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

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

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

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

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

We don’t 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 you the enrollee alone.  Self Plus One coverage is for you the enrollee and one eligible family member. Self and Family coverage is for you the enrollee and one or more eligible family members. Family members include your spouse and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office.  Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family.  You may change your enrollment 31 days before to 60 days after that event.  The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member.  When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. Benefits will not be available to your spouse until you are married. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

Contact your carrier to add a dependent 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 are enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

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

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

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

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

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

The benefits in this brochure are effective January 1.  If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1.  If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2023 benefits of your prior plan or option.  If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option.   However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2021 benefits until the effective date of your coverage with your new plan.  Annuitants’ coverage and premiums begin on January 1.  If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage (i.e., you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid.  You may be billed for services received directly from your provider.  You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums.  It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage.

AultCare Insurance Company currently holds NCQA Accreditation. Our current status is Accredited.

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.

If you are divorced from a Federal employee, or 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 for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get information about your coverage choices. You can also visit OPM's website at www.opm.gov/healthcare-insurance/healthcare/plan-information/guides. 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 FEHB Program coverage.

You may convert to a non-FEHB individual policy if:
• Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);
• You decided not to receive coverage under TCC or the spouse equity law; or
• You are not eligible for coverage under TCC or the spouse equity law.

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

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health,  a waiting period will not be imposed and your coverage will not be limited due to pre-existing conditions. When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 800-344-8858 or visit our website at www.aultcare.com.

This plan no longer offers its own non-FEHB plan for conversion purposes. If you would like to purchase health insurance through the Affordable Care Act's Health Insurance Marketplace, please visit www.HealthCare.gov. This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.

In lieu of offering a non-FEHB plan for conversion purposes, we will assist you, as we would assist you in obtaining a plan conversion policy, in obtaining health benefits coverage inside or outside the Affordable Care Act's Health Insurance Marketplace. For assistance in finding coverage, please contact us at 330-363-6360 or 800-344-8858 or visit our website at www.aultcare.com.

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

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 800-344-8858 or write to us at 2600 Sixth Street SW, Canton, OH 44710. You may also request replacement cards through our website: www.aultcare.com

HMO (High Option): You get care from “Plan providers” and “Plan facilities.” You will only pay copays, and you will not have to file claims.

HDHP Option: You will only pay deductibles and coinsurance and you will not have to file claims.

You get care from "Plan providers" and "Plan facilities."  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 physican 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 list Plan providers in the provider directory, which we update periodically. The list is also on our Website.

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

This plan provides Care Coordinators for complex conditions and can be reached at www.aultcare.com for assistance. Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The list is also on our Website.

HMO (High Option): 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 healthcare.

HDHP Option: You can get care from any “covered provider” or “covered facility.” How much we pay – and you pay – depends on the type of covered provider or facility you use. If you use our preferred providers, you will pay less.

HMO (High Option) only: Your primary care physician can be a family practitioner, internist, and pediatrician.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.

HMO (High Option): 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 obstetrician/gynecologist without a referral.

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 use our criteria when creating your treatment plan. The physician may have to get an authorization or approval 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 are 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.

HMO (High Option): 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 covered services from the effective date of your enrollment.  However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 800-344-8858. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

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

• you are discharged, not merely moved to an alternative care center;

• the day your benefits from your former Plan run out; or

• the 92^nd day after you become a member of this Plan, whichever happens first.

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

HDHP Option: We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our HDHP begins, call our Customer Service department immediately at 330-363-6360 or 800-344-8858.

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.

You must get prior approval for certain services. Failure to do so may result in a reduction of benefits.

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. 

Prior Authorization - 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.  

• Abdominoplasty / panniculectomy
• Artificial disc replacement of the lumber and cervical spine
• Artificial intervertebral disc replacement – Cervical
• Audible prescription reading devices
• Auditory brainstem implant
• Autologous chondrocyte implantation
• Blepharoplasty and related procedures
• BRCA/BART testing
• Breast reduction
• Cardiac CT, MRI
• Certain Drugs
• Certain MRIs;
• Certain radiology (X-rays) studies: (Call the AultCare Service center at 800-344-8858 or 330-363-6360 with questions)
• Certain Surgical Procedures including all non-emergency surgeries (Call the AultCare Service center at 800-344-8858 or 330-363-6360 with questions)
• Cochlear Implants
• Continuous glucose monitors
• Cranial orthosis for plagiocephaly
• CT Angiogram
• CT scans, MRI's
• Durable Medical Equipment in excess of $1,000 such as
• Endoscopic thoracic sympathectomy for treatment of hyperhidrosis
• External Defibrillators
• Gastric restrictive procedures for weight loss (Bariatric Surgery)
• Genetic/Molecular testing
• High frequency chest wall oscillation system
• Home healthcare
• Home PT / INR Monitoring devices
• Hospice Care;
• Hospital beds
• Implantable miniature telescope for end stage age related macular degeneration treatment
• Implanted hearing related devices such as Bone Anchored Hearing Aids (BAHA)
• In Utero Fetal Surgery
• Insulin pumps
• Intensive outpatient programs provided in and out of network;
• Interspinious process decompression system
• Kyphoplasty
• Laser therapy for vitiligo
• Mastopexy
• Medical Oncology 
  • Chemotherapy and related drugs paid by the medical plan
• Mental Health and Substance misuse disorder
• Non-emergent ambulance transportation
• Non-emergent surgeries
• Osteochondral allografts and auto grafts for treatment of focal articular cartilage defects of the knee
• Otoplasty
• Partial hospitalization programs provided in and out of network;
• PET CT Scans;
• Phototherapy
• Physical, occupational, speech, cognitive and growth hormone therapies;
• Pneumatic compression devices
• Potentially experimental, investigational or unproven medical services, including clinical trials
• Pressure reducing support surfaces
• Prosthetic devices including Artificial limbs and eyes
• Proton Beam Radiotherapy
• Radiation Therapy
• Radiofrequency volumetric tissue reduction
• Recombinant Human Bone Morphogenetic Protein -2 and Protein-7
• Reconstructive or cosmetic procedures
• Rehabilitation facility admissions;
• Rhinoplasty
• Scoliosis surgeries
• Sclerotherapy
• Septoplasty
• Skilled nursing facility admissions;
• Specialty Medications
• Speech generating devices
• Spinal Cord Stimulator
• Strabismus surgery if > 11 years of age
• Stress Testing 
  • Myocardial Perfusion Imaging (SPECT and PET)
• Stress Echocardiography
• Surgical repair of pectus deformities
• Surgical treatment for gynecomastia
• TMJ surgery
• Total ankle replacement
• Total joint replacements
• Trans catheter valve replacement/implantation
• Transcranial magnetic stimulation for treatment of depression
• Transgender Services
• Transplants
• Unicondylar knee replacements
• UPPP (Uvulopalatopharyngoplasty)
• Uvulectomy
• Vertebroplasty – Thoracic and Lumbar
• Wheel Chairs

HMO (High Option): Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice. Call 800-344-8858 or 330-363-6360. Failure to obtain prior authorization may result in a claim denial. See Precertification process above.

HDHP Option:The process known as pre-certification is an evaluation of your medical case by your provider and AultCare medical professionals to determine the appropriateness of your Hospital admission and expected length of stay. In some cases, an alternative to Hospital admission, such as outpatient treatment, may be recommended.

If your medical professional is an AultCare Provider, the pre-certification process will be handled for you by your provider when required. You are only responsible for alerting your provider that you are an AultCare participant. However, if your medical professional is not an AultCare Provider, you are responsible for seeing that utilization review procedures are followed. Contact the Utilization Review Department or the Service Center at 330-363-6360 or 800-344-8858. The Utilization Review Department will handle pre-certification and tell you if a second opinion is necessary for the procedure being done and encourages out patient surgery when medically necessary.

Depending on the circumstances and time constraints of your situation, you may be asked to have a form completed. When possible, utilization requirements will be met with a simple phone call by the Utilization Review Department to your Doctor. If you do not receive confirmation please call us at 800-344-8858 or 330-363-6360.

Failure to meet pre-certification requirements for Non-Panel Hospital admissions will result in a reduction of benefits.

First, your physician, your hospital, you, or your representative, must call us at 330-363-6360 or 800-344-8858 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

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

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

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

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

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

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

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 800-344-8858. You may also call OPM's Health Insurance 3 at (202)606-0755 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at 800-344-8858. 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 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 approval time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

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

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.

What happens when you do not follow the precertification rules when using non-network facilities

Upon occasion, it may be necessary for your AultCare Provider to refer you to a Physician outside the AultCare Network. In order for you to receive the greatest benefit possible from your AultCare Plan, the following procedure must be followed:

Your AultCare Provider must contact the pre-admission coordinator at the AultCare Utilization Management Department to explain the circumstances of the referral. This can be done by phone or by completing a referral form available to the Physician.

The completed referral request will be reviewed by the AultCare Medical Director. You and your Physician will be contacted directly as to whether the referral has been approved. If you do not receive written confirmation of your referral, please contact the AultCare Utilization Management Department at 330-363-6360 or 800-344-8858 prior to your appointment at the Non-AultCare Provider. When a referral is approved, benefits will be payable as outlined for other AultCare Providers, subject to UCR limitation.

When a referral is not approved, or the above procedure is not followed, benefits are payable as outlined for other Non-AultCare Providers.

Case Management: The goal of AultCare's Medical Case Management is managing the high cost of catastrophic illnesses while maintaining quality of care. Case management is used to describe a number of different approaches to planning, coordinating, providing and financing medical care. Case Management requires the simultaneous cooperation of AultCare, the Physician, the patient, and the patient's family. Telephonic follow up is provided to create and evaluate a goal oriented treatment plan. The focus of case management can include, but is not limited to, chronic disease states such as diabetes, COPD, or CHF, complex or catastrophic cases. Medical Case Management programs develop an individual plan designed to coordinate and mobilize healthcare resources to address specific medical problems and patient needs. The result should be a claim savings through effective medical management.

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 800-344-8858 or 330-363-6360.

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 and an extension of time to render our decision.

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 of the information was due.  We will base our decision on the information we already have.  We will write to you with our decision.

    3.    Write to you and maintain our denial.

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

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

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

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

HMO (High Option): A copay is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services.

Example: When you see your primary care physician, you pay a copay of $30 per office visit, and $40 per office visit for specialty care physicians.

HDHP Option: See coinsurance below.

HMO (High Option): There is no deductible under the HMO.

HDHP Option: A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them.

If you use PPO providers, the calendar year deductible is $2,000 for Self Only. Under a Self Plus One or Self and Family enrollment, the deductible is satisfied for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $4,000. If you use non-PPO providers, your calendar year deductible increases to a maximum of $4,000 for Self Only and $8,000 for Self Plus One or Self and Family.

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

And, if you change from Self and Family to Self Only, or from Self Only to Self and Family during the year, we will credit the amount of covered expenses already applied toward the deductible of your old enrollment to the deductible of your new enrollment.

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

HMO (High Option): See copay above.

HDHP 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: You pay 20% of our allowance for a Preferred Provider

Note: If your provider routinely waives (does not require you to pay) your copays, deductibles, or coinsurance, the provider is misstating the fee and may be violating the law. In this case, when we calculate our share, we will reduce the provider’s fee by the amount waived.

For example, if your physician ordinarily charges $100 for a service but routinely waives your 20% coinsurance, the actual charge is $80. We will pay $64 (80% of the actual charge of $80).

In-network providers agree to limit what they will bill you. Because of that, when you use a network provider, your share of covered charges consists of your copays (HMO High Option) or your deductible and coinsurance (HDHP Option).

HDHP Option: Here is an example about coinsurance: You see a network physician who charges $150, but our allowance is $100. If you have met your deductible, you are only responsible for your coinsurance. That is, you pay just – 20% of our $100 allowance ($20). Because of the agreement, your network physician will not bill you for the $50 difference between our allowance and his bill.

