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

See www.opm.gov/insure/health for enrollment information as well as:

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

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

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

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

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

Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and one eligible family member. Self and Family coverage is for the enrollee and one or more eligible family members. Family members include your spouse and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

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

Contact us to add a family member if you are already enrolled in Self and Family coverage.

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

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

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

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

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

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

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

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

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

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

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

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

OPM implements the Federal Employees Health Benefits Children’s Equity Act of 2000. This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the Federal Employees Health Benefits (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 on January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2023 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2022 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage, (i.e., you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid.  You may be billed for services received directly 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.

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

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

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. For assistance in finding coverage, please contact us at 671-647-3526 or customerservice@takecareasia.com.

TakeCare will mail 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.

You also have the convenience of displaying your ID card on your mobile device by downloading TakeCare's mobile app from the App Store (Apple) or GooglePlay (Android). You can also print a replacement card by using TakeCare's member portal, MyTakeCare. Go to https://www.takecareasia.com/mytakecare-web-portal for more information.

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 671-647-3526, email at customerservice@takecareasia.com or write to us at TakeCare Insurance Company, Inc.,    P.O. Box 6578 Tamuning, Guam 96931.

You can receive covered care from "in-network" and "out-of-network" providers. You will only pay copayments and/or coinsurance, and not have to file claims when using in-network providers. If you use out-of-network providers, you can expect to pay more out of your pocket. Most out-of-network providers will also want you to pay during the time of service. If this occurs, TakeCare will reimburse you for the eligible charges. See below.  

Medicare beneficiaries only have coverage for services received at Medicare-contracted facilities on Guam, CNMI, Hawaii, and the continental United States.  Medicare-eligible care and services will not be covered if non-emergency care and services are received at a facility or physician not contracted with Medicare. 

In-network providers are physicians and other healthcare professionals we contract with to provide covered services to our members.  We select and credential providers to participate in our network according to national quality and medical practice standards. 

We list in-network providers in our  Provider Directory, which is updated periodically. You can view the current directory on our website at www.takecareasia.com 

TakeCare 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.

We provide Care Coordinators for complex conditions. See Section 5(i) for more information or contact TakeCare Medical Referral Services (MRS) at (671) 300-5995 or via email tc.mrs@takecareasia.com for assistance. 

In-network facilities are hospital and other medical facilities we contract with to provide covered services to our members.  We select and credential facilities to participate in our network according to national quality and medical practice standards. 

We list in-network facilities in our  Provider Directory, which is updated periodically. You can view the current directory on our website at www.takecareasia.com

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 us to enforce the terms of our provider contract.

Providers and facilities not participating in TakeCare's network are considered out-of-network providers and facilities. You can get care from out-of-network providers, but you will share in a greater portion of the cost of care.

When using out-of-network providers and facilities,  you will pay 30% of eligible charges based on our allowance plus any difference between our allowance and the actual billed charges. If you are enrolled in the HDHP option, you must satisfy the deductible before any charges will be covered. Because we do not have agreements or contracts with out-of-network providers, they may require up front full payment during the time of service. If this occurs, TakeCare will reimburse you for its portion of eligible charges.

Note: Certain services always require prior approval, regardless of whether they are received from an in-network or out-of network provider or facility. If you self refer to a provider and or facility for services which require prior authorization, those services will not be covered.

It depends on the type of care you need. First, we recommend you and each family member choose a primary care physician. This decision is important since your primary care physician provides or arranges for most of your healthcare. To select or change your primary care physician, call us at 671-647-3526 or email at customerservice@takecareasia.com. You may choose to have a different primary care physician for each family member. 

If you are enrolled in the High or Standard options, you must receive a referral from your primary care physician to receive coverage for any specialist services (with the exception of OB/GYN). If you are enrolled in the HDHP option, you do not need a specialist referral.

Other services require prior authorization from TakeCare Medical Referral Services (MRS) to be covered.

Your primary care physician can be a family practitioner, internist, obstetrician/gynecologist, or pediatrician for children under 18 years of age.  Your primary care physician will provide most of your healthcare, or give you a referral to see a specialist if needed.

If you want to change primary care physicians or if your primary care physician leaves the Plan, contact us at 671-647-3526 or via email at customerservice@takecareasia.com.  We will help you select a new one. You may change your primary care physician anytime. Your change to the new primary care physician will be effective immediately.

A listing of in-network primary care physicians can be found in our provider directory. Go to www.takecareasia.com to view the directory online.

Your primary care physician will refer you to a specialist for needed care. However, you may see an OB/GYN within our network without a referral.

