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

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

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

We also want to inform you that the Patient Protection and ACA did not eliminate TCC or change the TCC rules.

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

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

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

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions. When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act's Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 800-356-2219 or visit our website at www.phs.org.

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

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 505-923-5678 or 800-356-2219 or TTY for the hearing impaired at 711 or toll-free at 800-659-8331. You may write to us at P.O. Box 27489, Albuquerque, NM  87125 You may also request replacement cards through our Website: www.phs.org/fehb.

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 physician or by another participating provider in the network.

Plan providers are physicians and other healthcare professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards. We obtain, verify, review, and evaluate practitioners’ competencies and qualifications on an ongoing basis to determine whether they can participate as providers in our Plan. Providers we credential include medical doctors, specialists, physician assistants, certified nurse practitioners, licensed social workers, and licensed professional counselors.

We list Plan providers in the provider directory, which we update periodically. The list is also on our Website at www.phs.org/fehb. The listings are first organized by region within New Mexico – Central New Mexico, Northern New Mexico, and Southern New Mexico. Each region, physicians, other providers, and facilities are organized by primary care physicians are listed as family practice, general practice, internal medicine, pediatrics, and OB/GYN’s acting as PCPs.

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, notational origin, age, disability, religion, sex or gender.

This plan provides Care Coordinators for complex conditions and can be reached at 800-356-2219 or through our website: www.phs.org/febh for assistance.   

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

It depends on the type of care you need.  First, you and each family member must choose a primary care physician.  This decision is important since your primary care physician provides or arranges for most of your health care. You must select a primary care physician from the PHP provider directory. Locations and phone numbers of the participating doctors are listed in the PHP provider directory or can be obtained by calling the Presbyterian Customer Service Center at 505-923-5678 or 800-356-2219 or TTY for the hearing impaired at 711 or toll-free at 800-659-8331 or by accessing our website at www.phs.org/fehb. By selecting a PCP who belongs to the plan, members are selecting their corresponding network of specialists, hospitals, and other providers to serve their healthcare needs.

Your primary care physician can be a family practice, general practice, internal medicine, pediatrics, and OB/GYN (if applicable) acting as a primary care physician. Your primary care physician will provide most of your healthcare or give you a referral to see a specialist.

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

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

Your primary care physician will create your treatment plan.  The physician may have to get an authorization or approval from us beforehand.  If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician.  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 physician, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.
• 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 physician 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 Center immediately at 800-356-2219 or 505-923-5678 or TTY for the hearing impaired at 711 or 800-659-8331. If you are new to the FEHB Program, we will arrange for you to receive 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; or
• the day your benefits from your former plan run out; or
• the 92nd day after you become a member of this Plan, whichever happens first.

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

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

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

Your primary care physician 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

We call this review and approval process pre-authorization.  Your physician must obtain pre-authorization for services such as, but not limited to: Durable Medical Equipment, Hospice, Acute Rehabilitation, Outpatient Rehab, Skilled Nursing Facilities, Hospitalization and Mental Health/Substance Use Disorder care.

Except in medical emergency you must obtain pre-authorization prior to seeing a non-Plan physician.  Your Plan physician must get our approval before sending you to a hospital.  If required medical services are not available from Plan providers, your Plan physician must request and obtain written authorization from the Presbyterian Health Plan Medical Director before you may receive services.

First, your physician, your hospital, you, or your representative must call us at 800-356-2219 or 505-923-5678 or TTY for the hearing impaired at 711 or 800-659-8331 before admission or services requiring prior authorization are rendered. 

Next, provide the following information:

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

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

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

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

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim.  You will then have up to 48 hours to provide 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 toll-free at 800-356-2219.  For the hearing impaired, call our TTY line at 711 or toll-free at 800-659-8331.  You may also call OPM’s Health Insurance 3 at 202-606-0737 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 toll-free at 800-356-2219.  For the hearing impaired, call our TTY line at 711 or toll-free at 800-659-8331.  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 telephone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital. 

You do not need to precertify 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 caesarean section, then you, your representative, your physician or the hospital must contact us on precertification of additional days.  Further, if your baby stays after you are discharged, your representative, your physician or the hospital must contact us for precertification of additional days for your baby.

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.

Certain services require approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

We call this review and approval process pre-authorization. Your physician must obtain pre-authorization for services such as, but not limited to: Durable Medical Equipment, Hospice, Acute Rehabilitation, Outpatient Rehab, Skilled Nursing Facilities, Hospitalization and Mental Health/Substance Use Disorder care.

Except in a medical emergency you must obtain pre-authorization prior to seeing a non-Plan physician. Your Plan physician must get our approval before sending you to a hospital. If required medical services are not available from Plan providers, your Plan physician must request and obtain written authorization from the Presbyterian Health Plan Medical Director before you may receive services.

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

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below. If your claim is in reference to a contraceptive, call 800-356-2219.

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 telephone, electronic mail, facsimile, or other expeditious methods.

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

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: High option, when you see your primary care physician for non-preventive services. you pay a copay of $25 per office visit, and when you go see a specialist, you pay a copay of $40 per office visit. When you see your primary care physician for preventive services, you pay nothing for the office visit and when you go see a specialist, you pay a copay of $40 for adult and $20 for children per office visit. When you go in the hospital, you pay $100 copay per day up to 5 days per admission.

A deductible is a fixed expense you must incur for certain covered services and supplies before the plan starts paying benefits.  Copays do not count toward any deductible.

• This High Option HMO plan does not have a deductible.
• The calendar year deductible is $500 per person under the Standard Option and $2,000 under the Wellness Option plan.  Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $500 under Standard Option and $2,000 under the Wellness Option plan.  Under a Self Plus One or Self and Family enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $1,000 under the Standard Option and $4,000 under the Wellness Option. 

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

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

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

Example: In our Plan, you pay 50% of our allowance for infertility services and durable medical equipment

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

After your (copays and coinsurance) total $6,350 for self only or $12,700 for Self Plus One or Self and Family enrollment under the High and Standard Options and $8,150 for self only or $16,300 for Self Plus One or Self and Family enrollment for the Wellness Option in any Calendar year, You do not have to pay any more for Covered services.  However, copays and/or coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copays and/or coinsurance for these services:

• Dental services
• Vision services
• Non-covered charges

Be sure to keep accurate records of your copays and/or coinsurance since you are responsible for informing us when you reach the maximum.

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

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

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

The No Surprises Act (NSA) is a federal law that provides you with protections against "surprise billing" and "balance billing" under certain circumstances.  A surprise bill is an unexpected bill you receive from a nonparticipating healthcare provider, facility, or air ambulance service for healthcare.  Surprise bills can happen when you receive emergency care - when you have little or no say in the facility or provider from whom you receive care.  They can also happen when you receive non-emergency services at participating facilities, but you receive some care from nonparticipating providers.   

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 unexpected bills.

In addition, your health plan adopts and complies with the surprise billing laws of New Mexico under the New Mexico Surprise Billing Protection Act (59A-57A, NMSA 1978) and the No Surprises Act.

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.phs.org or contact the health plan at 800-356-2219.

• 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

• Primary Care Physician

$25 copay per visit

$0 copay per visit for children up to age 26

(Waived if nursing visit only for allergy injections, injections such as insulin, heparin, and antibiotics, preventive adult and child immunizations)

$30 copay per visit

(Waived if nursing visit only for allergy injections, injections such as insulin, heparin, and antibiotics, preventive adult and child immunizations)

No deductible

First 4 visits: $20 copay, not subject to deductible

Subsequent visits: 30% coinsurance, subject to deductible

• Specialist

$40 copay per visit to specialist

$20 copay per visit to specialist for children up to age 26

(Waived if nursing visit only for allergy injections, injections such as insulin, heparin, and antibiotics, preventive adult and child immunizations)

$40 copay per visit

(Waived if nursing visit only for allergy injections, injections such as insulin, heparin, and antibiotics, preventive adult and child immunizations)

No deductible

$40 copay, not subject to deductible

Foot Care

• First 2 visits: $30 copay, not subject to deductible
• Subsequent visits: 30% coinsurance, subject to deductible

Applied Behavioral Analysis (ABA)

Diagnosis and Treatment for all children up to age 26

$0 copay per visit

$0 copay per visit

No deductible

30% coinsurance

Subject to deductible

Telehealth (Video) visits

An alternative access point for members to receive care for non-urgent medical issues such as upper respiratory infections, flu, cold, cough, and allergies. To access video visits you may visit the website at www.phs.org/videovisits.