Out-of-network providers have no agreement to limit what they will bill you. When you use an out-of-network provider, you will pay your deductible and coinsurance – plus any difference between our allowance and charges on the bill. Here is an example: You see an out-of-network physician who charges $150 and our allowance is again $100. Because you’ve met your deductible, you are responsible for your coinsurance, so you pay 40% of our $100 allowance ($40). Plus, because there is no agreement between the out-of-network physician and us, the physician can bill you for the $50 difference between our allowance and his bill.

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.

HMO (High Option): After your out-of-pocket expenses, including any applicable deductibles, copays and coinsurance total $6,850 for Self Only, or $13,700 for a Self Plus One or Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. The maximum annual limitation on cost sharing listed under Self Only of $6,850 applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

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

Example Scenario: Your plan has a $6,850 Self Only maximum out-of-pocket limit and a $13,700 Self Plus One or Self and Family maximum out-of-pocket limit. If you or one of your eligible family members has out-of-pocket qualified medical expenses of $6,850 or more for the calendar year, any remaining qualified medical expenses for that individual will be covered fully by your health plan. With a Self and Family enrollment out-of-pocket maximum of $13,700, a second family member, or an aggregate of other eligible family members, will continue to accrue out-of-pocket qualified medical expenses up to a maximum of $6,850 for the calendar year before their qualified medical expenses will begin to be covered in full.

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

•  Expenses in excess of our allowance or maximum benefit limitations
•  Any amounts you pay because benefits have been reduced for non-compliance with this Plan's cost   containment requirements.
•  Expenses in excess of Plan maximums

HDHP PPO benefit: Your out-of-pocket maximum is $4,000 for a Self Only and $8,000 for Self Plus One and Self and Family enrollment if you are using PPO providers. Only eligible expenses for PPO providers count toward this limit.

Non-PPO benefit (Non-participating providers): Your out-of-pocket maximum is $8,000 for a Self Only and $16,000 for a Self Plus One and Self and Family enrollment if you are using Non-PPO providers. Eligible expenses for network providers also count toward this limit. Your eligible out-of-pocket expenses will not exceed this amount whether or not you use network providers.

HDHP Option: After your out-of-pocket expenses, including any applicable deductibles, copays and coinsurance total $4,000 for Self Only, or $8,000 for a Self Plus One or Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. The maximum annual limitation on cost sharing listed under Self Only of $4,000 applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

Example Scenario: Your plan has a $4,000 Self Only maximum out-of-pocket limit and a $8,000 Self Plus One or Self and Family maximum out-of-pocket limit.   If you or one of your eligible family members has out-of-pocket qualified medical expenses of $4,000 or more for the calendar year, any remaining qualified medical expenses for that individual will be covered fully by your health plan. With a Self and Family enrollment out-of-pocket maximum of $8,000, a second family member, or an aggregate of other eligible family members, will continue to accrue out-of-pocket qualified medical expenses up to a maximum of $4,000 for the calendar year before their qualified medical expenses will begin to be covered in full.

Out-of-pocket expenses for the purposes of this benefit are:

• The 20% you pay for PPO Inpatient hospital charges, Surgical, Maternity and Diagnostic and treatment services

• The 40% you pay for non-PPO Inpatient hospital charges, Surgical, Maternity and Diagnostic and treatment services; and

The following cannot be included in the accumulation of out-of-pocket expenses:

• Expenses in excess of our allowance or maximum benefit limitations

• Any amounts you pay because benefits have been reduced for non-compliance with this Plan's cost containment requirements.

• Expenses in excess of Plan maximums

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

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 f your new option.

Facilities of the Department of Veterans Affairs, the Department of Defense, and the Indian Health Service are entitled to seek 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 to pay 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 Ohio.

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.aultcare.com or contact the health plan at.

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

Professional services of physicians

• In physician’s office
• Office medical consultations
• Second surgical opinion

$30 copay per office visit for Primary Care Physicians

$40 copay per office visit for Specialty Care Physicians

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap tests
• Pathology
• X-ray
• Non-routine Mammogram
• CT Scan
• MRI
• Ultrasound
• Electrocardiogram and EEG
• BRCA/BART testing - Prior approval is required, Page 21
• Genetic/Molecular testing - Prior approval is required, Page 86

• Nothing if you receive these services during your office visit
• See Section 5 (c) for any Facility related charges for these services

Routine physical every 12 months.

*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 please visit the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder

Routine mammogram

• Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.
• Hearing examinations and testing for ages 18 and over

Note: Any procedure, injection, diagnostic service, laboratory, or Xray 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.

Nothing

Nothing

Not covered:

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

• Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
• Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html
• You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org

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.

Complete maternity (obstetrical) care, such as:

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

Note: Here are some things to keep in mind:

• You do not need to precertify your vaginal delivery; see below 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 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.
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

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

Nothing for prenatal care or the first postpartum care visit; $30 per office visit for all postpartum care visits thereafter.

Inpatient benefit $150 copay per day up to a maximum of $600 per admission.

Contraceptive counseling on an annual basis

 A range of voluntary family planning services, limited to:

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

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

Nothing

Voluntary sterilization (See Surgical Procedures Section 5 (b)

$10 per office visit

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling
• Elective abortion

Diagnosis and treatment of infertility such as:

• Artificial insemination:
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)
• Fertility drugs - injectable and oral fertility drugs under Rx benefit

Fertility Preservation - to help mitigate the risk of infertility in members undergoing medical therapies prescribed by their providers and likely to result in infertility. Examples of treatment related to the potential risk of infertility include cancer, treatment of rheumatological or other medical conditions with cytotoxic therapies, or surgical or radiation therapies where there is a risk of impairment to the ovaries or testicles.

Covered Services include:

• Cryopreservation of gametes (eggs) for a period of one year while the member is undergoing treatment for the related condition
• Embryo cryopreservation for a period of one year while the member is undergoing treatment for the related condition Radiation shielding
• Ovarian transposition (oophoropexy)
• Surgical removal of the cervix
• Sperm cryopreservation for a period of one vear

Medications are not covered under this benefit. This benefit falls under Infertility Services and requires preauthorization. If a member leaves the Plan prior to the completion of these services, their coverage will be terminated, and preservation costs become the immediate responsibility of the member.

$40 per office visit

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

• Testing and treatment
• Allergy injections
• Allergy serum

Nothing

Not covered:

• Provocative food testing
• Sublingual allergy desensitization

• Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 38.

• Respiratory and inhalation therapy
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy
• Growth hormone therapy (GHT)
• Applied Behavior Analysis (ABA) – Children with autism spectrum disorder

Note: – We only cover GHT when we preauthorize the treatment. Call 800-344-8858 for preauthorization. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date you submit the information. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

$40 per office visit

60 visits per year, per service for each of the following:

• Qualified physical therapists
• Occupational therapists

Note: We only cover therapy when a provider:

• orders the care

Cardiac rehabilitation following a qualifying event is provided.

$40 per service, per each outpatient visit

Nothing per visit during covered inpatient admission.

Not covered:

• Long-term rehabilitative therapy
• Exercise programs

$40 per office visit

$40 per outpatient visit

Nothing per visit during covered inpatient admission.

• Hearing testing for children through age 17, which include:  hearing examinations, testing, and hearing aids for hearing loss (see Preventive care, children).

• Hearing aids up to $1,000 per ear every 36 months for ages 18 and over.

• When related to illness or injury, evaluation, diagnostic hearing tests (performed by an M.D., D.O., or audiologist), and treatment.

• Routine hearing screening performed during a child’s preventive care visit, see Section 5(a) Preventive care, children

External hearing aids, see Section 5(a) Orthopedic and prosthetic benefits.

Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants; see Section 5(a) Orthopedic and prosthetic devices.  For information on the professional charges for the surgery to insert BAHA or cochlear implants, 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.

$40 per office visit

Not covered: 

• Hearing services that are not shown as covered, such as routine hearing tests for hearing loss as the result of aging

$40 per office visit

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

$40 per office visit

• Eye exam to determine the need for vision correction for children and adults

Coverage includes:

• one complete refractory eye examination by a Plan provider every 24 months; and
• one set of prescribed frames Plan pays up to $55; or
• one set of single vision lenses Plan pays up to $35; or
• one set of bi-focal lenses Plan pays up to $55; or
• one set of tri-focal lenses Plan pays up to $150; or
• one set of prescribed contact lenses Plan pays up to $150

$40 per office visit

All charges over the maximum Plan payments.

Not covered:

• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery

$40 per office visit

• Artificial limbs and eyes; Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• External hearing aids and testing to fit them as shown in Hearing Services
• Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy.
  • Note: Internal prosthetic devices are paid as hospital benefits; see Section 5(c) for payment information. Insertion of the device is paid as surgery; see Section 5(b) for coverage of the surgery to insert the device.
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants.  Note: For information on the professional charges for the surgery to insert BAHA or cochlear implants, 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.
• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy.
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

Note: For information on the professional charges for the surgery to insert the implant, see Section 6(b) Surgical procedures. For information on the hospital and/or ambulatory surgery center benefits, see Section 6(c) Services provided by a hospital or other facility, and ambulance services.

Nothing

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

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

• Medical Foods - Members will have access to foods used to treat Inborn Errors of Metabolism OEM). Examples of Inborn Errors of Metabolism (IEM) include, but are not limited to phenylketonuria (PKU), Maple syrup urine disease (MSUD), Cystinuria, and Tyrosinemia. Special food products used to treat Inborn Errors of Metabolism (protein disorders, fatty acid oxidation disorders, and carbohydrate disorders) will be covered. This benefit does not include foods that are considered to be grocery items or foods that can be routinely obtained in grocery stores at the same or at minimally higher cost than similar items (e.g., gluten-free cookies, gluten-free pasta). This benefit will require preauthorization.

Note: Call us at 800-344-8858 as soon as your Plan physician prescribes this equipment. We will arrange with a healthcare provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

Nothing

• Home health care services 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.), home health aide, Physical Therapist (P.T.), Occupational Therapist (O.T.), and Licensed Social Worker (L.S.W.). Limited to 60 combined visits per calendar year. Preauthorization is required.
• Services include oxygen therapy, intravenous therapy and medications.

*NOTE - Site of care management is to ensure that you are provided the opportunity to receive highest quality, lowest cost access to care to receive medically appropriate medications. 

Coverage for services, procedures, medical devices, and drugs are dependent upon benefit eligibility as outlined in your specific benefit plan. The medical necessity of infused medications may be separately reviewed against evidence based medicine criteria.  This process is for determination of the necessity of hospital outpatient level of care for an IV or injectable therapy.  This applies, but not limited to, the following applicable specialty medication categories that require healthcare provider administration billed under the medical benefit.

• Antihemophilic Agents
• Blood product derivative/Immune Globulin
• Growth Hormone
• Immunosuppressive Agents
• Monoclonal Antibody

Nothing

$40 per office visit limited to 24 visits per year

Acupuncture treatments for lower back pain with a limit of twenty (20) visits per year 

$40 copay per visit

Coverage is provided for:

• Tobacco / E-cigarettes cessation programs, including: individual, group and phone counseling, over-the-counter (OTC) drugs and prescription drugs approved by the FDA to treat tobacco dependence. (see Prescription drug benefits)
• Childhood obesity screening programs and treatment interventions
• Diabetes self management training

Nothing for counseling for up to two quit attempts per year with up to 4 tobacco cessation/E-cigarettes counseling sessions per quit attempt.

Nothing

Telemedicine - the use of interactive audio, video or other electronic media for the purpose of diagnosis, consultation or treatment.

The Plan will not exclude from coverage a Telemedicine medical service solely because the service is not provided through a face-to-face consultation.