When you receive a specialist referral from your primary care physician, you must return to the primary care physician after the specialist 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. You may access mental healthcare and behavioral healthcare through your primary care physician for an initial consultation.  You must return to your primary care physician after your consultation with the specialist.  If your specialist recommends additional visits or services, your primary care physician will review the recommendation and authorize the visits or services as appropriate.  You should not continue seeing the specialist after the initial consultation unless your primary care physician and TakeCare's Medical Referral Service (MRS) Department has authorized the 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).
• Your primary care physician will create your treatment plan. The physician may have to get an authorization or approval from us beforehand. If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician.  If they decide to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate in our network, we will provide coverage based on your out-of- network benefits. 
• If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist.  You may receive services from your current specialist until we can make arrangements for you to see someone else.

If you have a chronic and disabling condition and lose access to your specialist because we:

• terminate our contract with your specialist for other than cause; 
• drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program plan; or
• reduce our Service Area and you enroll in another FEHB plan;

You may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us at 671-647-3526, or via email at customerservice@takecareasia.com. If we drop out of the FEHB Program, contact your new plan.

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

Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility. Because you are still responsible for ensuring that we are asked to pre-certify your care, you should always ask your physician or hospital whether they have contacted TakeCare. If you are using an out-of-network provider or facility, you are responsible for contacting us at 671-300-5995 or via email at tc.mrs@takecareasia.com.

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, contact our Customer Service department immediately at 671-647-3526 or via email at customerservice@takecareasia.com.  If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

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

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

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

Since your primary care physician arranges most referrals to specialists and inpatient hospitalization, the prior authorization approval process only applies to care shown below.

Prior to your elective inpatient hospital admission, our Medical Referral Services (MRS) department evaluates the medical necessity of your proposed stay and the number of days required to treat your condition using nationally-recognized medical care guidelines. 

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.  Prior authorization must be obtained for:  

• All surgical procedures except circumcisions if done within 31 days from the date of birth
• Audiological exams
• Bariatic surgery
• CT scans
• Gender reassignment surgery
• Growth Hormone Therapy (GHT) 
• Hospitalization
• Iatrogenic fertility preservation procedures
• MRIs
• Oncology consultations
• Out-of-area hospitalization
• Plastic/reconstructive consultation and procedures
• Podiatry procedures
• Sleep studies
• Specialty care follow up (testing and procedures)
• Transplants
• Other procedures including colonoscopy and endoscopy

Emergency services do not require prior authorization.  However, you, your representative, the physician, or the hospital must notify us within forty-eight (48) hours, or as soon as reasonably possible, after initial receipt of services if the emergency services results in your admission to a hospital in our service area. If you receive emergency services outside our service area, you must notify us within forty-eight (48) hours, or as soon as reasonably possible, after initial receipt of services even if you're not admitted to a hospital facility. 

First, your physician, your hospital, you, or your representative, must contact us at 671-300-5995 or via email at tc.mrs@takecareasia.com 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 fail to provide the information we've requested within 60 days from the date of the request, then we will notify you of your failure to follow these procedures as long as (1) your request is made to our customer service department and (2) your request names you, your medical condition or symptom, and the specific treatment, service, procedure, or product requested.  We will provide this notice within five days following the failure.  Notification may be oral, unless you request written correspondence.

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 the receipt of this notice 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 contacting us at 671-647-3526 or via email at customerservice@takecareasia.com. You may also call OPM’s Health Insurance 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, contact us at 671-647-3526 or via email at customerservice@takecareasia.com. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

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

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

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

If you or your physician requests 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.

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

If you have a pre-service claim and you do not agree with our decision regarding prior authorization of an inpatient admission or other services, you may request a review in accord with the procedures detailed below. If your claim is in reference to a contraceptive, call 671-674-3626 or email at customerservice@takecareasia.com

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

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

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

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

2. Ask you or your provider for more information.

You or your provider must send the information so that we receive it within 60 days of our request.  Once the information is received, a decision will be made within 30 more days and we will write to you with our decision.

If we do not receive the information within 60 days of our request, we will make a decision within 30 days of the date the information was first due based on the information already received.  We will write to you with our decision.

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

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

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

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

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

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

• HealthCare FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you and your tax dependents, including 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.

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

Example: When you see your primary care physician at the FHP Health Center, you pay a copayment of $5 per office visit, or $10 per office visit when you see a preferred in-network primary care physician, or $20 per office visit when you see another in-network primary care physician, if you are covered under the High Option. When you are admitted as an inpatient to an in-network hospital, you pay a $100 copayment per day up to $500 maximum per inpatient admission, if you are covered under the High Option.