$0 copay per visit

$0 copay per visit

No deductible

$0 copay

No deductible

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine Pap test
• Pathology
• X-ray
• Non-routine mammogram
• Ultrasound
• Electrocardiogram and EEG

Diagnostic tests are not subject to a copay regardless of whether an office visit is billed

Diagnostic tests are not subject to a copay regardless of whether an office visit is billed

First two diagnostic lab or x-ray have $0 copay, no deductible

30% coinsurance deductible applies for visits thereafter

Computed Axial Tomography (CAT) scans/Magnetic Resonance Imaging (MRI) tests/Positron Emission Topography (PET) scans

$100 copay per test

$50 copay per test

No deductible

30% coinsurance

Subject to deductible

Sleep Studies- Outpatient overnight stay without admission

$100 copay per test

$50 copay per test

No deductible 

30% coinsurance

Subject to deductible

Sleep Studies-Outpatient overnight stay with admission

$100/day copay per admission up to 5 days

30% coinsurance per admission

Deductible applies

30% coinsurance

Subject to deductible

Routine physical every year.

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

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/
• Screenings such as cancer, osteoporosis, depression,diabetes, high blood pressure, total blood cholesterol, HIV,and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force(USPSTF) website at https://www.uspreventiveservicestaskforce.org
• Individual counseling on prevention and reducing health risks
• 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://www.healthcare.gov/myhealthfinder

Nothing

Nothing

No deductible 

Nothing

No deductible

Routine mammogram - covered:

Nothing

Nothing

No deductible

Nothing 

No deductible

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

healthfinder.gov/myhealthfinder/default.aspx

Nothing

Nothing

No deductible

Nothing 

No deductible

Preventive Vision Exam - One exam per year

$0 copay when using Presbyterian Vision Plan Network Provider 

www.davisvision.com

Not covered, you pay all charges

Not covered, you pay all charges

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 copays, coinsurance, and deductible.

Not covered:

• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.

• Immunizations, boosters, and medications for travel or work-related exposure.

All charges

All charges

All charges 

• Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
• Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go 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

Nothing

Nothing

No deductible

Nothing

No deductible

Preventive Vision Exam - One exam per year up to age 26

$0 copay when using Presbyterian Vision Plan Network Provider

www.davisvision.com

Not covered, you pay all charges

Not covered, you pay all charges

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 copays, coinsurance, and deductible.

Not covered: Physical exams and immunizations required for obtaining or continuing employment or insurance, attending schools, camp or athletic exams or travel.

All charges

All charges

All charges

Complete maternity (obstetrical) care, such as:

• Prenatal care
• Screening for gestational diabetes
• Delivery
• Postnatal care

Note: Here are some things to keep in mind:

• You do not need to precertify your vaginal delivery; see page 19 for other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.
• We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Surgical services are covered under Section 5(b) and Hospital services are covered under Section 5(c).

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

$25 copay per visit up to a maximum of $150 per pregnancy

Specialists (Perinatologist) - $40 copay per visit to specialist

Delivery - Inpatient - $100/day copay per admission up to 5 days (included in inpatient hospital/facility inpatient admission copay)

$30 copay per visit up to a maximum of $300 per pregnancy - No deductible

Specialists (Perinatologist) - $40 copay per visit - No deductible

Delivery – Inpatient - 30% coinsurance/$2,000 Max per admission, Deductible applies

• $0 for routine prenatal care or for the first postpartum care visit; $40 per office visit for all postpartum care visits thereafter
• 0% coinsurance subject to deductible for delivery services

Nothing

No deductible

Nothing

No deductible

Not covered:

Circumcisions performed other than during the newborn Hospital stay are only covered when medically necessary.

All charges

All charges

All charges

Nothing

Nothing

No deductible

Nothing

No deductible

A range of voluntary family planning services, limited to:

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

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

Nothing

Nothing

No deductible

Nothing

No deductible

Voluntary sterilization (See Surgical Procedures Section 5 (b)

Nothing

Nothing

Nothing

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling

All charges

All charges

All charges

Diagnosis and treatment of infertility such as:

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

$25 copay per visit to primary care physician

$40 copay per visit to specialist

$30 copay per visit to primary care physician

$40 copay per visit to specialist

No deductible

30% coinsurance

Subject to deductible

• Fertility drugs
• Note:  We cover Injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit.

50% of plan allowance

50% of plan allowance

30% coinsurance 

Subject to deductible

• Iatrogenic Infertility Perseveration
• Services include the following procedures, when provided by or under the care or supervision of a Physician:
  
  • Collection of sperm
  • Cryo-preservation of sperm
    
  • Ovarian stimulation, retrieval of eggs
    
  • Oocyte cryo-preservation
    

Note: Refer to our web site www.phs.org/fehb for more information regarding coverage and exclusion criteria

30% of plan allowance

30% of plan allowance

30% of plan allowance

Not covered:

• Assisted reproductive technology (ART) procedures, such as:
  • In vitro fertilization (IVF)
  • Embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
• Services and supplies related to ART procedures
• Cost of donor sperm
• Cost of donor egg

All charges

All charges

All charges

• Testing and treatment
• Allergy injections

$25 copay per visit to primary care physician

$0 copay for children up to age 26 for participating providers

$40 copay per visit to specialist

$20 copay per visit to specialist for children up to age 26

Allergy injections are included in the office visit copay. If there is no office visit, allergy injections are not subject to a copay.

(waived if nursing visit only)

$30 copay per visit to primary care physician

$40 copay per visit to specialist

Allergy injections are included in the office visit copay. If there is no office visit, allergy injections are not subject to a copay.

(waived if nursing visit only)

No deductible

30% coinsurance

Subject to deductible

• Allergy serum

Nothing

Nothing

No deductible

30% coinsurance

Subject to deductible

Not covered: Provocative food testing and sublingual allergy desensitization

All charges

All charges

All charges

• Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 43.

• Respiratory and inhalation therapy
• Cardiac rehabilitation following qualifying event/condition is provided for up to 12 sessions.
• Dialysis - hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy
• Medical Drugs - All drugs and routes of administration provided or administered in an outpatient setting.
• Growth hormone therapy (GHT)

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

Note: We only cover GHT when we preauthorize the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Other services under You need prior Plan approval for certain services on page 82.

$25 copay per visit to primary care physician

$0 copay per visit to primary care physician for children up to age 26

$40 copayment per visit specialist 

50% of plan allowance up to a maximum of $400 per prescription

$30 copay per visit to primary care physician

50% of plan allowance up to a maximum of $400 per prescription

30% coinsurance, Subject to deductible

Associated medications, 50% of the plan allowance up to a maximum of $400 per prescription

Provided in patient or out-patient up to 2 months per condition if significant improvement is expected for the services of each of the following:

• Qualified physical therapists
• Occupational therapists

Note: We only cover therapy when a provider orders the care. In-patient or out-patient therapy may be extended 2 additional months if significant improvement is expected to continue and must be preauthorized by PHP. Autism Spectrum Disorders are not subject to these limitations for children up to age 22.

Note: We only cover therapy when a physician:

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

Significant improvement means:

• The patient is likely to meet all therapy goals for the first two months of therapy; or
• The patient has met all therapy goals in the preceding two months of therapy, as specifically documented in the therapy record.

$25 copay per visit

$0 copay per office visit for children up to age 26

Nothing per visit during covered inpatient admission

$30 copay per visit

No deductible

Nothing per visit during covered inpatient admission

First 60 visits per condition: $20 copay, Not subject to deductible

Subsequent visits 30% coinsurance, Subject to deductible

Nothing per visit during covered inpatient admission

Cardiac rehabilitation following qualifying event/condition is provided for up to 12 sessions with continuous electrocardiogram (ECG) monitoring and up to 24 sessions with intermittent ECG monitoring at an approved facility.