The Plan will pay for a Telemedicine Healthcare Service only if the service is a Covered Benefit under the Plan, is not excluded by the Plan; all the following requirements are met:

1.  The informed consent of the Covered Person, or another appropriate person with authority to make healthcare treatment decisions for the Covered Person, is obtained before Telemedicine Healthcare Services are provided;

2.  The Participating Health Professional is licensed or has obtained a certificate to provide Telemedicine Healthcare Services in the appropriate state of jurisdiction;

3.  The Participating Provider complies with minimal standards of care and all requirements set forth in rules and interpretive guidance adopted or issued by the State of Ohio (including, but not limited to,  the Ohio Medical Board) and/or the appropriate state of jurisdiction governing Telemedicine Healthcare Services and prescribing to persons not seen in person by a physician;

4.  The services are provided by a Primary Care Provider or any Doctor of Medicine (M.D.), Doctor of Osteopathic Medicine (D.O.), or licensed Behavioral Health Provider

5.  The service is a primary care, urgent care, or Behavioral Health service;  and

6.  The confidentiality of the covered person’s Protected Health Information is maintained as required by law.

$30 copay for Medical or Behavioral Health

Through the COVID - 19 Monitoring Program, members have access to Registered Nurses to assist with questions/concerns related to their COVID-19 diagnosis for a minimum of two weeks. This program not only offers monitoring, but also includes education about COVID - 19, community resources and a direct connection to the member’s primary care physician when necessary.  Free equipment provided to the member includes a blood pressure cuff and a pulse oximeter.  Access to a Registered Nurse is available through our internal program from (add a space) 7:30am to 4pm, and through our 24/7 Nurse line after regular business hours: 1-330-363-7620 or 1-866-422-9603.

$0 copay

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)

Eligible members must show each of the following criteria is present:

•  weighs 100 pounds over ideal weight OR has Body Mass Index of greater than 40, OR has Body Mass Index of greater than 35 and has a clinically serious condition (e.g., obesity hypoventilation, sleep apnea, diabetes, hypertension, cardiomyopathy, musculoskeletal dysfunction)

•  failure to lose significant weight or history of regaining weight despite compliance with nonsurgical programs

•  no specific correctable medical condition that would be the cause for obesity

•  must be age 18 or over

•  treatment provided by a surgical program experienced in bariatric surgeries using a multifisciplinary approach including medical, psychiatric, nutritional, exercise, psychological, and supportive consultations and counseling

• Insertion of internal prosthetic devices. See Section 5(a) – Orthopedic and prosthetic devices for device coverage information

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

Inpatient Hospital Physician - $200 copay

Inpatient Hospital - Copay of $150 per day up to a maximum of $600 per admission

Outpatient Physician - $50 copay

Outpatient Facility (Surgery) - $200 copay

• See Section 5 (c) for charges associated with the facility (i.e. hospital, surgical center, etc.)

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
– the condition produced a major effect on the member’s appearance and
– the condition can reasonably be expected to be corrected by such surgery

• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes.
• All stages of breast reconstruction surgery following a mastectomy, such as:
– Surgery to produce a symmetrical appearance of breasts;
– Treatment of any physical complications, such as lymphedemas;
– Breast prostheses and surgical bras and replacements (see Prosthetic devices)

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

• Gender Affirming Surgery - Prior Authorization Required.

Male to Female Surgical Services:

• Vaginoplasty
• Labiaplasty
• Clitoroplasty
• Vulvoplasty
• Urethroplasty
• Penectomy
• Orchiectomy
• Breast augmentation surgery
• Genital electrolysis, or hair removal prior to genital surgery

Not covered:

• Vocal feminization surgery or voice therapy
• Facial contouring: thyroid chondroplasty, brow lift, forehead contouring, malar (cheek) implants jaw and/or chin reshaping, lip shortening, scalp (hairline) advancement, rhinoplasty, hair grafts
• Other non-facial surgeries (i.e. liposuction, lipofilling, buttocks implant)
• Non-genital area electrolysis or laser hair removal (e.g., face, chest)

Female to Male Transition Services:

• Hysterectomy/salpingo-oophorectomy
• Reconstruction of the fixed part of the urethra
• Metoidioplasty
• Phalloplasty
• Colpectomy
• Vaginectomy
• Vulvectomy
• Scrotoplasty
• Colpoclesis
• Perineoplasty
• Implantation of erection and/or testicular prostheses
• Mastectomy

Not covered:

• Vocal masculinization surgery or voice therapy
• Facial contouring: augmentation thyroid chondroplasty (thyroid cartilage augmentation), chin implant, genioplasty, jaw implant
• Other non-facial surgeries: liposuction, lipofilling pectoral muscle implants, calf implants/mons lift/mons reduction

$40 per office visit

Inpatient Hospital Physician - $200 copay

Inpatient Hospital - Copay of $150 per day up to a maximum of $600 per admission

Outpatient Physician - $50 copay

Outpatient Facility (Surgery) - $200 copay

Gender Affirming Surgery:

• Inpatient Hospital Physician copay is $200
• Surgical procedures $200 copay
• Reconstructive surgery $200 copay
• Oral and maxillofacial surgery $200 copay
• Organ/Tissue transplants $200 copay
• Anesthesia $200 copay
• Inpatient hospital $200 copay
• Inpatient hospital or other covered facility $200 copay

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.

Not covered - Gender Affirming Surgery:

• Vocal feminization surgery or voice therapy
• Facial contouring: thyroid chondroplasty, brow lift, forehead contouring, malar (cheek) implants jaw and/or chin reshaping, lip shortening, scalp (hairline) advancement, rhinoplasty, hair grafts
• Other non-facial surgeries (i.e. liposuction, lipofilling, buttocks implant)
• Non-genital area electrolysis or laser hair removal (e.g., face, chest)
• Vocal masculinization surgery or voice therapy
• Facial contouring: augmentation thyroid chondroplasty (thyroid cartilage augmentation), chin implant, genioplasty, jaw implant
• Other non-facial surgeries: liposuction, lipofilling pectoral muscle implants, calf implants/mons lift/mons reduction

Oral surgical procedures, limited to:

• Removal of Partial and for fully bony impactions
• 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
• TMJ treatment and services(non-dental); and
• Other surgical procedures that do not involve the teeth or their supporting structures

$40 per office visit

Inpatient Hospital Physician - $200 copay

Inpatient Hospital - Copay of $150 per day up to a maximum of $600 per admission

Outpatient Physician - $50 copay

Outpatient Facility (Surgery) - $200 copay

Not covered:

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

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan.  Refer to Other services in Section 3 for prior authorization procedures. 

• Autologous pancreas islet cell transplant (as an adjunct to total or near total
  pancreatectomy) only for patients with chronic pancreatitis.
• Cornea
• Heart
• Heart/lung
• Intestinal transplants
  • Isolated Small intestines
  • 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.  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. Refer to Other services in Section 3 for prior authorization procedures.

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

Blood or marrow stem cell transplants  The Plan extends coverage for the diagnoses as indicated below.

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

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin's lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
  • Acute myeloid leukemia
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced neuroblastoma
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic luekemia (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. Ganther's disease, metachromatic leukodystrophy, adrenoleukodystropy)
  • Mucopolysaccharidosis (e.g. Hunter's syndrome, Hurler's syndrome, Sanfilippo's syndrome, Maroteaux'-Lamy syndrome variants)
  • Myelodysplasia/Myelodysplastic Syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Phagocytic Hemophagocyte deficiency diseases (e.g. Wiskott-Aldrich symdrome)
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell anemia
  • X-linked lymphoproliferative syndrome
• Autologous transplants for
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Breast Cancer
  • Ependymoblastoma
  • Epithelial ovarian cancer
  • Ewing's sarcoma
  • Multiple myeloma
  • Medulloblastoma
  • Pineoblastoma
  • Neuroblastoma
  • Testicular, Mediastinal, Retroperitoneal, and ovarian germ cell tumors

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

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

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e. myelogenous) leukemia
  • Advanced hodgkins lymphoma with recurrence (relapsed)
  • Advanced non-hodgkins lymphoma with recurrence (relapsed)
  • Acute myeloid leukemia
  • Advanced myeloproliferative disorders (MPDs)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic leukemia (CLL/SLL)
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e. Fanconi's PNH, pure red cell aplasia)
  • Myelodysplasia/Myelodysplastic Syndromes
  • Parpxysmal Nocturnal Hemoglobinuria
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia 
•     Autogolous transplants for
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin's lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
  • Amloidosis
  • 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 and 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 cost 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 Hodgkins lymphoma
  • Advanced non-Hodgkins lymphoma
  • Beta Thalassemia Major
  • Chronic inflammatory demyelination polyneuropathy (CIDP)
  • Myelodysplasia/Myelodysplastic Syndromes
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Sickle cell anemia
• Mini-transplants (non-myeloablative allogenic, reduced intensity conditioning or (RIC) for 
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous leukemia)
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma 
  • Breast cancer
  • Chronic lymphocytic leukemia
  • Chronic myelogenous leukemia
  • Colon cancer
  • Chronic lymphocytic leukemia/small lymphocytic leukemia (CLL/SLL) 
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Myeloproliferative disorders (MSDs)
  • Myelodysplasia/Myelodysplastic Syndromes
  • Non-small cell lung cancer
  • Ovarian cancer
  • Prostate cancer
  • Renal cell carcinoma
  • Sarcomas
  • Sickle cell anemia 
• Autologous Transplants 
  • Advanced Hodgkins lymphoma
  • Advanced non-Hodgkins lymphoma
  • Aggressive non-Hodgkin's lymphomas
  • Advanced Childhood kidney cancers
  • Advanced Ewing sarcoma
  • Breast Cancer
  • Chronic myelogenous lymphom
  • Childhood  rhabdomyosarcoma
  • Childhood myelogenous leukemia
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple sclerosis
  • Epithelial Ovarian Cancer
  • Mantle Cell (Non-Hodgkin lymphoma)
  • 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 screening tests and donor search expense for the actual solid organ donor or up to four bone marrow stem cell transplant donors per year from individuals unrelated to the patient in addition to the testing of family members.

Inpatient Hospital Physician - $200 copay

Inpatient Hospital - Copay of $150 per day up to a maximum of $600 per admission

Outpatient Physician - $50 copay

Outpatient Facility (Surgery) - $200 copay

Not covered:

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

Professional services provided in –

• Hospital (Inpatient)
• Hospital (Outpatient)
• Skilled Nursing facility
• Ambulatory surgical center
• Office

Inpatient Hospital Physician - $200 copay

Inpatient Hospital - Copay of $150 per day up to a maximum of $600 per admission

Outpatient Physician - $50 copay

Outpatient Facility (Surgery) - $200 copay

Male to Female Surgical Services

Genital Surgeries: 

• Vaginoplasty
• Labiaplasty
• Clitoroplasty
• Vulvoplasty
• Urethroplasty
• Penectomy
• Orchiectomy
• Breast augmentation surgery
• Genital electrolysis, or hair removal prior to genital surgery

Not covered:

• Vocal feminization surgery or voice therapy
• Facial contouring: thyroid chondroplasty, brow lift, forehead contouring, malar (cheek) implants jaw and/or chin reshaping, lip shortening, scalp (hairline) advancement, rhinoplasty, hair grafts
• Other non-facial surgeries (i.e. liposuction, lipofilling, buttocks implant)
• Non-genital area electrolysis or laser hair removal (e.g., face, chest)

Female to Male Transition Services

Genital Surgery:

• Hysterectomy/salpingo-oophorectomy
• Reconstruction of the fixed part of the urethra
• Metoidioplasty
• Phalloplasty
• Colpectomy
• Vaginectomy
• Vulvectomy
• Scrotoplasty
• Colpoclesis
• Perineoplasty
• Implantation of erection and/or testicular prostheses
• Mastectomy

Not covered:

• Vocal masculinization surgery or voice therapy
• Facial contouring: augmentation thyroid chondroplasty (thyroid cartilage augmentation), chin implant, genioplasty, jaw implant
• Other non-facial surgeries: liposuction, lipofilling pectoral muscle implants, calf implants/mons lift/mons reduction

Prior Authorization required

Inpatient Hospital Physician - $200 copay

Inpatient Hospital - Copay of $150 per day up to a maximum of $600 per admission

Surgical procedures $200 copay

Reconstructive surgery $200 copay

Oral and maxillofacial surgery $200 copay

Organ/Tissue transplants $200 copay

Anesthesia $200 copay

Inpatient hospital or other covered facility $200 copay

Outpatient Physician - $50 copay

Outpatient Facility (Surgery) - $200 copay

Prior Authorization required

Room and board, such as:

• Ward, semiprivate, or intensive care accommodations;
• General nursing care;

• Maternity Care;
• Meals and special diets.