A deductible is a fixed amount of money you must pay for certain covered services and supplies before we start paying benefits for them. Copayment and coinsurance amounts do not count toward your deductible. 

Under the High and Standard Options, there is no calendar year deductible.

Under the High Deductible Health Plan (HDHP) Option, with the exception of Preventive Care Services coverage, you must first meet your plan deductible before your medical coverage begins. The combined in-network and out-of-network plan deductible is considered satisfied and benefits are payable when your covered expenses reach $3,000 for Self Only or $6,000 for Self Plus One or $6,000 for Self and Family enrollment each calendar year. The Self and Family deductible can be satisfied when at least two (2) covered family members have met their individual deductible in a calendar year.

Encourage your healthcare provider to submit a claim to us on your behalf even if you haven't yet met your deductible. By doing so, we are able to track your out-of-pocket payments and credit your deductible during the year.  Alternatively, a TakeCare Deductible Claim Form should be filled out immediately and submitted to us to ensure accurate and complete information on all doctors, lab or pharmacy visits. It is your responsibility to track and submit deductible expenses (e.g. encounter tickets, invoices, receipts) and the required documentation. Deductible claim forms should be submitted to our Customer Service department. Track your out-of-pocket expenses through the MyTakeCare member portal.

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

Coinsurance is the percentage of our fee allowance that you must pay for your care.  If you are covered by the High Deductible Health Plan (HDHP) Option, coinsurance doesn’t begin until you have met your combined in-network and out-of-network plan deductible.

Example: Under the HDHP Option, once you've met your combined in-network and out-of-network plan deductible, you pay 20% coinsurance of our allowance for in-network services. Likewise, you pay 30% of our allowance plus any difference between our allowance and billed charges for out-of- network services once you've met your combined in-network and out-of-network plan deductible.

Our plan allowance is the maximum charge for which we will reimburse the provider for a covered service. For in-network providers, the allowance is the contracted rate paid by us. For out-of-network provider services outside our service area, allowance is the same as the usual, customary and reasonable charges in the geographic area. When using an out-of-network provider, you may be responsible for the difference between our allowance and billed charges in addition to your out-of-network copayment or coinsurance amount. For further details, see Section 11, Definitions of Terms We Use in This Brochure.

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

For High, Standard, and HDHP Options, we pay 100% of our allowable amount for the remainder of the calendar year after out-of-pocket expenses for coinsurance and/or copayments exceed:  

High Option: your combined in-network and out-of-network out-of-pocket maximum limit of $2,000 for Self Only enrollment, $4,000 for Self Plus One, or $6,000 for Self and Family enrollment. However, if you are using an out-of-network provider, you will continue to be responsible for any difference between our allowance and billed charges. Separately, your in-network prescription drug out-of-pocket maximum is $2,000 for Self Only enrollment, $4,000 for Self Plus One, or $6,000 for Self and Family enrollment.  

Standard Option: your combined in-network and out-of-network out-of-pocket maximum limit of $3,000 for Self Only enrollment, $6,000 for Self Plus One or Self and Family enrollment. However, if you are using an out-of-network provider, you will continue to be responsible for any difference between our allowance and billed charges. Separately, your in-network prescription drug out-of-pocket maximum is $3,000 for Self Only enrollment, $6,000 for Self Plus One or Self and Family enrollment.

HDHP Option: your in-network out-of-pocket maximum limit of $3,000 for Self Only enrollment, $6,000 for Self Plus One or Self and Family enrollment. There is no out-of-pocket limit when using an out-of-network provider under this option. Separately, your in-network prescription drug out-of-pocket maximum limit is $3,000 for Self Only enrollment, $6,000 for Self Plus One or $6,000 for Self and Family enrollment.

For all three of the above options, an individual under Self Plus One or Self and Family enrollment will never have to satisfy more than what is required for the out-of-pocket maximum limit under a Self Only enrollment. 

Under the High, Standard, and HDHP Options, your out-of-pocket payments for the following do not count toward your catastrophic protection out-of-pocket maximum:

• Deductible payments
• Contraceptive Devices
• Dental Services
• Vision Hardware
• Chiropractic Services
• Other supplemental benefits
• Charges in excess of our allowance
• Charges in excess of maximum benefit limitations 
• Services not covered

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

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

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

Facilities of the Department Veterans Affairs, the Department of Defense and the Indian Health Services 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 health care 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.