$40 copay per visit

$20 copay per office visit for children up to age 26

$40 copay per visit

No deductible

30% coinsurance

Subject to deductible

$40 copayment per visit

$20 copayment per office visit for children up to age 26

$40 copay per visit

No deductible

30% coinsurance, Subject to deductible

Not covered:

·    Long-term rehabilitative therapy

·    Exercise programs

All charges

All charges

All charges

Speech Therapy is covered for up to 2 months when provided by a licensed or certified speech therapist subject to the following:

• Speech Therapy is medically necessary
• Speech Therapy must be preauthorized by us
• Following the initial 2 months of treatment, in-patient or outpatient Speech Therapy may be extended for a period not to exceed 2 additional 2-month periods. Autism Spectrum Disorder is not subject to these limitations for children up to age 26.
  

$25 copay per visit

$0 copay per office visit for children up to age 26

Nothing per visit during covered inpatient admission.

$25 adult copay per visit

$0 child copay per visit

Not subject to deductible

Nothing per visit during covered inpatient admission.

First 60 visits per condition: $20 copay, Not subject to deductible

Subsequent visits: 30% coinsurance, Subject to deductible

Nothing per visit during covered inpatient admission.

Not covered:

Speech Therapy beyond 6 consecutive months.

All charges

All charges

All charges

• For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by and M.D., D.O., or audiologist

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

$15 copay per visit to primary care physician

$25 copay per visit to specialist

$15 copay per visit to primary care physician

$25 copay per visit to specialist

No deductible

30% coinsurance

Subject to deductible

• Hearing testing for children through age 26 (See Preventive care, children)

$0 copay per visit to primary care physician

$25 copay per visit to specialist

$0 copay per visit to primary care physician

$25 copay per visit to specialist

No deductible

30% coinsurance

Subject to deductible

• Hearing aids (for children under age 18 or 21 years of age if still attending high school). We limit coverage up to $2,200 every 36 months "per hearing impaired ear".

30% of the plan allowance

30% of the plan allowance

No deductible 

30% coinsurance 

Subject to deductible

Not covered:

• Hearing aids batteries
• Hearing aids, except for children under age 18 or under 21 if still attending high school
• Testing and examinations for hearing aids
• Hearing services that are not shown as covered

All charges

All charges

All charges

Preventive Vision Exam  - One exam per year

$0 copay

When using Presbyterian Vision Plan Network Provider

www.davisvision.com

Not covered

You pay all charges

Not covered

You pay all charges

• Eye exam to determine the need for vision correction for children through age 17 (see Preventive care, children)

• One Eye refraction per year for children under 6 when medically necessary to aid in the diagnosis of certain eye diseases

$0 copay per visit to primary care physician

$20 copay per visit to specialist

$0 copay per visit to primary care physician

$20 copay per visit to specialist

No deductible

30% coinsurance

Subject to deductible

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

30% of plan allowance

50% of plan allowance

30% coinsurance

Subject to deductible

• Medically necessary service - disease or injury to the eye

$25 copay per visit to primary care physician

$40 copay per visit to specialist

$30 copay per visit to primary care physician

$40 copay per visit to specialist

No deductible

30% coinsurance

Subject to deductible

Not covered:

• Eyeglasses or contact lenses and after age 26
• Eye exam for Standard Option
• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery
• Replacement of all items referenced in this section due to loss, neglect, theft, misuse, abuse or for convenience.

All charges

All charges

All charges

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

$25 copay per visit to primary care physician

$40 copay per visit to specialist

$30 copay per visit to primary care physician

$40 copay per visit to specialist

No deductible

First 2 visits: $30 copay, Not subject to deductible

Subsequent visits: 30% coinsurance, Subject to deductible

Not covered:

• Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above

• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

All charges

All charges

• Artificial limbs and eyes
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
• External hearing aids
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants
• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy.

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

30% of plan allowance

30% of plan allowance

30% coinsurance

Subject to deductible

Not covered:

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

Prosthetic replacements provided less than 3 years after the last one we covered

All charges

All charges

All charges

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

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

Note:  Call us at 800-356-2219 or 505-923-567 as soon as your Plan physician prescribes this equipment.  We will arrange with a healthcare provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

30% of plan allowance

50% of plan allowance

30% coinsurance

Subject to deductible

Not covered:

• Deluxe equipment such as motor driven wheelchairs, chair lifts, or beds, when standard equipment is available and adequate.  
• Repair and replacement due to loss, neglect, theft, misuse, abuse, to improve appearance or for convenience. Also repair and replacement of items under the manufacturer or supplier’s warranty. If the Member has a functional wheelchair, regardless of the original purchaser of the wheelchair, additional wheelchair(s) are not Covered. One-month rental of a wheelchair is Covered if a Member owned wheelchair is being repaired.

All charges

All charges

All charges

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

Nothing

Nothing

No deductible

30% coinsurance

Subject to deductible

• Specialty Pharmaceuticals are self-administered, meaning they are administered by the patient, a family member or care-giver.  Specialty Pharmaceuticals are often used to treat complex chronic, rare diseases and/or life threatening conditions. Most Specialty Pharmaceuticals require Prior Authorization and must be obtained through the specialty pharmacy network.  Specialty Pharmaceuticals are often high cost, typically greater than $600 for a 30-day supply.
• Specialty Pharmaceuticals are not available through the mail order option and are limited to a 30-day supply.  Some Specialty Pharmaceuticals may have additional day supply limitations.
• The medications listed on the formulary are subject to change pursuant to the management activities of Presbyterian Health Plan.

50% of plan allowance up to a maximum of $400 per prescription

50% of plan allowance up to a maximum of $400 per prescription

50% coinsurance up to $400 per prescription

Not covered:

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

All charges

All charges

All charges

Chiropractic Services - 30 visits per year if medically necessary.

• Your Plan physician must determine that your treatment will result in significant improvement in your condition
• Chiropractic treatment is specifically limited to treatment by means of manual manipulation, by the use of hands, and ultrasound therapy
• Subluxation must be documented by chiropractic examination and documented in the chiropractic records
• Chiropractic X-rays are only covered when performed by a chiropractor for the following clinical situations, unless clinically relevant X-rays already exist:
  • Acute trauma with a suspected fracture, such as motor vehicle accidents or slip and fall accidents
  • Clinical evidence of significant osteoporosis: recent fracture of the spine, wrist or hip; loss of height over ½ inch, or spine curvature consistent with osteoporotic fractures; or
  • Abnormal neurologic or orthopedic findings suggesting spinal nerve impingement
• Manipulation of the spine and extremities
• Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

$30 copay per office visit - Adult

• 30 visits per year if determined medically necessary

$20 copay per office visit - Children up to age 26

• 20 visits per year if determined medically necessary

$30 copay per office visit 

• 30 visits only per year if determined medically necessary

No Deductible

$30 copay per office visit

• 30 visits only per year if determined medically necessary

No Deductible

Not covered:

• Chiropractic treatment for chronic subluxation or rheumatoid arthritis, allergy, muscular dystrophy, multiple sclerosis, pneumonia, chronic lung disease, and other diseases/conditions
• Rolfing
• Massage therapy
• Naturopathic services
• Hypnotherapy

All charges

All charges

All charges

Acupuncture- 30 visits per year if determined medically necessary by a Doctor of Medicine or osteopathy for: 

• pain relief

• anesthesia
• Acupuncture treatment for other medical conditions will be covered only if the following conditions are met:
  • There is evidence-based medical literature that clearly supports the safety,  efficacy and appropriateness of this treatment for the specific medical condition for which authorization is requested
  • ­Acupuncture must be part of a coordinated plan of care
• Biofeedback is only covered for treatment of Raynaud’s disease or phenomenon and urinary or fecal incontinence

$30 copay per office visit - Adult

• 30 visits adults only per year if determined medically necessary

$20 copay per office visit - Children up to age 26

• 20 visits per year if determined medically necessary

$30 copay per office visit

No deductible

$30 copay per office visit

No deductible

Not covered:

• Naturopathic services
• Hypnotherapy
• Biofeedback

All charges

All charges

All charges 

Coverage is provided for:

• Tobacco Cessation programs, including individual/group/telephone counseling, over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence
• Diabetes self management
• Childhood obesity screening programs and treatment interventions

No copay for educational classes and programs. Regular plan benefits apply to medical services.