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

Copay of $150 per day up to a maximum of $600 per admission

Other hospital services and supplies, such as:

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• 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

Inpatient Hospital Physician - $200 copay

Not covered:

• Custodial care
• Personal comfort items, such as phone, television, barber services, guest meals and beds
• Private nursing care, except when medically necessary

• Non-covered facilities, such as nursing homes, schools

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

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

Outpatient Physician - $50 copay

Outpatient Facility (Surgery) - $200 copay

Extended care benefit:

The Plan provides a comprehensive range of benefits, with no day or dollar limit when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan. All necessary services are covered, including:

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

Nothing

Not covered:

• Custodial care 
• Rest Cures
• Domiciliary
• Convalescent care

• Supportive and palliative care
• Inpatient and outpatient care
• Family counseling

Note: limited to life expectancy of six (6) months or less

Nothing

• Local professional ambulance service in emergency situation. Prior-authorization is required for non-emergent transport.

• Emergency care at a doctor’s office
• Emergency care at an urgent care center
• Emergency care as an outpatient at a hospital, including doctor’s services

Note: We waive the ER copay if you are admitted to the hospital.

$125 copay

Not covered:

• Elective care or non-emergency care

• Emergency care at a doctor's office
• Emergency care at an urgent care center
• Emergency care as an outpatient at a hospital, including doctor's services

Note: We waive the ER copay if you are admitted to the hospital.

$125 copay

Not covered:

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

Local professional ambulance service in emergency situations. Prior-authorization is required for non-emergency transport.

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

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

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

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 alcoholism and drug misuse, including detoxification, treatment and counseling
• Professional charges for intensive outpatient treatment in a provider's office or other professional setting
• Electroconvulsive therapy

$40 per office visit

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

Nothing if you receive these services during your office visit; otherwise, $40 per office visit

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

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

• Room and board, such as semiprivate or intensive accommodations, general ursing care, meals and special diets, and other hospital services

Inpatient Hospital Physician - $200 copay

Inpatient Hospital - $150 copay per day up to a maximum of $600 per admission

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

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

Outpatient Physician - $50 copay

Outpatient Facility (Surgery) - $200 copay

Telemedicine - the use of interactive audio, video or other electronic media for the purpose of diagnosis, consultation or treatment.

The Plan will not exclude from coverage a Telemedicine medical service solely because the service is not provided through a face-to-face consultation.

The Plan will pay for a Telemedicine Healthcare Service only if the service is a Covered Benefit under the Plan, is not excluded by the Plan; all the following requirements are met:

1. The informed consent of the Covered Person, or another appropriate person with authority to make healthcare treatment decisions for the Covered Person, is obtained before Telemedicine Healthcare Services are provided;
2. The Participating Health Professional is licensed or has obtained a certificate to provide Telemedicine Healthcare Services in the appropriate state of jurisdiction;
3. The Participating Provider complies with minimal standards of care and all requirements set forth in rules and interpretive guidance adopted or issued by the State of Ohio (including, but not limited to, the Ohio Medical Board) and/or the appropriate state of jurisdiction governing Telemedicine Healthcare Services and prescribing to persons not seen in person by a physician;
4. The services are provided by a Primary Care Provider or any Doctor of Medicine (M.D.), Doctor of Osteopathic Medicine (D.O.), or licensed Behavioral Health Provider
5. The service is a primary care, urgent care, or Behavioral Health service;  and
6. The confidentiality of the covered person’s Protected Health Information is maintained as required by law.

$30 copay for Medical or Behavioral Health

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

• Drugs and medications that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered.
• Drugs for sexual dysfunction (see Section 3, prior approval)
• Contraceptive drugs and devices
• Intravenous fluids and medication for home use are covered under Medical and Surgical Benefits
• Growth hormone
• Fertility Drugs - Oral and injectable fertility drugs under Rx benefit
• Drugs to treat gender dysphoria
• Insulin: a copay applies to each 34-day supply
• Diabetic testing supplies are available at no cost to you through your pharmacy plan.

  The following CONTOUR NEXT ONE products are $0 copay (No prior-authorization required)

  • Blood glucose meter and all related blood glucose testing supplies  (To order your free meter, call 1-800- 401- 8440, code CTR-OPX).
  • Contour Next Test Strips
  • Contour Next Control Solutions
  • Microlet Next Lancing Device
  • Microlet Lancets
  • All generic Lancets

  All other testing supplies and products for diabetes are subject to the related pharmacy Tier and copay (whichever applies, 34-day or 90-day supply), or will require an approved exception (prior authorization from the treating physician).

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

Note: Pharmacy Formulary can be found on the web at www.aultcare.com or call AultCare Customer Service at 330-363-6360 or 800-344-8858.

Retail: 1 to 34-day supply

o Tier 1 (Preventive Maintenance List Drugs) - $0 copay

o Tier 2 (Generics) - $10 copay

o Tier 3 (Preferred Brand) - $20 copay or 30% coinsurance, whichever is greater, with a $350 maximum copay per prescription

o Tier 4 (Non-preferred Brand) - $45 copay or 50% coinsurance, whichever is greater, with a $350 maximum copay per prescription

o Tier 5 (Generic Specialty/Limited Distribution) - $100 copay (30-day supply only)

o Tier 6 (Brand Specialty/Limited Distribution) - $125.00 or 20% whichever is greater with a $500.00 max copay (30 days supply only)

Specialty drugs require preauthorization and must be purchased at AultCare Preferred Specialty Pharmacy.

Mail Order (90-day supply)

o Tier 1 (Preventive Maintenance List Drugs) - $0 copay

o Tier 2 (Generic) - $27 copay

o Tier 3 (Preferred Brand) - $55 copay or 25% coinsurance, whichever is greater, with a maximum copay per prescription of $350

o Tier 4 (Non-Preferred Brand) - $120 or 45% whichever is greater, with a maximum copay per prescription of $350

o Tier 5 (Generic Specialty/Limited Distribution) - $100 copay (30-day supply only).

o Tier 6 (Brand Specialty/Limited Distribution) - $125.00 or 20% whichever is greater with a $500.00 max copay (30 days supply only)

Specialty drugs require preauthorization and must be purchased at AultCare’s preferred Specialty Pharmacy.

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

Preventive Care medications to promote better health as recommended by ACA

The following drugs and supplements are covered without cost-share, even if over-the-counter, are prescribed by a healthcare professional and filled at a network pharmacy.  To receive this benefit a prescription from a doctor must be presented to pharmacy.

• Aspirin (81mg - 325mg) for adults age 69 and younger, including females who are at high risk of preeclampsia after 12 weeks gestation.
• Folic acid 0.4mg and 0.8mg for adultsup to age 50.
• Liquid iron single entity and combo products for children 6-12months.
• Fluoride tablets, solution (not toothpaste, rinses) for children age 0-6
• Statin use for the Primary Prevention of Cardiovascular Disease in Adults

Note:  Preventive Medications with a 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 dose aspirin for certain patients.  For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

Contraceptive drugs and devices

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

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

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

Note: Contraceptives are covered at 100% for members through age 50 as follows:

• If a generic version is available, it will be covered at 100%. However, the brand name version will be subject to the plans cost sharing.
• If a generic version is unavailable the brand name will be covered at 100%.
• If the member is unable to take the generic version, Prior Authorization will be required for the brand name medication. If approved, the brand name will be covered at 100%.

Tobacco Cessation drugs

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence requires a written prescription and  are covered in-network only under the Tobacco Cessation benefit.

Nothing

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Vitamin Supplements, nutrients and food supplements not listed as a covered benefit are not covered except as shown above, even if a physician prescribes or administers them
• Non-prescription medications unless specifically indicated elsewhere
  
• Medical supplies such as dressings and antiseptics

30% of allowable charges

Preventive and Diagnostic

• Oral Exam (one per year)
• Prophylaxis or cleaning (one per year)
• Annual application of fluoride up to age 12
• Sealants
• X-rays, including bite wings (limited to once per year) and panoramic (limited to once every 5 years)
• Vitality test
• Oral cancer exam
• Study Models
• Emergency treatment, limited to the relief of pain, bleeding, swelling or life threatening conditions
• Diagnostic services

Basic Restorative

• Restorative
• Endodontics
• Periodontics
• Oral Surgery
• Prosthodontics

Major Restorative

• Full and partial dentures
• Fixed bridges
• Crowns
• Inlays
• Onlays

• replacement period for major service such as crowns/dentures/bridges every five years
• replacement of congentially missing tooth

Not covered:

**Implants and Related Services

**Other dental services not shown as covered

The Plan covers preventive care services, such as periodic health evaluations (e.g., annual physicals), screening services (e.g., mammograms), routine prenatal and well-child care, child and adult immunizations, tobacco and nicotine cessation programs, obesity weight loss programs, disease management and wellness programs. These services are covered at 100% if you use a network provider and the services are described in Section 5 Preventive care. You do not have to meet the deductible before using these services.

After you have paid the Plan’s deductible, we pay benefits under traditional in-network coverage described in Section 5.  The Plan typically pays 80% for in-network and 60% for out-of-network care.

Covered services include:

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

By law, HSAs are available to members who are not enrolled in Medicare, cannot be claimed as a dependent on someone elses tax return, have not received VA (except for veterans with a service-connected disability) and/or Indian Health Service (HIS) benefits within the last three months or do not have other health insurance coverage. In 2023, for each month you are eligible for an HSA premium pass through, we will contribute to your HSA $83.33 per month for a Self Only enrollment, $145.00 per month for a Self Plus One or $166.66 for a Self and Family enrollment.  In addition to our monthly contribution, you have the option to make additional tax-free contributions to your HSA, so long as total contributions do not exceed the limit established by law, which is an annual $3,850 for Self Only and $7,750 for Self Plus One and Self and Family. See maximum contribution information on page 73. You can use funds in your HSA to help pay your health plan deductible. You own your HSA; so the funds can go with you if you change plans or employment.

Federal tax tip: There are tax advantages to fully funding your HSA as quickly as possible. Your HSA contribution payments are fully deductible on your Federal tax return. By fully funding your HSA early in the year, you have the flexibility of paying medical expenses from tax-free HSA dollars or after tax out-of-pocket dollars. If you don't deplete your HSA and you allow the contributions and the tax-free interest to accumulate, your HSA grows more quickly for future expenses.

HSA features include:

• Your HSA is administered by Health Equity.
• Your contributions to the HSA are tax deductible
• You may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions (i.e.: Employee Express, MyPay, etc.)
• Your HSA earns tax-free interest
• You can make tax-free withdrawals for qualified medical expenses for you, your spouse and dependents. (See IRS publication 502 for a complete list of eligible expenses.)
• Your unused HSA funds and interest accumulate from year to year
• It's portable and the HSA is owned by you and is yours to keep, even when you leave Federal employment or retire
• When you need it, funds up to the actual HSA balance are available.

Important consideration if you want to participate in a Healthcare Flexible Spending Account (HCFSA): If you are enrolled in this HDHP with a Health Savings Account (HSA), and start or become covered by a HCFSA (such as FSAFEDS offers-see Section 11), this HDHP cannot continue to contribute to your HSA. Similarly, you cannot contribute to an HSA if your spouse enrolls in an HCFSA. Instead, when you inform us of your coverage in a HCFSA, we will establish an HRA for you.

If you are not eligible for an HSA, for example you are enrolled in Medicare or have another health plan; we will administer and provide an HRA instead. You must notify us that you are ineligible for an HSA.