TakeCare must comply with the NSA protections that hold you harmless from unexpected bills.

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.takecareasia.com/NSA or contact us at 671-647-3526 or toll-free, 877-484-2411, or via email at customerservice@takecareasia.com. 

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

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

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges

FHP Health Center: $5 copayment per visit

Preferred in-network: $10 copayment per visit

Other in-network: $20 copayment per visit

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges

FHP Health Center: $5 copayment per visit

Preferred in-network: $15 copayment per visit

Other in-network: $25 copayment per visit

Out-of-network: 30% 
coinsurance of our allowance plus any difference between our allowance and billed charges

In-network: $40 copayment per visit

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges

In-network: $40 copayment per visit

Out-of-network:  30% coinsurance of our allowance plus any difference between our allowance and billed charges

Emergency Services In Area

• Urgent care services at FHP Health Center

$15 copayment per visit 

$15 copayment per visit

• Hospital emergency room

In-network: $75 copayment per visit 

Out-of-network: $75 copay per visit 

In-network: $100 copayment per visit

Out-of-network: $100 copayment per visit 

Emergency Services Out of Area

• At doctor’s office, Urgent Care Clinic,  or Hospital emergency room 

In-network: $100 copayment per visit

Out-of-network: $100 copayment per visit plus any difference between our allowance and billed charges

In-network: 20% coinsurance 

Out-of-network: 20% coinsurance 

In-network:

Retail (30 day supply)

$10 copayment - generic formulary
$25 copayment - brand formulary
$70 copayment - non-formulary
$100 copayment - preferred specialty
$200 copayment - non-preferred specialty 

Mail Order (90 day supply)
$0 copayment - generic formulary
$50 copayment - brand formulary
$100 copayment - non-formulary 
Not Covered - specialty

Out-of-network: Not covered

In-network:

Retail (30 day supply)

$15 copayment - generic formulary
$40 copayment - brand formulary
$100 copayment - non-formulary
$100 copayment - preferred specialty
$250 copayment - non-preferred specialty

Mail Order (90 day supply)
$0 copayment - generic formulary
$80 copayment - brand formulary
$160 copayment - non-formulary
Not Covered - specialty

Out-of-network: Not covered

In-network: $100 copayment per visit

Out-of-network:  30% coinsurance of our allowance plus any difference between our allowance and billed charges

In-network: $150 copayment per visit

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges

In-network: $100 copayment per day, up to $500 maximum per inpatient admission

Out-of-network: 30% copay of our allowance plus any difference between our allowance and billed charges

In-network: $150 copayment per day, up to $750 maximum per inpatient admission

Out-of-network: 30% copay of our allowance plus any difference between our allowance and billed charges

In-network: All charges above $25 per visit. Maximum of 20 visits per calendar year

Out-of-network: Not covered

In-network: All charges above $25 per visit. Maximum of 20 visits per calendar year

Out-of-network: Not covered

In-network: All charges above $100 per benefit year

Out-of-network: Not covered

In-network: All charges above $100 per benefit year

Out-of-network: Not covered

In-network: All charges above $300 per ear, every two years

Out-of-network: Not covered

In-network: All charges above $300 per ear, every two years

Out-of-network: Not covered

In-network: Nothing for preventive services, 20% coinsurance of covered charges for restorative and simple extractions, 75% coinsurance of covered charges for prosthodontics

Out-of-network: 30% coinsurance of covered charges for preventive services,  50% coinsurance of covered charges for restorative and simple extractions, 95% coinsurance of covered charges for prosthodontics. In addition, you are responsible for charges between covered charges and billed charges

In-network: Nothing for preventive services. All other dental services are not covered

Out-of-network: 30% coinsurance of covered charges for preventive services plus any difference between covered charges and billed charges. All other dental services are not covered

Your combined in-network and out-of-network annual maximum for out-of-pocket expenses (coinsurance and copayments) for covered medical services is limited to $2,000 for Self Only enrollment, $4,000 for Self Plus One enrollment, or $6,000 for Self and Family enrollment. However, if you are using an out-of-network provider, you will continue to be responsible for any difference between our allowance and billed charges. Separately, your in-network prescription drug out-of-pocket maximum is $2,000 for Self Only enrollment, $4,000 for Self Plus One enrollment, or $6,000 for Self and Family enrollment. An individual under Self Plus One or Self and Family enrollment will never have to satisfy more than what is required for the out-of-pocket maximum limit under a Self Only enrollment

However, certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses even if you reach your out-of-pocket maximum (e.g., expenses in excess of the Plan’s allowable amount or benefit maximum). See page 25 for more information