No copay for Tobacco Cessation drugs in conjunction with Tobacco Cessation Program.  Quantity limits apply maximum of two 90-day treatment regiments.

No copay for educational classes and programs. Regular plan benefits apply to medical services.

No copay for tobacco cessation drugs in conjunction with Tobacco Cessation Program.  Quantity limits apply maximum of two 90-day treatment regiments.

No deductible

$0

Not subject to deductible

$40 copay per office visit

$20 copay per office visit for children up to age 26

$40 copay per office visit

No deductible

$0

Not subject to deductible

Not covered:

•  Hypnotherapy
• Acupuncture is not covered under the Tobacco Cessation Counseling benefit. However, acupuncture for tobacco cessation is covered under the acupuncture benefit subject to the acupuncture copay and benefit limitation

All charges 

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Surgical treatment of morbid obesity (bariatric surgery) -- a condition in which an individual weighs 100 pounds or 100% over their normal weight according to current underwriting standards; eligible members must be age 18 or over. Note: Refer to our web site www.phs.org/fehb for more information regarding coverage and exclusion criteria.
• Insertion of internal prosthetic devices. See 5(a) - Orthopedic and prosthetic devices for device coverage information
• Voluntary sterilization (e.g., Tubal ligation, Vasectomy)
• Treatment of burns

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

Outpatient - $200 copay per visit, No deductible (included in hospital/facility outpatient copay)

Inpatient - $100/day copay per admission up to 5 days (included in hospital/facility inpatient admission copay)

Outpatient - 30% coinsurance/$2,000 Max per surgery, Deductible applies

Inpatient - 30% coinsurance/$2,000 Max per admission, Deductible applies

30% coinsurance 

Subject to deductible

Not covered:

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

All charges

All charges

All charges 

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

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

• Gender Affirming Surgery
  • Transgender services with a diagnosis of gender dysphoria, please contact health plan for detailed information. Prior Authorization is required.
  • Male-to-Female(MtF) - Surgical procedures include, but are not limited to: penectomy, orchiectomy, vaginoplasty, vulvoplasty, labiaplasty, clitoroplasy.
  • Female-to-Male (FtM) - Surgical procedures include, but are not limited to: mastectomy, hysterectomy, salpingo-oophorectomy, vaginectomy, metoidoplasty/phalloplasty (including penile prosthesis), urethroplasty, scotoplasty (including testicualr prostheses).

Outpatient - $200 copay per visit, No deductible (included in the hospital/facility outpatient copay)

Inpatient - $100/day copay per admission up to 5 days (included in hospital/facility inpatient admission copay)

Outpatient - 30% coinsurance/$2,000 Max per surgery, Deductible applies

Inpatient - 30% coinsurance/$2,000 Max per admission, Deductible applies

30% coinsurance

Subject to deductible

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.

All charges

All charges

All charges

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;
• TMJ benefit (Limited) - Please refer to Section 5(h) Dental Benefits.

Outpatient - $200 copay per visit, No deductible (included in the hospital/facility outpatient copay)

Inpatient - $100/day copay per admission up to 5 days (included in hospital/facility inpatient admission copay)

Outpatient - 30% coinsurance/$2,000 Max per surgery, Deductible applies

Inpatient - 30% coinsurance/$2,000 Max per admission, Deductible applies

30% coinsurance

Subject to deductible

Not covered

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

All charges

All charges

All charges

These solid organ transplants are covered. Solid organ transplants are limited to:

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

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

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

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below.

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

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

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

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

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

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

• Allogeneic transplants for
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Beta Thalassemia Major
  • Chronic inflammatory demyelination polyneuropathy (CIDP)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Sickle cell anemia
• Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning or RIC) for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Breast cancer
  • Chronic lymphocytic leukemia
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Colon cancer
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Myelodysplasia/Myelodysplastic Syndromes
  • Multiple sclerosis
  • Myeloproliferative disorders (MDDs)
  • Non-small cell lung cancer
  • Ovarian cancer
  • Prostate cancer
  • Renal cell carcinoma
  • Sarcomas
  • Sickle cell anemia
• Autologous Transplants for
  • Advanced Childhood kidney cancers
  • Advanced Ewing sarcoma
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Aggressive non-Hodgkin lymphomas
  • Breast Cancer
  • Childhood rhabdomyoarcoma
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Early state (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
• National Transplant Program (NTP)

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

Outpatient - $200 copay per visit, No deductible (included in the hospital/facility outpatient copay)

Inpatient - $100/day copay per admission up to 5 days (included in hospital/facility inpatient admission copay)

Outpatient - 30% coinsurance/$2,000 Max per admission, Deductible applies

Inpatient - 30% coinsurance/$2,000 Max per admission, Deductible applies

30% coinsurance

Subject to deductible

Not covered:

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

All charges

All charges

All charges

Professional services provided in -

• Hospital (inpatient)

Inpatient - $100/day copay per admission up to 5 days (included in hospital/facility inpatient admission copay)

30% coinsurance/$2,000 Max per admission, Deductible applies

30% coinsurance 

Subject to deductible

Professional services provided in -

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

$25 copay per visit to primary care physician

$0 copay per visit to primary care physician for children up to age 26

$40 copay per visit to specialist

$20 copay per office visit to specialist for children up to age 26

Outpatient - $200 copay per visit, deductible does not apply (included in the hospital/facility outpatient copay)

$30 copay per visit to primary care physician, No deductible

$40 copay per visit to specialist, No deductible 

Outpatient - 30% coinsurance/$2,000 Max per surgery, Deductible applies

30% coinsurance 

Subject to deductible

Room and board, such as

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

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

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.

$100/day copay per admission up to 5 days

30% coinsurance/$2,000 Max per admission, Deductible applies

30% coinsurance 

Subject to deductible

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

All charges

All charges

All charges

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

Intensive outpatient treatment is equal to 60 consecutive days and 60 consecutive equals one admission, confinement or episode of care.  One copay will apply per 60 days or episode of care.

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.

$150 copay per visit

30% coinsurance/$2,000 Max per surgery

Deductible applies

30% coinsurance 

Subject to deductible

Not covered:  Blood and blood derivatives not replaced by the member

All charges

All charges

All charges

Skilled nursing facility (SNF): 60 days per member per Calendar year

Note: We cover room and board and other necessary services that you require and a SNF provides.  The Plan must preauthorize the services that your Plan physician recommends

$100/day copay per admission up to 5 days (included in hospital/facility inpatient admission copay)

30% coinsurance

Deductible applies

30% coinsurance 

Subject to deductible

All charges

All charges

All charges 

The following services are covered for in-patient and in-home hospice benefits

• Inpatient hospice care
• Physician visits by plan hospice physicians
• Home health care by approved home health care personnel
• Physical therapy
• Medical supplies
• Drugs and medication for the terminally ill patient
• Respite care for a period not to exceed five continuous days for every 60 days of hospice care. Only two respite cares are available during a hospice benefit period

Notes: - Benefits are provided for in a Plan hospice or facility approved by the plan physician and preauthorized by the plan.

The hospice benefit period must begin while you are covered with this benefit, and coverage through the plan must be continued throughout the benefit period in order for hospice benefits to continue.

The hospice benefits period is defined as:

Beginning on the date the plan physician certifies that you are terminally ill with a life expectancy of six months or less; and ending six months after it began, or upon death.

If you require an extension of the hospice benefit period, the hospice must provide a new treatment plan and the plan physician must recertify your medical condition to us. No more than one additional hospice benefit period will be preauthorized by us.