In 2023, we will give you an HRA credit of $1,000 per year for a Self Only enrollment, $1,740 for a Self Plus One and $2,000 for Self and Family enrollment.  You can use funds in your HRA to help pay your health plan deductible and/or for certain expenses that don’t count toward the deductible. 

HRA features include:

• For our HDHP option, the HRA is administered by AultCare Health Plan.
• Entire HRA credit (prorated from your effective date to the end of the plan year) is available from your effective date of enrollment
• Tax-free credit can be used to pay for qualified medical expenses for you and any individuals covered by this HDHP
• Unused credits carryover from year to year
• HRA credit does not earn interest
• HRA credit is forfeited if you leave Federal employment or switch health insurance plans.
• An HRA does not affect your ability to participate in an FSAFEDS Healthcare Flexible Spending Account (HCFSA). However, you must meet FSAFEDS eligibility requirements. 

An annual deductible of $2,000 Self Only and $4,000 Self Plus One and Self and Family is applied before any plan benefits are paid.  Benefit payments for non-network provider services are based on usual, customary, and reasonable criteria.  The deductible and coinsurance are subject to out-of-pocket maximums of $4,000 Self Only and $8,000 Self Plus One and Self and Family in-network and $8,000 Self Only and $16,000 Self Plus One and Self and Family out-of-network.

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

Health Savings Account (HSA)

Health Reimbursement Arrangement (HRA)

Provided when you are ineligible for an HSA

This is the HDHP's HSA for you with Health Equity, this HDHP’s custodian as defined by Federal tax code and approved by IRS. See Eligibility section for more information.

Health Equity
HealthEquity, Inc.
15 W. Scenic Pointe Dr., Ste. 400
Draper, UT 84020
Phone 877-694-3942 or www.healthequity.com

AultCare Health Plan is the HRA fiduciary for this Plan.

AultCare
2600 Sixth Street SW P.O. Box 6910
Canton, OH44706

800-344-8858 or www.aultcare.com

Set-up fee is paid by the HDHP.

No additional cost to the member.

None

You must:

• Enroll in this HDHP
• Have no other health insurance coverage (does not apply to specific injury, accident, disability, dental, vision or long-term case coverage)
• Not be enrolled in Medicare
• Not be claimed as a dependent on someone else’s tax return
• Not have received VA (except for veterans with a service-connected disability) and/or Indian Health Service (HIS) benefits in the last three months
• Complete and return all banking paperwork.

You must enroll in this HDHP.

Eligibility is determined on the first day of the month following your effective day of enrollment and will be prorated for length of enrollment.

If you are eligible for HSA contributions, a portion of our monthly health plan premium is deposited to your HSA each month. Premium pass through contributions are based on the effective date of your enrollment in the HDHP.

Note: If your effective date in the HDHP is after the 1st of the month, the earliest your HSA will be established is the 1st of the following month.

In addition, you may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions (i.e., Employee Espress, MyPay, etc.)

Eligibility for the annual credit will be determined on the first day of the month and will be prorated for the length of enrollment. The entire amount of your HRA will be available to you upon your enrollment.

For 2023, a monthly premium pass through of $83.33 will be made by the HDHP directly into your HSA each month.

For 2023, your HRA annual credit is $1,000 (prorated for mid-year enrollment).

For 2023, a monthly premium pass through of $145.00 will be made by the HDHP directly into your HSA each month.

For 2023, your HRA annual credit is $1,740 (prorated for mid-year enrollment).

For 2023, a monthly premium pass through of $166.67 will be made by the HDHP directly into your HSA each month.

For 2023, your HRA annual credit is $2,000 (prorated for mid-year enrollment).

The maximum that can be contributed to your HSA is an annual combination of HDHP premium pass through and enrollee contribution funds, which when combined, do not exceed the maximum contribution amount set by the IRS of $3,850 for Self Only or $7,750 for Self Plus One or Self and Family.

If you enroll during Open Season, you are eligible to fund your account up to the maximum contribution limit set by the IRS.  To determine the amount you may contribute, subtract the amount the Plan will contribute to your account for the year from the maximum allowable contribution.

You are eligible to contribute up to the IRS limit for partial year coverage as long as you maintain your HDHP enrollment for 12 months following the last month of the year of your first year of eligibility.  To determine the amount you may contribute, take the IRS limit and subtract the amount the Plan will contribute to your account for the year.

If you do not meet the 12 month requirement, the maximum contribution amount is reduced by 1/12 for any month you were inelgibile to contribut to an HSA.  If you exceed the maximum contribution amount, a portion of your tax reduction is lost and a 10% penalty is imposed.  There is an exception for death or disability.

You may rollover funds you have in other HSAs to this HDHP HSA (rollover funds do not affect your annual maximum contribution under this HDHP).

HSAs earn tax-free interest (does not affect your annual maximum contribution).

Catch-up contribution discussed on page 67.

The full HRA credit will be available, subject, to proration, on the effective date of enrollment. The HRA does not earn interest.

You may make an annual maximum contribution of $3,850.

You cannot contribute to the HRA.

You may make an annual maximum contribution of $7,750.

You cannot contribute to the HRA.

You may make an annual maximum contribution of $7,750.

You can not contribute to the HRA.

You can access your HSA by the following methods:

Debit card

Withdrawal form

You can pay the out-of-pocket expenses for yourself, your spouse or your dependents (even if they are not covered through the HDHP) from the funds available in your HSA.

You can pay the out-of-pocket expenses for qualified medical expenses for individuals covered under the HDHP.

Non-reimbursed qualified medical expenses are allowable if they occur after the effective date of your enrollment in this Plan.

See Availability of funds below for information on when funds are available in the HRA.

See IRS Publication 502 for a list of eligible medical expenses. Physician prescribed over-the-counter drugs and Medicare premiums are also reimbursable. Most other types of medical insurance premiums are not reimburseable.

If you are under age 65, withdrawal of funds for non-medical expenses will create a 20% income tax penalty in addition to any other income taxes you may owe on the withdrawn funds.

Funds are not available for withdrawal until all the following steps are completed:

• Your enrollment in this HDHP is effective (effective date is determined by your agency in accord with the event permitting the enrollment change)

• The HDHP receives record of your enrollment and initially establishes your HSA account with the fiduciary by providing information it must furnish and by contributing the minimum amount required to establish an HSA

• The fiduciary sends out HSA paperwork for the enrollee to complete and the fiduciary receives the completed paperwork.

The HRA credit will be available, subject to proration, on the effective date of enrollment.

You can take this account with you when you change plans, separate or retire.

If you retire and remain in this HDHP, you may continue to use and accumulate credits in your HRA.

All contributions are aggregated and cannot exceed the maximum contribution amount set by the IRS of $3,850 for Self Only and $7,750 for Self plus One or Self and Family. You may contribute your own money to your account through payroll deductions, or you may make lump sum contributions at any time, in any amount not to exceed an annual maximum limit. If you contribute, you can claim the total amount you contributed for the year as a tax deduction when you file your income taxes. Your own HSA contributions are either tax-deductible or pre-tax (if made by payroll deduction). You receive tax advantages in any case. To determine the amount you may contribute, subtract the amount the Plan will contribute to your account for the year from the maximum contribution amount set by the IRS. You have until April 15 of the following year to make HSA contributions for the current year.

If you newly enroll in an HDHP during Open Season and your effective data is after January 1st or you otherwise have partial year coverage, you are eligible to fund your account up to the maximum contribution limit set by the IRS as long as you maintain your HDHP enrollment for 12 months following the last month of the year of your first year of eligibility. If you do not meet this requirement, a portion of your tax reduction is lost and a 10% penalty is imposed. There is an exception for death or disability.

If you are age 55 or older, the IRS permits you to make additional “catch-up” contributions to your HSA. The allowable catch-up contribution is $1,000.   Contributions must stop once an individual is enrolled in Medicare. Additional details are available on the U.S. Department of Treasury website at www.treasury.gov/resource-center/faqs/Taxes/Pages/Health-Savings-Accounts.aspx.

You can use your HSA to pay for “qualified medical expenses,” as defined by IRS Code 213(d). These expenses include, but are not limited to, medical plan deductibles, diagnostic services covered by your plan, long-term care premiums, health insurance premiums if you are receiving Federal unemployment compensation, physician prescribed over-the-counter drugs, LASIK surgery, and some nursing services.

When you enroll in Medicare, you can use the account to pay Medicare premiums or to purchase health insurance other than a Medigap policy. You may not, however, continue to make contributions to your HSA once you are enrolled in Medicare.

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

Please review the chart on page 66 which details the differences between an HRA and an HSA. The major differences are:

• you cannot make contributions to an HRA

• funds are forfeited if you leave the HDHP

• an HRA does not earn interest,

•  FEHB law does not permit qualified medical expenses to include services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest, as allowed under state law.

Routine physical every 12 months.

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
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder

 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 please visit the Health and Human Services (HHS) website at https://www.healthcare-gov/preventive-care-women/

Adult Immunizations endorsed by the Center for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practice (ACIP) schedule.

In network: Nothing

Out-of-network: 50% of the plan allowance and any difference between our allowance and the billed amount

Routine mammogram – covered

In network: Nothing

Out-of-network: 50% of the plan allowance and any difference between our allowance and the billed amount

Routine exams limited to:

• One routine OB/GYN exam including one Pap smear and related services every 12 months
• routine eye exam every 12c months (see Vision services)
• routine hearing exam every 12 months (see Hearing services)

In-network: Nothing

Out-of-network: 50% of any difference between our allowance and the billed amount

Not covered:

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

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

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

Note: A complete list of preventive care services recommended under the U.S. Preventive Services Task Force is available (USPSTF) is available online at: www.uspreventiveservicestaskforce.org
HHS: www.healthcare.gov/preventive-care-benefits/
ACIP recommendations on immunizations, please refer to the National Immunization Program Web site at:
www.cdc.gov/vaccines/schedules/index.html
CDC: www.cdc.gov/vaccines/schedules/index.html

For additional information:
www.healthfinder.gov/myhealthfinder/default.aspx

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

In-network: Nothing

Out-of-network: 50% of any difference between our allowance and the billed amount

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.

After you meet the deductible, we pay the allowable charge (less your coinsurance or copay) until you meet the annual catastrophic out-of-pocket maximum.

In-network: After you meet the deductible, you pay the indicated coinsurance or copay for covered services. You may choose to pay the coinsurance from your HSA or HRA, or you can pay for them out-of-pocket

Out-of-network: After you meet the deductible, you pay the indicated coinsurance based on our Plan allowance and any difference between our allowance and the billed amount

Professional services of physicians

• In physician’s office

• Office medical consultations

•Second surgical opinion

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap test
• Pathology
• X-ray
• Non-routine Mammogram
• CT Scan
• MRI
• Ultrasound
• Electrocardiogram and EEG
• BRCA/BART testing - Prior approval is required, Page 18
• Genetic/Molecular testing - Prior approval is required, Page 18

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount.

Complete maternity (obstetrical) care, such as:

• Prenatal care (see Section 5(a) Preventive care)
• Screening for gestational diabetes
• Delivery
• Postnatal care

Note: Prenatal care is covered under Preventive Care (not subject to the deductible)

Note: Here are some things to keep in mind:

• You do not need to precertify your vaginal delivery; see below 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 cover an extended inpatient stay if medically necessary but you, your representatives, your doctor, or your hospital must recertify the extended stay.
• We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment. 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.

 Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

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

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

CONTACT PLAN**

A range of voluntary family planning services, limited to:

• Voluntary sterilization (see Surgical procedures Section 5)
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo Provera)
• Intrauterine devices (IUDs)
• Diaphragms

Note: We cover oral and injectable fertlity drugs under the prescription drug benefit.

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Reversal of voluntary surgical sterilization.