Your combined in-network and out-of-network annual maximum for out-of-pocket expenses (coinsurance and copayments) for covered medical services is limited to $3,000 for Self Only enrollment, $6,000 for Self Plus One enrollment or Self and Family enrollment. However, if you are using an out-of-network provider, you will continue to be responsible for any difference between our allowance and billed charges. Separately, your in-network prescription drug out-of-pocket maximum is $3,000 for Self Only enrollment, $6,000 for Self Plus One enrollment or Self and Family enrollment. An individual under Self Plus One or Self and Family enrollment will never have to satisfy more than what is required for the out-of-pocket maximum limit under a Self Only enrollment

However, certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses even if you reach your out-of-pocket maximum (e.g., expenses in excess of the Plan’s allowable amount or benefit maximum). See page 25 for more information

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. This includes follow-up colonoscopies after a positive non-invasive stool-based screening test or direct visualization test. 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, breast cancer screening, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of preventive care benefits for women, go to the Health and Human Services (HHS) website at https://www.healthcare.gov/preventive-care-women/
• To build your personalized list of preventive services, go to https://health.gov/myhealthfinder
• Routine mammogram - covered

In-network: Nothing

Out-of-network:  30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network:  30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule found at https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html.

In-network: Nothing

Out-of-network:  30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network:  30% coinsurance of our allowance plus any difference between our allowance and billed charges.

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

All charges

All charges

• Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines, go to https://brightfutures.aap.org
• Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.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

In-network: Nothing

Out-of-network:  30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network:  30% coinsurance of our allowance plus any difference between our allowance and billed charges.

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

All charges

All charges

Professional services of physicians

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

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

Preferred In-network: Primary Care - $10 copayment per visit, Specialist Care - $40 copayment per visit

In-network: Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

Preferred In-network: Primary Care - $15 copayment per visit, Specialist Care - $40 copayment per visit

In-network: Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Professional services of physicians

• During a hospital stay
• In a skilled nursing facility

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

At home

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing 

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered

• Off-island care for services received without prior authorization from TakeCare Medical Referral Services (MRS) department, except in the case of emergency.
• Specialty care services aren't covered when received without written referral from your primary care physician, except in the case of OB/GYN services.

Consultations via phone, audio/video services using a computer, tablet, or smartphone with in-network primary care or specialty providers, including behavioral health, on or off island. 

For specialty consultations, referral by primary care provider is required and coverage is limited to certain specialties.

Contact your provider regarding the availability of telehealth services and TakeCare for covered specialties.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

Preferred In-network: Primary Care - $10 copayment per visit, Specialist Care - $40 copayment per visit

In-network: Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: All charges

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

Preferred In-network: Primary Care - $15 copayment per visit, Specialist Care - $40 copayment per visit

In-network: Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: All charges

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap tests
• Pathology
• Electrocardiogram and EEG

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• X-rays
• Non-routine mammograms
• Ultrasound

FHP Health Center: $5 copayment in addition to regular office visit copayment.

In-network: $20 copayment in addition to regular office visit copayment. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: $5 copayment in addition to regular office visit copayment.

In-network: $25 copayment in addition to regular office visit copayment. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Prior authorization required for the following services:

• CT Scan
• MRI
• Sleep Studies

FHP Health Center: $30 copayment in addition to regular office visit copayment.

In-network: $40 copayment in addition to regular office visit copayment. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: $30 copayment in addition to regular office visit copayment.

In-network: $40 copayment in addition to regular office visit copayment. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Prior authorization required for the following services:

• Nuclear Medicine

In-network: $40 copayment in addition to regular office visit copayment. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: $40 copayment in addition to regular office visit copayment. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Complete maternity (obstetrical) care, such as:

• Prenatal care
• Screening for gestational diabetes 
• Delivery
• Postnatal care
• Breastfeeding support, supplies and counseling for each birth

Note: Here are some things to keep in mind:

• You do not need to have your vaginal delivery pre-authorized by TakeCare if in the service area. However, prior authorization is required for vaginal delivery services (i.e., prenatal care, delivery, and postnatal care) outside the service area.
• 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.
• 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   We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment.  Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

In-network:  Primary Care, Specialist - Nothing; Outpatient Facility - $100 copayment; Inpatient hospital - $100 copayment per day, up to $500 maximum per inpatient admission.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network:  Primary Care, Specialist - Nothing; Outpatient Facility - $150 copayment; Inpatient hospital - $150 copayment per day, up to $750 maximum per inpatient admission.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Breastfeeding support, supplies and counseling for each birth.