$100/day copay per admission up to 5 days (included in hospital/facility inpatient admission copay)

30% coinsurance

Deductible applies

30% coinsurance 

Subject to deductible

Not covered:

• Food, housing and delivered meals
• Volunteer services
• Comfort items
• Homemaker and housekeeping services
• Private duty nursing
• Pastoral and spiritual counseling and
• Bereavement counseling

All charges

All charges 

Local professional ambulance service when medically appropriate

$50 copay per occurrence

$50 copay per occurrence

30% coinsurance, Subject to deductible

Ground Ambulance

$50 copay per occurrence

$50 copay per occurrence

30% coinsurance, Subject to deductible

Air ambulance

$100 copay per occurrence

$100 copay per occurrence

30% coinsurance, Subject to deductible

• Emergency care at a doctor’s office

$25 copay per visit to primary care physician

$0 copay per visit to primary care physician for children up to age 26

$40 copay per visit to specialist

$20 copay per visit to specialist for children up to age 26 

$30 copay per visit to primary care physician

$40 copay per visit to specialist, No deductible

$200 copay per visit, No deductible

$300 copay for the first 2 visits, No deductible

Subsequent visits: 30% coinsurance, Subject to deductible

• Emergency care at an urgent care center

$40 copay per visit

$40 copay per visit

No deductible

$40 copay per visit

No deductible

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

$150 copay per visit

$200 copay per visit, No deductible

If admitted to a hospital, then deductible and coinsurance will apply

$300 per visit for the first 2 visits, No deductible applies

30% coinsurance, thereafter, Subject to deductible 

Not covered: Elective care or non-emergency care

All charges

All charges

All charges 

• Emergency care at a doctor’s office

$25 copay per visit to primary care physician

$0 copay per visit to primary care physician for children up to age 26

$40 copay per visit to specialist

$20 copay per visit to specialist for children up to age 26 

$30 copay per visit to primary care physician

$40 copay per visit to specialist

No deductible

30% coinsurance, Subject to deductible

• Emergency care at an urgent care center

$40 copay per visit

$20 copay per visit for children up to age 26

$40 copay per visit

No deductible

$40 copay per visit

No deductible 

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

$150 copay per visit

$200 copay per visit, No deductible

If admitted to a hospital, then deductible and coinsurance will apply

$300 per visit for the first 2 visits, No deductible applies

30% coinsurance, thereafter, Subject to deductible 

Not covered:

• Elective care or non-emergency care
• Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
• Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

All charges

All charges

All charges

Professional ambulance service when medically appropriate.

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

$50 copay per occurrence

$50 copay per occurrence

30% coinsurance, Subject to deductible

• Ground ambulance

$50 copay per occurrence

$50 copay per occurrence, No deductible

30% coinsurance, Subject to deductible

• Air ambulance

$100 copay per occurrence

$100 copay per occurrence, No deductible

30% coinsurance, Subject to deductible

Inter-Facility Transfer:

• Ground Ambulance

Nothing

No deductible

30% coinsurance, Subject to deductible

• Air Ambulance

$100 copay per occurrence

$100 copay per occurrence, No deductible

30% coinsurance, Subject to deductible

All charges

All charges

All charges

Your cost sharing responsibilities are not greater than for other illnesses or conditions.  

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

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

$25 copay per visit

$0 copay per office visit for children up to age 26

$30 copay per visit

No deductible

First 4 visits: $20 copay, Not subject to deductible 

Subsequent visits 30% coinsurance, Subject to the deductible 

Applied Behavioral Analysis (ABA)

Diagnosis and treatment for all children up to age 26

$0 copay per visit

$0 copay per visit

No deductible

30% coinsurance

Subject to deductible 

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

Nothing if received during the office visit or inpatient hospital admission; otherwise applicable physician visit copay

Nothing if received during the office visit or inpatient hospital admission; otherwise applicable physician visit copay

No deductible

30% coinsurance

Subject to deductible

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

$100/day copay per admission up to 5 days

30% coinsurance/$2,000 Max per admission, Deductible applies

30% coinsurance, Subject to deductible

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

• Services in approved treatment programs, such as partial hospitalization, half-way house, residential treatment center, full-day hospitalization, or facility-based intensive outpatient treatment.

Intensive outpatient treatment is equal to 60 consecutive days and 60 consecutive equals one admission, confinement or episode of care.  One copay will apply per 60 days or episode of care.

$150 copay per visit

30% coinsurance/$2,000 Max per event, Deductible applies

30% coinsurance

Subject to deductible

Tobacco and nicotine cessation medications that require a prescription by Federal Law.  Quantity limits apply maximum of two 90-day regimens.

$0 copay

$0 copay

$0 copay

Over the counter (OTC) Tobacco and Nicotine Cessation

Products covered if prescribed by a plan doctor in conjunction with the Plan's Tobacco  and Nicotine Cessation Program.  Quantity limits apply maximum of two 90-day regimens.

$0 copay

$0 copay

$0 copay

We cover the following medications and supplies on the Preferred drug list when prescribed by a Plan physician and obtained from a network pharmacy or through our mail order program:

• Drugs and medications that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered
• Insulin
• Diabetic supplies limited to: 
• Disposable needles and syringes for the administration of covered medications
• Drugs for sexual dysfunction
• Drugs to treat gender dysphoria (GNRH Analogs and Cross-Sex hormones)
  • Preferred formulary agents - Testosterone, Lupron, Lupron Depot - Prior Authorization is required

Retail

Tier 0 - Maintenance Medication category to include medications and supplies used to treat diabetes, opioid overdose, and asthma.

$0 copay per 30 day supply up to the maximum dosing recommended by the manufacturer or FDA maximum recommended dosage.

Tier 1 - Preferred Generic Drugs

$10 copay per 30-day supply up to the maximum dosing recommended by the manufacturer or FDA maximum recommended dosage

Tier 2 - Preferred Brand Drugs

$75 copay per

30-day supply up to the maximum dosing recommended by the manufacturer or FDA maximum recommended dosage

Tier 3 - Non-Preferred Drugs

$80 copay per 30-day supply up to the maximum dosing recommended by the manufacturer or FDA maximum recommended dosage

Tier 4 - Specialty Pharmaceuticals

50% of plan allowance up to a maximum out-of-pocket of $400 per prescription

Mail order

Tier 0 - Maintenance Medication (for certain chronic conditions). For more information, see Maintenance Medications note on page 71.

2 copays per 90 day supply up to the maximum dosing recommended by the manufacturer or FDA maximum recommended dosage.

Tier 1 - Preferred Generic Drugs

$20 copay per 90-day supply up to the maximum dosing recommended by the manufacturer or FDA maximum recommended dosage

Tier 2 - Preferred Brand Drugs

$100 copay per 90-day supply up to the maximum dosing recommended by the manufacturer or FDA maximum recommended dosage

Tier 3 - Non-Preferred Drugs

$150 copay per 90-day supply up to the maximum dosing recommended by the manufacturer or FDA maximum recommended dosage

Tier 4 - Specialty Pharmaceuticals

Not available for Mail order

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

Retail

Tier 0 - Maintenance Medication category to include medications and supplies used to treat diabetes, opioid overdose, and asthma.

$0 copay per 30 day supply up to the maximum dosing recommended by the manufacturer or FDA maximum recommended dosage.

Tier 1 - Preferred Generic Drugs

$10 copay per 30-day supply up to the maximum dosing recommended by the manufacturer or FDA maximum recommended dosage

Tier 2 - Preferred Brand Drugs

$50 copay per 30-day supply up to the maximum dosing recommended by the manufacturer or FDA maximum recommended dosage

Tier 3 - Non-Preferred Drugs

$80 copay per 30-day supply up to the maximum dosing recommended by the manufacturer or FDA maximum recommended dosage

Tier 4 - Specialty Pharmaceuticals

50% of plan allowance up to a maximum out-of-pocket of $400 per prescription

Mail order

Tier 0 - Maintenance Medication (for certain chronic conditions). For more information, see Maintenance Medications note on page 71.

2 copays per 90 day supply up to the maximum dosing recommended by the manufacturer or FDA maximum recommended dosage.

Tier 1 - Preferred Generic Drugs

$20 copay per 90-day supply up to the maximum dosing recommended by the manufacturer or FDA maximum recommended dosage

Tier 2 - Preferred Brand Drugs

$100 copay per 90-day supply up to the maximum dosing recommended by the manufacturer or FDA maximum recommended dosage

Tier 3 - Non-Preferred Drugs

$150 copay per 90-day supply up to the maximum dosing recommended by the manufacturer or FDA maximum recommended dosage

Tier 4 - Specialty Pharmaceuticals

Not available for Mail order

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

Retail

Tier 0 - Maintenance Medication category to include medications and supplies used to treat diabetes, opioid overdose, and asthma.