• Genetic testing or counseling

• Elective abortion

Diagnosis and treatment of infertility such as:

• Artificial insemination:
– intravaginal insemination (IVI)
– intracervical insemination (ICI)
– intrauterine insemination (IUI)

• Fertility drugs - injectable and oral fertility drugs under Rx benefit

Fertility Preservation - to help mitigate the risk of infertility in members undergoing medical therapies prescribed by their providers and likely to result in infertility. Examples of treatment related to the potential risk of infertility include cancer, treatment of rheumatological or other medical conditions with cytotoxic therapies, or surgical or radiation therapies where there is a risk of impairment to the ovaries or testicles.

Covered Services include:

• Cryopreservation of gametes (eggs) for a period of one year while the member is undergoing treatment for the related condition
• Embryo cryopreservation for a period of one year while the member is undergoing treatment for the related condition Radiation shielding
• Ovarian transposition (oophoropexy)
• Surgical removal of the cervix
• Sperm cryopreservation for a period of one vear

Medications are not covered under this benefit. This benefit falls under Infertility Services and requires preauthorization. If a member leaves the Plan prior to the completion of these services, their coverage will be terminated, and preservation costs become the immediate responsibility of the member.

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

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

• Testing and treatment
• Allergy injections

In-network: 20% of the Plan allowance

In-network: Nothing

• 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 83.

• Respiratory and inhalation therapy
• Cardiac rehabilitation following a qualifying event/condition, is provided.
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy
• Growth hormone therapy (GHT) 
• Applied Behavioral Analysis up to 20 hours per week.

Note: – We only cover GHT when we preauthorize the treatment. Call 330-363-6360 for preauthorization. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date you submit the information. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

60 visits per year, per service of each of the following:

• Qualified physical therapists
• Occupational therapists

Note: We only cover therapy to when a physician:

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

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Long-term rehabilitative therapy
• Exercise programs

In-network: 20% of the Plan allowance

When related to illness or injury, evaluation, diagnostic hearing tests (performed by an M.D., D.O., or audiologist), and treatment.

• Routine hearing screening performed during a child’s preventive care visit, see Section 5(a) Preventive care, children

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered: 

• Hearing services that are not shown as covered, such as routine hearing tests for hearing loss as the result of aging

All charges

• Eye exam to determine the need for vision correction for children through age 17

Note: See Preventive care, children for eye exams for children.

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery

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

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

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

• Artificial limbs and eyes; Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Hearing aids and testing to fit them as shown in Hearing Services
• Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy.  Note:  See Section 5(b) for coverage of the surgery to insert the device.

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

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Orthotics unless more than supportive devices for the feet
• Arch supports
• Heel pads and heel cups
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices

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;
• Speech generating devices;
• Blood glucose monitors;
• Insulin pumps.

• Medical Foods - Members will have access to foods used to treat Inborn Errors of Metabolism OEM). Examples of Inborn Errors of Metabolism (IEM) include, but are not limited to phenylketonuria (PKU), Maple syrup urine disease (MSUD), Cystinuria, and Tyrosinemia. Special food products used to treat Inborn Errors of Metabolism (protein disorders, fatty acid oxidation disorders, and carbohydrate disorders) will be covered. This benefit does not include foods that are considered to be grocery items or foods that can be routinely obtained in grocery stores at the same or at minimally higher cost than similar items (e.g., gluten-free cookies, gluten-free pasta). This benefit will require preauthorization.

Note: Call us at 800-344-8858 as soon as your Plan physician prescribes this equipment. We will arrange with a healthcare provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered: Motorized wheelchairs

• Home health care services 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.), home health aide, Physical Therapist (P.T.), Occupational Therapist (O.T.), and Licensed Social Worker (L.S.W.). Limited to 60 combined visits per calendar year. Preauthorization is required.

• Services include oxygen therapy, intravenous therapy and medications.
 

Not covered:

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

*NOTE - The site of care management is to ensure that you are provided the opportunity to receive highest quality, lowest cost access to care to receive medically appropriate medications. 

Coverage for services, procedures, medical devices, and drugs are dependent upon benefit eligibility as outlined in your specific benefit plan. The medical necessity of infused medications may be separately reviewed against evidence based medicine criteria.  This process is for determination of the necessity of hospital outpatient level of care for an IV or injectable therapy.  This applies, but not limited to, the following applicable specialty medication categories that require healthcare provider administration billed under the medical benefit.

• Antihemophilic Agents
• Blood product derivative/Immune Globulin
• Growth Hormone
• Immunosuppressive Agents
• Monoclonal Antibody

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

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

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Limited to 24 visits per year

Acupuncture treatments for lower back pain with a limit of twenty (20) visits per year

20% coinsurance per visit subject to the deductible

Coverage is provided for:

• Tobacco Cessation programs, including:
  • individual, group and phone counseling
  • prescription drugs approved by the FDA to treat tobacco dependence. (see Prescription drug benefits)
• Childhood obesity
• Diabetes self management training

Nothing for counseling for up to 2 quit attempts per year with up to 4 tobacco cessation counseling sessions per quit attempt.

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

Telemedicine - the use of interactive audio, video or other electronic media for the purpose of diagnosis, consultation or treatment.

The Plan will not exclude from coverage a Telemedicine medical service solely because the service is not provided through a face-to-face consultation.

The Plan will pay for a Telemedicine Healthcare Service only if the service is a Covered Benefit under the Plan, is not excluded by the Plan; all the following requirements are met:

1.  The informed consent of the Covered Person, or another appropriate person with authority to make healthcare treatment decisions for the Covered Person, is obtained before Telemedicine Healthcare Services are provided;

2.  The Participating Health Professional is licensed or has obtained a certificate to provide Telemedicine Healthcare Services in the appropriate state of jurisdiction;

3.  The Participating Provider complies with minimal standards of care and all requirements set forth in rules and interpretive guidance adopted or issued by the State of Ohio (including, but not limited to,  the Ohio Medical Board) and/or the appropriate state of jurisdiction governing Telemedicine Healthcare Services and prescribing to persons not seen in person by a physician;

4.  The services are provided by a Primary Care Provider or any Doctor of Medicine (M.D.), Doctor of Osteopathic Medicine (D.O.), or licensed Behavioral Health Provider

5.  The service is a primary care, urgent care, or Behavioral Health service;  and

6.  The confidentiality of the covered person’s Protected Health Information is maintained as required by law.

20% of plan allowance in-network after deductible for Medical or Behavioral Health

Through the COVID - 19 Monitoring Program, members have access to Registered Nurses to assist with questions/concerns related to their COVID-19 diagnosis for a minimum of two weeks. This program not only offers monitoring, but also includes education about COVID - 19, community resources and a direct connection to the member’s primary care physician when necessary.  Free equipment provided to the member includes a blood pressure cuff and a pulse oximeter.  Access to a Registered Nurse is available through our internal program from (add a space) 7:30am to 4pm, and through our 24/7 Nurse line after regular business hours: 1-330-363-7620 or 1-866-422-9603.

Nothing

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Treatment of morbid obesity (bariatric surgery)

Eligible members must show each of the following criteria is present:

– weighs 100 pounds over ideal weight OR has Body Mass Index of greater than 40, OR has Body Mass Index of greater than 35 and has a clinically serious condition (e.g., obesity hypoventilation, sleep apnea, diabetes, hypertension, cardiomyopathy, musculoskeletal dysfunction)
– failure to lose significant weight or history of regaining weight despite compliance with nonsurgical programs
– no specific correctable medical condition that would be the cause for obesity
– must be age 18 or over
– treatment provided by a surgical program experienced in bariatric surgeries using a multifisciplinary approach including medical, psychiatric, nutritional, exercise, psychological, and supportive consultations and counseling

• Insertion of internal prosthetic devices. See Section 5(a) – Orthopedicandprosthetic 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.

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
– the condition produced a major effect on the member’s appearance and
– the condition can reasonably be expected to be corrected by such surgery

Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Example of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed finger and toes.

• All stages of breast reconstruction surgery following a mastectomy, such as:
– surgery to produce a symmetrical appearance of breasts;
– treatment of any physical complications, such as lymphedemas;
– breast prostheses and surgical bras and replacements (see Prosthetic devices)

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

• Gender Affirming Surgery - Prior Authorization Required.

Male to Female Surgical Services:

• Vaginoplasty
• Labiaplasty
• Clitoroplasty
• Vulvoplasty
• Urethroplasty
• Penectomy
• Orchiectomy
• Breast augmentation surgery
• Genital electrolysis, or hair removal prior to genital surgery

Not covered:

• Vocal feminization surgery or voice therapy
• Facial contouring: thyroid chondroplasty, brow lift, forehead contouring, malar (cheek) implants jaw and/or chin reshaping, lip shortening, scalp (hairline) advancement, rhinoplasty, hair grafts
• Other non-facial surgeries (i.e. liposuction, lipofilling, buttocks implant)
• Non-genital area electrolysis or laser hair removal (e.g., face, chest)

Female to Male Transition Services:

• Hysterectomy/salpingo-oophorectomy
• Reconstruction of the fixed part of the urethra
• Metoidioplasty
• Phalloplasty
• Colpectomy
• Vaginectomy
• Vulvectomy
• Scrotoplasty
• Colpoclesis
• Perineoplasty
• Implantation of erection and/or testicular prostheses
• Mastectomy

Not covered:

• Vocal masculinization surgery or voice therapy
• Facial contouring: augmentation thyroid chondroplasty (thyroid cartilage augmentation), chin implant, genioplasty, jaw implant
• Other non-facial surgeries: liposuction, lipofilling pectoral muscle implants, calf implants/mons lift/mons reduction

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

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.

Not covered:

• Vocal feminization surgery or voice therapy
• Facial contouring: thyroid chondroplasty, brow lift, forehead contouring, malar (cheek) implants jaw and/or chin reshaping, lip shortening, scalp (hairline) advancement, rhinoplasty, hair grafts
• Other non-facial surgeries (i.e. liposuction, lipofilling, buttocks implant)
• Non-genital area electrolysis or laser hair removal (e.g., face, chest)
• Vocal masculinization surgery or voice therapy
• Facial contouring: augmentation thyroid chondroplasty (thyroid cartilage augmentation), chin implant, genioplasty, jaw implant
• Other non-facial surgeries: liposuction, lipofilling pectoral muscle implants, calf implants/mons lift/mons reduction

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
• TMJ treatment and services (non dental); and
• Other surgical procedures that do not involve the teeth or their supporting structures.

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

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

These solid organ transplants are subject to medical necessity and experimental/investigational review by the plan.  Refer to Other services in Section 3 for prior authorization procedures.  

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

These tandem blood  or marrow stem cell transplants for covered transplants are subject to medical necessity review by the plan. 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. 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.

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

• Allogeneic transplants for
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin's lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
  • Acute myeloid leukemia
  • Advanced myeloproliferative disorders (MPDs)
  • Advanced neuroblastoma
  • 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, metachromaticleukodystrophy, adrenoleukodystrophy)
  • Mucopolysaccharidosis (e.g., Hunter's syndrome, Hurler's syndrome, Sanfillippo's syndrome, and maroteaux-lamy syndrome variance) 
  • Myelodysplasia Myelodysplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott/Aldrich syndrome)
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell anemia
  • X-linked lymphoproliferative syndrome
• Autologous transplants for
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Breast Cancer
  • Ependymoblastoma
  • Epithelial ovarian cancer
  • Ewing's sarcoma
  • Multiplemyeloma
  • Medulloblastoma
  • Pineoblastoma
  • Neuroblastoma
  • Testicular, Mediastinal, Retroperitoneal, and ovarian germ cell tumors

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

Refer to other services in Section 3 for prior authorization procedures.