In-network:  Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network:  Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered

• Routine sonograms to determine fetal age, size, or gender.
• Maternity-related services outside our service area unless pre-authorized by TakeCare's Medical Referral Services (MRS) department.

Medical foods to treat physician-diagnosed Inborn Errors of Metabolism (IEM) including Phenylketonuria (PKU) as prescribed by a physician.

Maximum Annual Benefit: $5,000 per covered individual

In-network: 20% coinsurance 

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: 20% coinsurance 

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered

• Special food items which can be routinely obtained in grocery stores at the same or at a minimally higher cost than similar items (e.g., gluten-free cookies, gluten-free pasta).

All charges

All charges

Contraceptive counseling on an annual basis.

A range of voluntary family planning services, limited to:

• Voluntary sterilization (See Surgical procedures Section 5 (b)
• Surgically implanted FDA-approved contraceptives
• Injectable FDA-approved contraceptive drugs (such as Depo Provera)
• FDA-approved Intrauterine devices (IUDs)
• FDA-approved Diaphragms

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

Note: If the member chooses to use a branded product when a generic is available, the member will pay the difference between the brand and generic cost rather than paying "Nothing".

However, if a branded product is considered medically necessary by the prescribing physician, it will be covered the same as a generic with no cost sharing for the member.

In-network:  Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network:  Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling

Diagnosis and treatment of infertility such as:

• Artificial insemination: (Up to three cycles per pregnancy attempt) 
  • intravaginal insemination (IVI)
  • intracervical insemination (ICI)

In-network: Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Specialist Care - 50% coinsurance of our allowance. (Coinsurance is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Injectable fertility drugs

Note: We cover oral fertility drugs under Section 5(f) Prescription drug benefits. 

In-network: $15 copayment per injection in addition to the office visit copayment.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: $15 copayment per injection in addition to the office visit coinsurance.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

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

Iatrogenic fertility preservation procedures (retrieval of and freezing of eggs or sperm) are covered for infertility caused by chemotherapy, pelvic radiotherapy, ovary or testicle removal and other gonadotoxic therapies for the treatment of disease as well as infertility associated with medical and surgical gender transition treatment.

Covered services include the following procedures, when provided by or under the care or supervision of a physician:

• Collection of sperm
• Ovarian simulation, retrieval of eggs and fertilization
• Sperm or egg cryo-preservation storage for up to one year

Notes:

• Fertility preservation procedures require prior authorization. See Section 3, Other services
• Iatrogenic fertility preservation, including related Medical Travel Benefit charges, is limited to $10,000 per member per benefit year

In-network: Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: Not covered.

In-network: Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: Not covered.

Not covered:

• Embryo transfer
• Long-term storage costs (greater than one year)
• Egg harvesting or embryo implantation procedures beyond two attempts
• Elective fertility preservation, such as egg freezing due to natural aging

All charges

All charges

• Testing and treatment
• Allergy injections

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network: Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Clinic: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network: Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Allergy serum

In-network: nothing in addition to the office visit copayment. 

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: nothing in addition to the office visit copayment.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Provocative food testing and sublingual allergy desensitization

• Chemotherapy and Radiation therapy
  
  Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under Organ/Tissue Transplants on page 55.

• Respiratory and inhalation therapy
• Cardiac rehabilitation following qualifying event/condition is provided for up to 20 sessions per benefit period.
• Intravenous (IV) / Infusion Therapy – Home IV and antibiotic therapy
• Growth hormone therapy (GHT)

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

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

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $20 copayment per visit ; Specialist - $40 copayment per visit; Outpatient Facility - $100 copayment; Inpatient hospital - $100 copayment per day, up to $500 maximum per inpatient admission. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $25 copayment per visit ; Specialist - $40 copayment per visit; Outpatient Facility - $150 copayment; Inpatient hospital - $150 copayment per day, up to $750 maximum per inpatient admission. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Dialysis - hemodialysis and peritoneal dialysis

In-network:  Primary Care - $20 copayment per visit ; Specialist Care - $40 copayment per visit; Outpatient Facility - $100 copayment; Inpatient hospital - $100 copayment per day, up to $500 maximum per inpatient admission. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network:  Primary Care - $25 copayment per visit ; Specialist Care - $40 copayment per visit; Outpatient Facility - $150 copayment; Inpatient hospital - $150 copayment per day, up to $750 maximum per inpatient admission. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Unlimited outpatient services and up to two (2) consecutive months per condition for the services of each of the following:

• Qualified physical therapists
• occupational therapists

Note: We only cover therapy when a physician:

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

We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury.