$0 copay per 30 day supply up to the maximum dosing recommended by the manufacturer or FDA maximum recommended dosage.

Tier 1 - Preferred Generic Drugs

$10 copay per 30-day supply up to the maximum dosing recommended by the manufacturer or FDA maximum recommended dosage

Tier 2 - Preferred Brand Drugs

$50 copay per 30-day supply up to the maximum dosing recommended by the manufacturer or FDA maximum recommended dosage

Tier 3 - Non-Preferred Drugs

$80 copay per 30-day supply up to the maximum dosing recommended by the manufacturer or FDA maximum recommended dosage

Tier 4 - Specialty Pharmaceuticals

50% of plan allowance up to a maximum out-of-pocket of $400 per prescription

Mail order

Tier 0 - Maintenance Medication (for certain chronic conditions). For more information, see Maintenance Medications note on page 71.

2 copays per 90 day supply up to the maximum dosing recommended by the manufacturer or FDA maximum recommended dosage.

Tier 1 - Preferred Generic Drugs

$20 copay per 90-day supply up to the maximum dosing recommended by the manufacturer or FDA maximum recommended dosage

Tier 2 - Preferred Brand Drugs

$100 copay per 90-day supply up to the maximum dosing recommended by the manufacturer or FDA maximum recommended dosage

Tier 3 - Non-Preferred Drugs

$150 copay per 90-day supply up to the maximum dosing recommended by the manufacturer or FDA maximum recommended dosage

Tier 4 - Specialty Pharmaceuticals

Not available for Mail order

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

Note:

Maintenance Medications are used for the management and prevention of complications from conditions such as high blood pressure, high cholesterol, diabetes, opioid overdose and asthma. For a full list of Maintenance Medications, please visit  www.phs.org/fehb.

Specialty Pharmaceuticals are self-administered, meaning they are administered by the patient, a family member or care-giver.  Specialty Pharmaceuticals are often used to treat complex chronic, rare diseases and/or life threatening conditions. Most Specialty Pharmaceuticals require Prior Authorization and must be obtained through the specialty pharmacy network.  Specialty Pharmaceuticals are often high cost, typically greater than $600 for a 30-day supply.

Some specialty medications may qualify for third-party copay assistance is used, the Member shall not receive credit toward their maximum out-of-pocket or deductible for any copay or coinsurance amounts that are applied to a manufacturer coupon or rebate.  

Specialty Pharmaceuticals are not available through the mail order option and are limited to a 30-day supply.  Certain Specialty Pharmaceuticals are limited to an initial fill, up to a 14-day supply to ensure patients can tolerate the new medication.

The medications listed on the formulary are subject to change pursuant to the management activities of Presbyterian Health Plan. For a complete list of Specialty Pharmaceuticals and to determine which require Prior Authorization, please see the Presbyterian Pharmacy website at: www.phs.org/fehb (Prescription Drug Benefit).

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

Contraceptive coverage is available at no cot 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.

Methods of preferred generic oral contraceptives, injectable contraceptives or contraceptive devices.  For a complete list of these preferred products and exceptions please see the Presbyterian Pharmacy website at www.phs.org/fehb.

An emergency contraceptive is covered over-the-counter (OTC) at no cost if prescribed by a physician and purchased at a network pharmacy. Reimbursement for over-the-counter contraceptives can be submitted by downloading the Member Medical and Pharmacy Claim Form which can be found at www.phs.org/fehb

$0 copay

$0 copay

$0 copay

• Oral fertility drugs

50% of plan allowance

50% of plan allowance

50% of plan allowance

• Special Medical Foods are covered when prescribed by a physician for treatment for Genetic Inborn Errors of Metabolism, when used in treatment to compensate for the metabolic abnormality and to maintain adequate nutritional status, when you are under the physician’s ongoing care and when preauthorized by Us.

30% of plan allowance

30% of plan allowance

30% of plan allowance

Not covered 

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Fertility drugs
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies 
• Nonprescription medications unless specifically indicated elsewhere

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation program benefits. (see page 66)

Preventive medications to promote better health as recommended by Affordable Care Act (ACA).

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

• Aspirin (81 mg) for men age 45-79 and women age 55-79 and women of childbearing age
• Folic acid supplements for women of childbearing age 400 & 800 mcg
• Liquid iron supplements for children age 0-1 year
• Fluoride tablets, solution (not toothpaste, rinses) for children age 0-6
• Anti-cholesterol agents "statins"
• Bowel preparations for members age 50 years or older.
• Naloxone injectable with nasal atomizer.

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

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

Nothing

Nothing

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Drugs obtained at a non-network pharmacy; except for out-of-area emergencies
• Vitamins, nutrients and food supplements not listed as a covered benefit, even if a physician prescribes or administers them
• Replacement prescriptions resulting  from loss, theft, or destruction
• Drugs from which there is a nonprescription equivalent available
• Medical supplies such as dressings and antiseptics
• Nonprescription medications
• Drugs for which prior approval has been denied or not obtained
• Special Medical Foods are not for use by the general public and may not be available in stores or supermarkets.  Special Medical Foods are not those foods included in a health diet intended to decrease the risk of disease, such as reduced-fat foods, low sodium foods, or weight loss products.  Special Medical Foods are not covered for conditions that are not present at birth.
• Bulk powders
• Drugs that have not been approved by the FDA.
• Injectable fertility drugs, including those provided in a physician's office.
• Discount cards or Prescription Drug Savings cards to not apply to Deductible or Out-of-pocket maximums.
• Herbal or alternative medicine and holistic supplements.
• Vaccinations, drugs and immunizations for the primary intent of medical research or Non-Medically Necessary purpose(s) such as, but not limited to, licensing, certification, employment, insurance or functional capacity examinations related to employment.
• Immunizations for the purpose of foreign travel, flight and or passports.
• Bioidentical hormone replacement therapy (BHRT), also known as bioidentical hormone therapy or natural hormone therapy including "all-natural" pills, creams, lotions and gels.
• Prescription Drugs/Medications that are identified by Drug Efficacy Study Implementation (DESI) as Less than Effective LTE drugs are Not Covered.
• Nutritional supplements as prescribed by the attending Practitioner/Provider or as sole source of nutrition are Not Covered.
• Infant formula is Not Covered.
• Drugs and supplied for cosmetic purposes
• Drugs to enhance athletic performance
• Fertility drugs
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
• Nonprescripton medications medicines

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation program benefits. (See page 66).

All Charges

All Charges

All Charges

$25 copay per visit to primary care physician

$40 copay per visit to specialist

$30 copay per visit to primary care physician

$40 copay per visit to specialist

30% coinsurance  

Subject to deductible

Dental benefits (Limited)

Limited dental services will be provided.  Services include, but are not limited to, the following:

• Oral surgery medically necessary to treat infections or abscess of the teeth that involve the fascia or have spread beyond the dental space.
• Removal of infected teeth in preparation for certain surgeries or radiation therapy of the head and neck.

Temporomandibular Joint Disorders (TMJ)

The treatment of Temporomanidibular Joint disorders (TMJ) are subject to the same conditions and limitations as are applicable to treatment of any other joint in the body.  Orthodontics are not covered unless the TMJ disorder is the result of an injury.  (See also Oral and Maxillofacial surgery Section 5(a).

$25 copay per visit to primary care physician

$40 copay per visit to specialist

$30 copay per visit to primary care physician

$40 copay per visit to specialist

30% coinsurance, Subject to deductible 

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

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

For any of your health concerns, 24 hours a day, 7 days a week, you may call 505-923-5570 or toll-free at 866-221-9679. and talk with a registered nurse who will discuss treatment options and answer your health questions. For the hearing impaired, call our TTY line at 711 or 800-659-8331. The PresRN Line is confidential. You will be asked to provide some basic information to ensure that you are part of the Presbyterian Health Plan. There is no limit to the number of calls you can make.

Contact our Customer Service Center at 711 or toll-free at 800-659-8331.