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin's lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
  • Acute myeloid leukemia
  • Advanced myeloproliferative disorders (MPDs)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Marrow faliure and related disorders (i.e., Fanconi's PNH, pure red cell Aplasia)
  • Paraoxysmal 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 and if approved by the Plans 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 hospitilazation related to treating the patients condition) if it is not provided by the clinical trial.  Section 9 has additional information on cost 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 (CDIP)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Sickle cell anemia
• Mini-transplants (non-myeloblative allogenic, reduced intensity conditioning or RIC) for
  •  Acute lymphocytic or non-lymphocytic (ie., myelogenous)leukemia
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Breast Cancer
  • Chronic lymphocytic leukemia
  • Chronic myelogenous leumekia
  • Colon Cancer
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Myeloproliferative disorders (MDDs)
  • Myelodysplasia/Myelodysplastic Syndromes
  • Non-small cell lung cancer
  • Ovarian cancer
  • Prostate cancer
  • Renal cell carcinoma
  • Sarcomas
  • Sickle cell anemia
• Autogolous Transplants
  • Advanced Childhood kidney cancers
  • Advanced Ewing sarcoma
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Aggressive non-Hodgkin lymphomas
  • Childhood  rhabdomyosarcoma
  • Chronic myelogenous leukemia
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Early stage (indolent or non advanced) small cell lymphocytic lymphoma
  • 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 screening tests and donor search expense for the actual solid organ donor or up to four bone marrow stem cell transplant donors in addition to the testing of family members.

Not covered: 

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

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Professional services provided in –

• Hospital (inpatient)

Professional services provided in -

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

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Male to Female Surgical Services

Genital Surgeries: 

• Vaginoplasty
• Labiaplasty
• Clitoroplasty
• Vulvoplasty
• Urethroplasty
• Penectomy
• Orchiectomy
• Breast augmentation surgery
• Genital electrolysis, or hair removal prior to genital surgery

Not covered:

• Vocal feminization surgery or voice therapy
• Facial contouring: thyroid chondroplasty, brow lift, forehead contouring, malar (cheek) implants jaw and/or chin reshaping, lip shortening, scalp (hairline) advancement, rhinoplasty, hair grafts
• Other non-facial surgeries (i.e. liposuction, lipofilling, buttocks implant)
• Non-genital area electrolysis or laser hair removal (e.g., face, chest)

Female to Male Transition Services

Genital Surgery:

• Hysterectomy/salpingo-oophorectomy
• Reconstruction of the fixed part of the urethra
• Metoidioplasty
• Phalloplasty
• Colpectomy
• Vaginectomy
• Vulvectomy
• Scrotoplasty
• Colpoclesis
• Perineoplasty
• Implantation of erection and/or testicular prostheses
• Mastectomy

Not covered:

• Vocal masculinization surgery or voice therapy
• Facial contouring: augmentation thyroid chondroplasty (thyroid cartilage augmentation), chin implant, genioplasty, jaw implant
• Other non-facial surgeries: liposuction, lipofilling pectoral muscle implants, calf implants/mons lift/mons reduction

Prior Authorization required

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Prior Authorization required

Room and board, such as:

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

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

• Other hospital services and supplies, such as:
• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• 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

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

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

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

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

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Extended care benefit:

The Plan provides a comprehensive range of benefits, with no day or dollar limit when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan. All necessary services are covered, including:

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

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Custodial care
• Rest Cures
• Domiciliary
• Convalescent care

• Supportive and palliative care
• Inpatient and outpatient care
• Family counseling

Note: limited to life expectancy of six (6) months or less

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Local professional ambulance service when medically appropriate

Note: Local professional ambulance service in emergency situations. Prior-authorization is required for non-emergent transport.

20% of the Plan allowance and any difference between our allowance and the billed amount

• Emergency care at a doctor’s office

• Emergency care at an urgent care center

• Emergency care as an outpatient at a hospital, including doctor’s services

In-network: 20% of the Plan allowance

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Not covered:

• Elective care or non-emergency care

Local professional ambulance service in emergency situations. Prior-authorization is required for non-emergency transport.

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

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

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

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

In-network:  20% of the Plan allowance

Out-of-network:  40% of the Plan allowance and any difference between our allowance and the billed amount

• Outpatient diagnostic tests provided and billed by a licensed mental health and substance misuse 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

In-network:  20% of the Plan allowance

Out-of-network:  40% of the Plan allowance and any difference between our allowance and the billed amount

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

In-network:  20% of the Plan allowance

Out-of-network:  40% of the Plan allowance and any difference between our allowance and the billed amount

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

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

In-network:  20% of the Plan allowance

Out-of-network:  40% of the Plan allowance and any difference between our allowance and the billed amount

Telemedicine - the use of interactive audio, video or other electronic media for the purpose of diagnosis, consultation or treatment.

The Plan will not exclude from coverage a Telemedicine medical service solely because the service is not provided through a face-to-face consultation.

The Plan will pay for a Telemedicine Healthcare Service only if the service is a Covered Benefit under the Plan, is not excluded by the Plan; all the following requirements are met:

1. The informed consent of the Covered Person, or another appropriate person with authority to make healthcare treatment decisions for the Covered Person, is obtained before Telemedicine Healthcare Services are provided;
2. The Participating Health Professional is licensed or has obtained a certificate to provide Telemedicine Healthcare Services in the appropriate state of jurisdiction;
3. The Participating Provider complies with minimal standards of care and all requirements set forth in rules and interpretive guidance adopted or issued by the State of Ohio (including, but not limited to, the Ohio Medical Board) and/or the appropriate state of jurisdiction governing Telemedicine Healthcare Services and prescribing to persons not seen in person by a physician;
4. The services are provided by a Primary Care Provider or any Doctor of Medicine (M.D.), Doctor of Osteopathic Medicine (D.O.), or licensed Behavioral Health Provider
5. The service is a primary care, urgent care, or Behavioral Health service;  and
6. The confidentiality of the covered person’s Protected Health Information is maintained as required by law.

$30 copay for Medical or
Behavioral Health

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

• Drugs and medications that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered.
• Insulin: a copay applies to each 34-day supply
• Drugs for sexual dysfunction (see Section 3, prior approval)
  • Contraceptive drugs and devices
  • Diabetic supplies, including insulin syringes, needles, glucose test tablets and test tape, Benedict's solution or equivalent, and acetone test tablets.
  • Intravenous fluids and medication for home use are covered under Medical and Surgical Benefits
  • Growth hormone
• Fertility Drugs - Oral and injectable fertility drugs under Rx benefit
• Drugs to treat gender dysphoria
• Diabetic supplies limited to: Disposable needles and syringes for the administration of covered medications

• Diabetic testing supplies are available at no cost to you through your pharmacy plan.

  The following CONTOUR NEXT ONE products are $0 copay (No prior-authorization required)

  • Blood glucose meter and all related blood glucose testing supplies  (To order your free meter, call 1-800- 401- 8440, code CTR-OPX).
  • Contour Next Test Strips
  • Contour Next Control Solutions
  • Microlet Next Lancing Device
  • Microlet Lancets
  • All generic Lancets

  All other testing supplies and products for diabetes are subject to the related pharmacy Deductible and Coinsurance (whichever applies, 34-day or 90-day supply), or will require an approved exception (prior authorization from the treating physician).

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

Note: Pharmacy Formulary can be found on the web at www.aultcare.com or call AultCare Customer Service at 330-363-6360 or 800-344-8858.

Using Prescription card: 20% of discounted amount.

Not using Prescription drug card: 20% of plan allowance. No applicable discount.

Preventive Care medications to promote better health as recommended by ACA

The following drugs and supplements are covered without cost-share, even if overthe-counter, are prescribed by a healthcare professional and filled at a network pharmacy. To receive this benefit a prescription from a doctor must be presented to pharmacy.

• Aspirin (81mg - 325mg) for adults age 69 and younger, including females who are at high risk of preeclampsia after 12 weeks gestation.
• Folic acid 0.4mg and 0.8mg for adults up to age 50.
• Liquid iron single entity and combo products for children 6-12months.
• Fluoride tablets, solution (not toothpaste, rinses) for children age 0-6
• Statin use for the Primary Prevention of Cardiovascular Disease in Adults
• All Drugs on the Preventive Maintenance Drug list

Note: Preventive Medications with a 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 dose aspirin for certain patients. For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/
browse-recommendations

Nothing

Women's contraceptive drugs and devices

Note: Over-the-counter contraceptives drugs and devices approved by the FDA require a written prescription by an approved provider.
Note: Contraceptives are covered at 100% for members through age 50 as follows:

• If a generic version is available, it will be covered at 100%. However, the brand name version will be subject to the plans cost sharing.
• If a generic version is unavailable the brand name will be covered at 100%.
• If the member is unable to take the generic version, Prior Authorization will be required for the brand name medication. If approved, the brand name will be covered at 100%.

Nothing

Tobacco Cessation drugs

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence requires a written prescription and are covered in-network only under the Tobacco Cessation benefit.

In-network: Nothing

Out-of-network: All Charges

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Vitamin Supplements, nutrients and food supplements not listed as a covered benefit are not covered except as shown above, even if a physician prescribes or administers them
• Non-prescription medications
• Medical supplies such as dressings and antiseptics

All Charges

In-network:  20% of the Plan allowance

Out-of-network:  40% of the Plan allowance and any difference between our allowance and the billed amount

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

• We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative benefit. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary.  Until you sign and return the agreement, regular contract benefits will continue.
• Alternative benefits will be made available for a limited time period and are subject to our ongoing review.  You must cooperate with the review process.
• By approving an alternative benefit, we do not guarantee you will get it in the future.
• The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw 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).

Weekly cancer education sessions are presented by doctors, nurses and other professionals. The sessions are held by the Aultman Cancer Center and co-sponsored by the American Cancer Society. For information/registration, you may call 330-438-6290 or go online at www.cancer.org/treatment/supportprogramsservices/onlinecommunities/participateinacancereducationclass/icancopeonline/index. Free parking is available.

The Aultman Institute publishes a newsletter to keep you informed on a variety of issues related to your good health. Visit our Website at www.aultcare.com

Visit this Website www.aultman.org for information on:

General health topics

Links to healthcare news

Cancer and other specific diseases

Drugs/medication interactions

Kids’ health

Patient safety information

Several helpful web site links.

For each HSA and HRA account holder, we maintain a complete claims payment history online through www.aultcare.com.

Your balance will also be shown on your explanation of benefits (EOB) form.

You will receive an EOB after every claim.

If you have an HSA:

• You will receive a monthly bank statement from Health Equity outlining your account balance and activity for the month.
• You may also access your account on-line at www.healthequity.com

If you have an HRA:

• Your HRA balance will be available online through www.aultcare.com

Your balance will also be shown on your EOB form.

As a member of this HDHP, you may choose any provider. However, you will receive discounts when you see a network provider. Directories are available online at www.aultcare.com

Pricing information for medical care and prescription drugs is available at www.aultcare.com

Link to online pharmacy through www.aultcare.com

Patient safety information is available online at www.aultcare.com

Case Management: The goal of AultCare's Medical Case Management is managing the high cost of catastrophic illnesses while maintaining quality of care. Case management is used to describe a number of different approaches to planning, coordinating, providing and financing medical care. Case Management requires the simultaneous cooperation of AultCare, the Physician, the patient, and the patient's family. Telephonic follow up is provided to create and evaluate a goal oriented treatment plan. The focus of case management can include, but is not limited to, chronic disease states such as diabetes, COPD, or CHF, complex or catastrophic cases. Medical Case Management programs develop an individual plan designed to coordinate and mobilize healthcare resources to address specific medical problems and patient needs. The result should be a claim savings through effective medical management.

In most cases, providers and facilities file claims for you. Your provider must file on the form CMS-1500, Health Insurance Claim Form. Your facility must file on the UB-04 form. For claims questions and assistance, contact us at 800-344-8858 or at our Website at www.aultcare.com.

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

• Covered member’s name, date of birth, address, phone number and ID number;

• Name and address of the provider or facility that provided the service or supply;

• Dates you received the services or supplies;

• Diagnosis;

• Type of each service or supply;

• The charge for each service or supply;

• A copy of the explanation of benefits, payments, or denial from any primary payor-such as the Medicare Summary Notice (MSN);

• Receipts, if you paid for your services. Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills.