These therapies also apply to habilitation services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may also include speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

In-network: $15 copayment per office visit; nothing for home visits; nothing during covered inpatient admission. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: $15 copayment per office visit; nothing for home visits; nothing during covered inpatient admission. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Long-term rehabilitative therapy
• Exercise programs, lifestyle modification programs
• Equipment, supplies or customized devices related to rehabilitative therapies, except those provided under Section 5(a) Durable Medical Equipment
• Services provided by schools or government programs
• Developmental and Neuroeducational testing and treatment beyond initial diagnosis
• Hypnotherapy
• Psychological testing
• Vocational rehabilitation

Inpatient cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is covered for up to 90 days per benefit period.

Outpatient cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is covered for up to 20 sessions per benefit period.

In-network: Specialist Care - $40 copayment per office visit; nothing for home visits; nothing during covered inpatient admission. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Specialist Care - $40 copayment per office visit; nothing for home visits; nothing during covered inpatient admission. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Qualified Speech Therapist

In-network: $15 copayment per office visit; nothing for home visits; nothing during covered inpatient admission. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: $15 copayment per office visit; nothing for home visits; nothing during covered inpatient admission. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Hearing testing and treatment for adults, when medically necessary
• For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist
• Hearing aid testing and evaluation for adults

Adult hearing aid benefits and limits: (see Orthopedic and prosthetic devices, page 45)

Note: Hearing testing for children through age 17 to determine the need for hearing correction is covered under Preventive Care for Children.

In-network: Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Hearing services that are not shown as covered
• Hearing aids, testing and examinations for children 

• Annual eye exams through age 17 to determine the need for vision correction

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Annual eye exams for adults 
  
  
  

FHP Health or Vision Centers: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit. 

In-network: Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit. 

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health or Vision Centers: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit.  

In-network: Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit. 

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Refraction Exam

Refraction exams will be covered as part of the annual eye exam if member meets any of the following criteria:

1. Fails a screening or risk assessment test;
2. Reports a visual problem; or
3. Cannot complete a screening (e.g. developmental delay)

Otherwise, applicable member share for refraction exam applies. 

FHP Vision Center: $10 copayment per visit

In-network: $15 copayment per visit

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Vision Center: $25 copayment per visit

In-network: $40 copayment per visit

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Prescription eyeglasses or contact lenses

In-network: All charges in excess of $100 per benefit year

Out-of-network: All charges

In-network: All charges in excess of $100 per benefit year

Out-of-network: All charges

• Medical and surgical benefits for the diagnosis and treatment of diseases of the eye

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit. 

In-network: Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit. 

In-network: Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Eye exercises and orthoptics (vision therapy)
• Radial keratotomy and other refractive surgery such as LASIK (Laser-Assisted Stromal In-situ Keratomileusis) surgery
• Routine vision services outside the service area

• Foot care and podiatry services

Note: When you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes, routine foot care may be covered. Prior authorization is required.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit. 

In-network: Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit. 

In-network: Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Routine footcare including: 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 eyes
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy (up to two (2) surgical bras per benefit year)
• Internal prosthetic devices, such as spinal implants, bone segments, artificial disks, artificial joints, artificial plates, stents, leads, intraocular lenses, and surgically implanted breast implant following mastectomy. 
• Single and dual pacemakers, biventricular pacemakers, pacemaker monitors, accessories such as pacemaker batteries and leads, including the cost of the devices, their placement, repair or replacement and related Medical Travel Benefit, hospital, and surgical charges will accrue towards the Pacemaker Annual Limit of $50,000 per member.
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome. 
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants

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

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit.  In addition to the copayment, you are responsible for 10% coinsurance of our allowance for the device.

In-network: Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit. In addition to the copayment, you are responsible for 10% coinsurance of our allowance for the device. (Copayment and coinsurance is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Clinic: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit.  In addition to the copayment, you are responsible for 10% coinsurance of our allowance for the device.

In-network: Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit. In addition to the copayment, you are responsible for 10% coinsurance of our allowance for the device. (Copayment and coinsurance is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Orthopedic devices, such as braces

FHP Clinic: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit.  In addition to the copayment, you are responsible for 10% coinsurance of our allowance for the device.