• PRESious Beginnings is a statewide program that determines high-risk pregnancies and offers care management, literature and use of videos. Peri-Natal nurses are available for questions Monday through Friday 8:30 a.m. to 5:00 p.m. to assist with high-risk pregnancy questions. For additional information, call 505-724-6500
• Doula services are available for Members who deliver at Presbyterian Hospital. For more information, call 505-724-6500.

One preventive vision exam per year for adults and children and no charge on the High Option only. Discounts also available.  Please visit Presbyterian Vision administered by Versant Health under the Davis Vision Network at www.davisvision.com for further information.

Routine patient care costs that are incurred as a result of participation in a Cancer Clinical Trial in New Mexico are Covered.

Routine patient care costs mean:

• Medical services or treatment that is a benefit under this health plan that would  be Covered if the patient were receiving standard cancer treatment; or
• A drug provided to a patient during a Cancer Clinical Trial if the drug has been approved by the Federal Food and Drug Administration, whether or not that organization has approved the drug for use in treating the patient’s particular condition, but only to the extent that the drug is not paid for by the manufacturer, distributor or provider of the drug.

Routine patient care costs are Covered for Members in a Cancer Clinical Trial if:

• The Cancer Clinical Trial is undertaken for the purposes of the prevention of or the prevention of reoccurrence, early detection, or treatment of cancer for which no equally or more effective standard cancer treatment exists.
• The Cancer Clinical Trial is not designed exclusively to test toxicity or disease pathophysiology and it has a therapeutic intent.
• The Cancer Clinical Trial is being provided in New Mexico as part of a scientific study of a new therapy or intervention.
• There is not a non-Investigational treatment equivalent to the Cancer Clinical Trial.
• There is a reasonable expectation shown in clinical or pre-clinical data that the Cancer Clinical Trial will be at least as efficacious as any non-Investigational alternative.
• There is a reasonable expectation based on clinical data that the medical treatment provided in the Cancer Clinical Trial will be at least as effective as any other medical treatment.
• Pursuant to the patient informed consent, Presbyterian is not liable for damages associated with the treatment provided during any phase of a Cancer Clinical Trial.

The Clinical Trial Test must be conducted with the approval of a federal organization such as National Institutes of Health or the FDA.

• If services are not available from a Participating Provider/Practitioner, PHP will Cover services of a Non-Participating Provider/Practitioner only if the Provider/Practitioner agrees to accept PHP’s normal reimbursement for similar services, and services are provided in New Mexico.
• Any care related to the Clinical Trial Test that is investigational requires Benefit Certification by PHP. Those medical services that are not investigational such as lab and X-ray services would require Preauthorization as identified in this Section 3.

Exclusions:

• Any Cancer Clinical Trials provided outside of New Mexico as well as, those that do not meet the requirements indicated above.
• Costs of the Clinical Trial that is customarily paid for by government, biotechnical, pharmaceutical or medical device industry sources.
• Services from Non-Participating Providers/Practitioners, unless services from a Participating Provider/Practitioner are not available. Any Non-Participating services must be Preauthorized by PHP and provided for in New Mexico. The cost of a non-FDA-approved investigational drug, device or procedure.
• The cost of a non-healthcare service that the patient is required to receive as a result of participation in the Cancer Clinical Trial.
• Cost associated with managing the research that is associated with the Cancer Clinical Trial.
• Costs that would not be Covered if non-investigational treatments were provided.
• Cost of tests that are necessary for the research of the Clinical Trial.
• Costs paid or not charged for by the Cancer Clinical Trial Providers.

Video Visits is an alternative access point for members to receive care for non-urgent medical issues such as upper respiratory infections, flu, cold, cough, and allergies. For more information, please see page 26.

Members may utilize the Pharmacy Cost Calculator to look up prescriptions, determine coverage, copays, and locate participating pharmacies.  This tool can be accessed at www.phs.org/fehb.

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, contact us at 505-923-5678 or toll-free at 800-356-2219 or for the hearing impaired at 505-923-5699 or toll-free at 877-298-7407, or at our Web site at www.phs.org/fehb.

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 payer – such as the Medicare Summary Notice (MSN); and
• Receipts, if you paid for your services.
• For emergency or urgent care services outside the United States you are responsible for ensuring that claims are appropriately translated and that the monetary exchange, on the date of service, is clearly identified when submitting claims.

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

Submit your claims to: 

Presbyterian Health Plan
P.O. Box 27489
Albuquerque, NM 87125-7489

If a charge is made to you for covered pharmacy benefits, you must provide proof of such charge with a copy of the pharmacy receipt with the name of the drug, quantity dispensed, and National Drug Code (NDC) number.  Any charge shall be paid only upon receipt of proof satisfactory to the Plan of the occurrence, character and extent of the event and services for which claim is made.

Submit your claims to:

Presbyterian Health Plan
Attn: Pharmacy
P.O. Box 27489
Albuquerque , NM 87125-7489

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

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

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

You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us.  For urgent care claims, 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 telephone customer assistance) and help with filing claims and appeals (including external reviews) in the applicable non-English language.  The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

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

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

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

b) Send your request to us at: P.O. Box 27489 Albuquerque, NM 87125-7489 ; and

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

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

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

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

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

a) Pay the claim; or  

b) Write to you and maintain our denial; or

c) Ask you or your provider for more information.

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

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

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

You must write to OPM within:

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

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

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
• Copies of documents that support your claim, such as physician’s 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 the 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 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 payer and the other plan pays a reduced benefit as the secondary payer. 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.phs.org/fehb.

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

When we are the secondary payer, 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. We follow the NAIC guidelines regarding Coordination of Benefits. 

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

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

Every job-related injury or illness should be reported as soon as possible to your supervisor.  Injury also means any illness or disease that is caused or aggravated by the employment as well as damage to medical braces, artificial limbs and other prosthetic devices.  If you are a federal or portal 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 corm CA-16 and form OWCP-1500/HCFA=1500 to your provider, or sent 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 similar federal or state agency determines they much provider; or
• OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws. 

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

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

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

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

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

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

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

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

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

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

An approved clinical trial includes a phase I, phase II, phase III or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug 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 – cost related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not part of the patient’s routine care.  (a) This plan covers some of these costs, providing the plan determines the services are medically necessary.  For more specific information see page 93.  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 clinical trials.  This plan does not cover these costs.

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

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

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

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

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

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

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. You will not need to do anything. To find out if you need to do something to file your claim, call us at 800-356-2219 or see our Website at www.phs.org/fehb.

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.

We do not waive any costs if the Original Medicare Plan is your Primary Payor.

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

Benefit Description: Deductible
High Option You Pay Without Medicare: $0
High Option You Pay With Medicare Part B: $0
Standard Option You Pay Without Medicare: $500 self only/$1,000 family
Standard Option You Pay With Medicare Part B: $500 self only/$1,000 family
Wellness Option You Pay Without Medicare:  $2,000
Wellness Option You Pay With Medicare Part B: $2,000

Benefit Description: Out-of-Pocket Maximum
High Option You Pay Without Medicare: $6,350 self only/$12,700 family
High Option You Pay With Medicare Part B: $6,350 self only/$12,700 family
Standard Option You Pay Without Medicare: $6,350 self only/$12,700 family
Standard Option You Pay With Medicare Part B: $6,350 self only/$12,700 family
Wellness Option You Pay Without Medicare: $8,150 self only/ $16,300 family
Wellness Option You Pay With Medicare Part B:  $8,150 self only/ $16,300 family

Benefit Description: Part B Reimbursement Offered
High Option You Pay Without Medicare: N/A
High Option You Pay With Medicare Part B: N/A
Standard Option You Pay Without Medicare: N/A
Standard Option You Pay With Medicare Part B: N/A
Wellness Option You Pay Without Medicare: N/A
Wellness Option You Pay With Medicare Part B: N/A

Benefit Description: Primary Care Physician
High Option You Pay Without Medicare: $25
High Option You Pay With Medicare Part B: $0
Standard Option You Pay Without Medicare: $30 copay
Standard Option You Pay With Medicare Part B: $0
Wellness Option You Pay Without Medicare: First 4 visits: $20 copay, subsequent visits 30% coinsurance
Wellness Option You Pay With Medicare Part B: $0