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

Submit your claims to:

AultCare Health Plan
2600 Sixth Street SW
Canton, Ohio 44710
800-344-8858

If you have an urgent care claim, please contact our Customer Service Department at 800-344-8858.  Urgent care claims must meet the definition found in Section 11 of this brochure, and most urgent care claims will be claims for access to care rather than claims for care already received.  We will notify you of our decision not later than 24 hours after we receive the claim as long as you provide us with sufficient information to decide the claim.   If  you or your authorized representative fails to provide sufficient information to allow us to, we will inform you or your authozied representative of the specific information necessary to complete the claim not later than 24 hours after we receive the claim and a time frame for our receipt of this information.  We will decide the claim within 48 hours of (i) receiving the information or (ii) the end of the time frame, whichever is earlier.

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

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 preapproved course of treatment as an appealable decision.  If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.

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, then we will make a decsion within 24 hours after we receive the claim.

As indicated in Section 3, certain care requires Plan approval in advance.  We will notify you of our decision within 15 days after the receipt of the pre-service claim.  If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 15-day.  Our notice will include the circumstances underlying the request for the extention and the date when a decision is expected.

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

If you fail to follow these pre-service claim procedures, then we will notify you of your failure to follow these procedures as long as (1) your request is made to our customer service department and (2) your request names you, your medical condition or symptom, and the specific treatment, service, procedure, or product requested.  We will provide this notice within 5 days following the failure or 24 hours if your pre-service claim is for urgent care.  Notification may be oral, unless you request written correspondence.

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

If we need an extention 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. 

You may designate an authorize 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 percent of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language. You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions of your EOB's 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

b) Send your request to us at: AultCare Health Plan, 2600 Sixth Street SW, Canton, Ohio 44710; 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) 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.

We have 30 days from the date we receive your request to:

a) Pay the claim (or, if applicable, arrange for the healthcare provider to give you the care); or

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

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

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

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

In the case of an appeal of an urgent care claim, we will notify you of our decision not later than 72 hours after receipt of your reconsideration request. We will hasten the review process, which allows oral or written requests for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods.

If you do not agree with our decisions 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, Insurance Operations, Health Insurance 3, 1900 E Street, NW, Washington, DC 20415-3630.

Send OPM the following information:

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

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

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

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

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

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

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

Note: If you have a serious or life threatening condition (one that may cause permanenet loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 1-800-344-8858. We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal. You may call OPM's Health Insurance 3 at (202) 606-0737 between 8 a.m. and 5 p.m. Eastern Time.

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

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

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

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

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

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

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

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

We do not cover services that:

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

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

Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these state programs, eliminating your FEHB premium.  For information on suspending your FEHB enrollment, contact your retirement or employment  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 provisions 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 if that payment.  Our right of reimbursement extends to nay payment received by settlement, judgement or otherwise.

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

 Reimbursement to us out of the payment shall take first priority (before any of the rights of any other parties are honored) and is not impacted by how the judgment, settlement, or other recovery is characterized, desinged 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 the 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 1-877-888-3337 (TTY 1-877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits.  Providing your FEHB information may reduce your out-of-pocket cost.

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

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

• Routine care costs – costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition, whether the patient is in a clinical trial or is receiving standard therapy.
• 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.

Medicare is a health insurance program for:

• People 65 years of age or older;
• Some people with disabilities under 65 years of age;
• People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).

Medicare has four parts:

• Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in Medicare-covered employment, you should be able to qualify for premium-free Part A insurance. (If you were a Federal employee at any time both before and during January 1983, you will receive credit for your Federal employment before January 1983.) Otherwise, if you are age 65 or older, you may be able to buy it. Contact 800-MEDICARE (800-633-4227), (TTY 877-486-2048) for more information.
• Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social Security check or your retirement check.
• Part C (Medicare Advantage). You can enroll in a Medicare Advantage plan to get your Medicare benefits. We offer a Medicare Advantage plan. Please review the information on coordinating benefits with Medicare Advantage plans on the next page.
• Part D (Medicare prescription drug coverage). There is a monthly premium for Part D coverage. Before enrolling in Medicare Part D, please review the important disclosure notice from us about the FEHB prescription drug coverage and Medicare. The notice is on the first inside page of this brochure.

For people with limited income and resources, extra help in paying for a Medicare prescription drug plan is available. For more information about this extra help, visit the Social Security Administration online at www.socialsecurity.gov, or call them at 800-772-1213 (TTY 800-325-0778).

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 secondary.  This is true whether or not they accept Medicare. 

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

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

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

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 800-344-8858 or see our Website at www.aultcare.com.

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

• Medical services and supplies provided by physicians and other healthcare professionals.

Please review the following examples which illustrates your cost share if you are enrolled in Medicare Part B and the AultCare High Option Plan.  Medicare will be primary for all Medicare eligible services.  Members must use providers who accept Medicare's assignment. You can find more information about how our plan coordinates benefits with Medicare at www.aultcare.com.

Benefit Description AultCare High Option Plan: Deductible
High Option You pay without Medicare Part B: $0 copay
High Option You pay with Medicare Part B: $0 copay

Benefit Description AultCare High Option Plan: Primary Care Physician
High Option You pay without Medicare Part B: $30 copay
High Option You pay with Medicare Part B: $0 copay

Benefit Description AultCare High Option Plan: Specialist
High Option You pay without Medicare Part B: $40 copay
High Option You pay with Medicare Part B: $0 copay

Benefit Description AultCare High Option Plan: Inpatient Hospital
High Option You pay without Medicare Part B: $150 copay per day, up to $600 copay per admission
High Option You pay with Medicare Part B: $0 copay

Benefit Description AultCare High Option Plan: Outpatient Hospital
High Option You pay without Medicare Part B: $200 copay
High Option You pay with Medicare Part B: $0 copay

The decision to enroll in Medicare is yours. We encourage you to apply for Medicare benefits 3 months before you turn age 65. It’s easy. Just call the Social Security Administration toll-free number 800-772-1213 (TTY 877-325-0778) to set up an appointment to apply. If you do not apply for one or more Parts of Medicare, you can still be covered under the FEHB Program.

If you can get premium-free Part A coverage, we advise you to enroll in it. Most Federal employees and annuitants are entitled to Medicare Part A at age 65 without cost. When you don’t have to pay premiums for Medicare Part A, it makes good sense to obtain the coverage. It can reduce your out-of-pocket expenses as well as costs to the FEHB, which can help keep FEHB premiums down.

Everyone is charged a premium for Medicare Part B coverage.  The Social Security Administration can provide you with premium and benefit information.  Review the information and decide if it makes sense for you to buy the Medicare Part B coverage.  If you do not sign up for Medicare Part B when you are first eligible, you may be charged a Medicare Part B late enrollment penalty of a 10% increase in premium for every 12 months you are not enrolled.  If you did not take Part B at age 65 because you were covered under FEHB as an active employee (or you were covered under your spouses group health insurance plan and he/she was an active employee), you may sign up for Part B (generally without an increased premium) within 8 months from the time you or your spouse stopped working or are no longer covered by the group plan.  You also can sign up at any time while you are covered by the group plan.

If you are eligible for Medicare, you may have choices in how you get your healthcare.  Medicare Advanatage is the term used to describe the various private health plan choices available to Medicare beneficiaries.  The information in the next few pages shows how we coordinate benefits with medicare, depending on whether you are in the Original Medicare Plan or a private Medicare Advantage plan.

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 (800-633-4227), (TTY 877-486-2048) or at www.medicare.gov.

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

This Plan and our Medicare Advantage plan: You may enroll in Prime Time Health Plan and also remain enrolled in our FEHB plan. We will coordinate benefits when Prime Time Health Plan is primary, you must use Prime Time's network and/or service area. We will waive some of our copays, coinsurance, or deductibles.

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 if you use our Plan providers, even outside of your Medicare Advantage plan’s network and/or service area . 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 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 cancer, whether the patient is in a clinical trial or is receiving standard therapy.
• Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care.
• Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes are generally covered by the clinical trials. These costs are generally covered by the clinical trials. This plan does not cover these costs. 

Coinsurance is the percentage of our allowance that you must pay for your care. You may also be responsible for additional amounts. See page 28.

A copay is a fixed amount of money you pay when you receive covered services. See page 27.

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

Care provided primarily for maintenance of the patient or which is designed essentially to assist the patient in meeting his activities of daily living and which is not primarily provided for its therapeutic value in the treatment of an illness, disease, bodily injury or condition.

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 page 28.

The Plan’s Utilization Management team gathers information from various sources before making an independent evaluation to determine medical appropriateness and/or the experimental/investigational nature of new technology, i.e., the application of existing technology or new medical procedures, drugs, or devices. The Plan’s decision is made in good faith, following a detailed factual background investigation of the claim and proposed service and interpretation of the Plan provisions. Sources the Plan may use include the Federal Drug Administration, Medicare guidelines, published scientific articles, and related medical society guidelines. If the plan decides that a service or supply is not medically appropriate and/or is experimental/investigational, that service or supply will not be eligible.

Coverage provided by the Company for the Plan participant and dependants, if applicable.

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

A service or supply given by a Provider that is required to diagnose or treat your condition, illness or injury and which we determine is:

• Appropriate with regard to standards of good medical practice;

• Not solely for the convenience of you or a provider;

• The most appropriate supply or level or service which can be safely provided to you. When applied to the care of an Inpatient, this means that the services cannot be safely provided to you as an Outpatient.

Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways.

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

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

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

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

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at 800-344-8858.  You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Office visits -

Primary Care Physician $30 copay 

Specialist  $40 copay

33

$150 copay per day up to $600 per admission

$200 copay

$200 copay

$50 copay

43

$125 copay (waived if admitted)
 

56

$40 copay

58

Tier 1 (Preventative Maintenance List Drugs) $0 copay

Tier 2 (Generic) $10 copay

Tier 3 (Preferred Brand) $20 copay or 30% coinsurance whichever is greater with a $350 maximum copay 

Tier 4 (Non-preferred Brand) $45 copay or 50% coinsurance whichever is greater with a $350 maximum copay 

Tier 5 (Specialty Generic) $100 (30 day supply only).

Tier 6 (Specialty Preferred Brand) $125 copay or 20% coinsurance whichever is greater with a $500 maximum copay (30 day supply only).

61

Tier 1 (Preventative Maintenance Drugs)  $0 copay

Tier 2 (Generic)  $27 copay

Tier 3 (Preferred Brand) $55 copay or 25% coinsurance whichever is greater, with a $350 maximum copay 

Tier 4 (Non-preferred Brand) $120 copay or 45% coinsurance whichever is greater, with a $350 maximum copay 

Tier 5 (Specialty Generic) $100 copay (30 day supply only).

Tier 6 (Preferred Specialty) $125 copay or 20% coinsurance whichever is greater, with a $500 maximum copay (30 day supply only).

61

Accidental injury benefit - Nothing

Preventive dental care - 30% coinsurance

65

$40 copay per office visit

38

Multiple support groups and nurse hotline.

113

$6,850 Self Only enrollment, $13,700 Self Plus One or Self and Family enrollment

28

Nothing

78

20% coinsurance of plan allowance

40% coinsurance of plan allowance plus amount over plan allowance.

80

20% coinsurance of plan allowance
40% coinsurance of plan allowance plus amount over plan allowance.


20% coinsurance of plan allowance

40% coinsurance of plan allowance plus amount over plan allowance.

90

20% coinsurance of plan allowance
40% coinsurance of plan allowance plus amount over plan allowance

103

20% coinsurance of plan allowance

40% coinsurance of plan allowance plus amount over plan allowance

105

20% coinsurance of plan allowance

107

20% coinsurance of plan allowance
40% coinsurance of the plan allowance and any difference over plan allowance

112

Multiple support groups and nurse hotline.

113

$4,000 Self Only or $8,000 Self Plus One or Self and Family enrollment per year.
$8,000 Self Only or $16,000 Self Plus One or Self and Family enrollment per year.

Some costs do not count toward this protection

28