Benefit Description: Specialist
High Option You Pay Without Medicare: $40
High Option You Pay With Medicare Part B: $0
Standard Option You Pay Without Medicare: $40 copay
Standard Option You Pay With Medicare Part B: $0
Wellness Option You Pay Without Medicare: $40 copay
Wellness Option You Pay With Medicare Part B: $0

Benefit Description: Inpatient Hospital
High Option You Pay Without Medicare: $100 copay/day, $500 copay maximum
High Option You Pay With Medicare Part B: $0
Standard Option You Pay Without Medicare: 30% Coinsurance, Subject to Deductible, $2,000 max per admission
Standard Option You Pay With Medicare Part B: $0
Wellness Option You Pay Without Medicare:  30% coinsurance
Wellness Option You Pay With Medicare Parts B: $0

Benefit Description: Outpatient Hospital
High Option You Pay Without Medicare: $200 copay
High Option You Pay With Medicare Part B: $0
Standard Option You Pay Without Medicare: 30% Coinsurance, Subject to Deductible, $2,000 max per admission
Standard Option You Pay With Medicare Part B: $0
Wellness Option You Pay Without Medicare:  30% coinsurance
Wellness Option You Pay With Medicare Part B: $0

Benefit Description: Incentives Offered
High Option You Pay Without Medicare: N/A
High Option You Pay With Medicare Part B: N/A
Standard Option You Pay Without Medicare: N/A
Standard Option You Pay With Medicare Part B: N/A
Wellness Option You Pay Without Medicare: N/A
Wellness Option You Pay With Medicare Part B: N/A

You can find more information about how our plan coordinates benefits with Medicare in Presbyterian Health Plan at www.phs.org/fehb

You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask.  You must also tell us about other coverage you or your covered family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare.

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (1-800-633-4227) 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: You may enroll in the Presbyterian Senior Care Medicare Advantage Plan for FEHBP and also remain enrolled in the Presbyterian Health Plan’s FEHBP Commercial Plan. The Presbyterian Senior Care Medicare Advantage Plan will be primary and the Presbyterian Health Plan’s FEHBP Commercial plan will have coverage for prescription drugs. So, if you are enrolled in Medicare Part D, the Presbyterian Health Plan FEHBP Commercial plan will coordinate your prescription drug coverage with Medicare Part D. You must select a primary care provider from the Presbyterian Senior Care Plan, however, referrals are not required for network specialists, except for: Podiatry; Otolaryngology (Ear, Nose, and Throat); Occupational, Physical and Speech/Language Therapies. Presbyterian Senior Care and Presbyterian Health Plan’s FEHBP Commercial plan will coordinate your medical benefits.

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

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

When we are the primary payor, we process the claim first.  If you enroll in Medicare Part D and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan. 

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

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

See Section 4, page 21.

See Section 4, page 21.

See Section 4, page 21.

A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. See Section 4, page 21.

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

Plan allowance means the maximum dollar amount that an insurer will consider reimbursing for a covered service or procedure. This dollar amount may not be the amount ultimately paid to the provider as it  may be reduced by the co-insurance, deductible or amount beyond the annual maximum.

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 Surprise Act.

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

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

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

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

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Center at 505-923-5678 or 800-356-2219 or TTY for the hearing impaired at 711 or toll-free at 800-659-8331 or by accessing our website at www.phs.org/fehb.  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.

Us and We refer to Presbyterian Health Plan. 

Office visit copay:
Primary Care Physician $25 - $0 copay per visit for children up to age 26
Specialist $40 - $20 copay per visit for children up to age 26

(Waived if nursing visit only for allergy injections, injections such as insulin, heparin, and antibiotics, preventive adult and child immunizations)

25

$100/day up to 5 days

56-57

$150

57-58

$40 urgent care center; $150 for ER visit

61

$40 urgent care center; $150 for ER visit

62-63

Regular cost sharing

$25 copay per visit

$0 copay per office visit for children up to age 26

64-65

Tier 0 - $0 Maintenance Medication (for certain chronic conditions); Mail order $0

Tier 1 - $10 Generic (Preferred) drugs; Mail order $20

Tier 2 - $75 Brand (Preferred) drugs; Mail order $100

Tier 3 - $80 non-Brand (Non-preferred) drugs; Mail order $150

Tier 4 – Specialty Pharmaceuticals

50% of the plan allowance up to a maximum out-of-pocket of $400 per prescription; Not available mail order

69-76

Limited benefit.
Applicable physician visit copay

77-78

30% of the plan allowance
Applicable physician visit copay (eye exam for children).

37-38

Flexible benefits option; Services for deaf and hearing impaired, pregnancies, Presbyterian Healthcare Services, vision, acupuncture, chiropractic, cancer clinical trials, massage therapy, meals on wheels, fitness center, vision and hearing hardware discounts.

79-81

Nothing after $6,350/Self Only or $12,700/Self Plus One and Self and Family enrollment per year

Some costs do not count toward this protection

21-22

Office visit copay:
Primary Care Physician $30
Specialist $40 

(Waived if nursing visit only for allergy injections, injections such as insulin, heparin, and antibiotics, preventive adult and child immunizations)

25

30% coinsurance* /$2,000 Max per admission
Deductible applies

56-57

30% coinsurance* /$2,000 Max per surgery
Deductible applies

57-58

$40 urgent care center; $200 for ER visit

61

$40 urgent care center; $200 for ER visit 

62-63

Regular cost sharing

$30 copay per visit

No deductible

64-65

Tier 0 - $0 Maintenance Medication (for certain chronic conditions); $0 Mail order

Tier 1 - $10 Generic (Preferred) drugs; $20 Mail order

Tier 2 -  $50 Brand (Preferred) drugs; $100 Mail order

Tier 3 - $80 non-Brand (Non-preferred) drugs; $150 Mail order

Tier 4 - Specialty Pharmaceuticals

50% of the plan allowance up to a maximum out-of-pocket of $400 per prescription, not available mail order

69-76

Limited benefit

Applicable physician visit copay

77-78

50% of the plan allowance

Applicable physician visit copay (eye exam for children).

37-38

Flexible benefits option; Services for deaf and hearing impaired, pregnancies, Presbyterian Healthcare Services, vision, acupuncture, chiropractic, cancer clinical trials, massage therapy, meals on wheels, fitness center, vision and hearing hardware discounts.

79-81

Nothing after $6,350/Self Only or $12,700/Self Plus One enrollment or Self and Family enrollment per year.

Some costs do not count toward this protection.

21-22

Office visit copay

Primary Care Physician First 4 visits: $20 copay

Subsequent visits: 30% coinsurance*

Specialist $40 copay

25

30% coinsurance*

56-57

30% coinsurance*

57-58

Urgent care $40 per visit No deductible

Emergency First 2 visits: $300 copay

No deductible 

Subsequent Visits: 30% coinsurance

Subject to deductible

61

Urgent care $40 copay

Emergency First 2 visits $300 copay

Subsequent Visits: 30% coinsurance*

62-63

Regular cost sharing

First 4 visits $20 copay

Subsequent visits 30% coinsurance*

64-65

Tier 0 - $0 Maintenance Medication (for certain Chronic conditions): Mail order $0

Tier 1 - $10 Generic (Preferred) drugs; Mail order $20

Tier 2 - $50 Brand (Preferred) drugs; Mail order $100

Tier 3 - $80 non-Brand (Non-preferred) drugs; Mail order $150

Tier 4 - Specialty Pharmaceuticals 

50% of the plan allowance up to maximum of $400 per prescription (Not subject to deductible) 

Not available mail order

69-76

Limited benefit

Applicable physician visit copayment 

77-78

30% of the plan allowance 

Applicable physician visit copay (eye exam for children). 

37-38

Flexible benefits option: Services for deaf and hearing impaired, Presbyterian Healthcare Services, vision, acupuncture, chiropractic, cancer clinical trails, massage therapy, meals on wheels, fitness center, vision and hearing hardware discounts.

79-81

Nothing after $8,150/Self Only or $16,300/Self Plus One and Self and Family enrollment per year

Some costs do not count toward this protection

21-22