In-network: Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit. In addition to the copayment, you are responsible for 10% coinsurance of our allowance for the device. (Copayment and coinsurance is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• External hearing aid for adults (limited to $300 maximum benefit per ear every two (2) years)

In-network: All charges in excess of $300 per ear, every two years

Out-of-network: All charges

In-network: All charges in excess of $300 per ear, every two years

Out-of-network: All charges

Not covered:

• Orthopedic and corrective shoes
• Arch supports, foot orthotics, heel pads and heel cups
• Artificial limbs 
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Lumbosacral supports
• Splints
• Over-the-counter (OTC) items
• Internal prosthetics such as heart valves, automatic implantable cardioverter defibrillator (AICD) and other implantable devices not specified above.
• Prosthetic replacements provided less than 3 years after the last one we covered

e will cover the rental or purchase of DME, at our option, including repair and adjustment. Covered items include:

• Manual hospital beds
• Standard manual wheelchairs
• Crutches/walk aids
• Oxygen Concentrators
• Portable Oxygen Tanks
• CPAP (Continuous Positive Airway Pressure)
• BPAP (Bi-Level Positive Airways Pressure)

Note

Pre-authorization is required. Contact us at 671-300-5995 or via email at
tc.mrs@takecareasia.com as soon as your your physician prescribes this equipment. We will arrange with a healthcare provider to rent or sell you DME at discounted rates and will tell you more about this service when you call. 

In-network: 15% coinsurance towards rental or purchase of covered equipment from an in-network provider. You will be advised of the coinsurance amount when the pre-authorization is issued.

Out-of-network: All charges

In-network: 15% coinsurance towards rental or purchase of covered equipment from an in-network provider. You will be advised of the coinsurance amount when the pre-authorization is issued.

Out-of-network: All charges

We will cover the following devices with a written prescription:

• Blood Glucose Monitors
• Continuous Glucose Monitor (CGM) System, including transmitter and sensors, if patient is actively participating in TakeCare’s Diabetes Management Program and meets criteria for coverage based on HbA1c level

In-network: Nothing

Out-of-network: All charges

In-network: Nothing

Out-of-network: All charges

Not covered:

• Motorized wheelchairs
• Motorized beds
• CPAP and BPAP supplies including masks other than those packaged by the manufacturer with a new machine
• Insulin pumps

Home healthcare ordered by a physician, pre-authorized by us, and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide while under an active treatment plan with a home health agency including services such as:

• Oxygen therapy, intravenous therapy and medications.
• Services ordered by a physician for members who are confined to the home.
• Nursing
• Medical supplies included in the home health plan of care.
• Physical therapy, speech therapy, occupational therapy, and respiratory therapy.

In-network: Nothing

Out-of-network:  30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network:  30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• 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.

Chiropractic services - You may self refer to a participating chiropractor for up to 20 visits per benefit year.

Services are limited to:

• Manipulation of the spine and extremities
• Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application 
• Osteopathic Manipulative Treatment (OMT) when provided by a licensed, trained and credentialed practitioner.

In-network: All charges above $25 per visit and all charges after your 20th visit in a benefit year.

Out-of-network: All charges 

In-network: All charges above $25 per visit and all charges after your 20th visit in a benefit year.

Out-of-network: All charges 

Not covered:

• Consults and evaluations
• Ancillary services for chiropractic purposes (e.g., x-rays)

All charges

Acupuncture Services - You may self refer to a participating acupuncture practitioner for up to 20 visits per benefit year.

The Plan defines acupuncture as the practice of insertion of needles into specific exterior body locations to relieve pain, to induce surgical anesthesia, or for therapeutic purposes.

These providers are required to submit itemized bills and their Federal Tax I.D. Number (if a United States provider) as outlined in Section 7, Filing a claim for covered services.

In-network: All charges above $25 per visit and all charges after 20th visit per benefit year.

Out-of-network: All charges

In-network: All charges above $25 per visit and all charges after 20th visit per benefit year.

Out-of-network: All charges

Massage Therapy - You may self refer to a participating, licensed massage therapist for up to 20 visits per benefit year.

These providers are required to submit itemized bills and their Federal Tax I.D. Number (if a United States provider) as outlined in Section 7, Filing a claim for covered services.

In-network: $10 copayment per visit (up to 20 visits per benefit year).

Out-of-network: All charges

In-network: $10 copayment per visit (up to 20 visits per benefit year).

Out-of-network: All charges

Not covered:

• Chelation therapy except for acute arsenic, gold, mercury or lead poisoning; or use of Desferoxamine in iron poisoning
• Naturopathic services and medicines
• Homeopathic services and medicines
• Rolfing

All charges

All charges

Programs are administered through the TakeCare Wellness Center including:

• Cardiac Risk Management Class
• Nicotine Cessation Program 
• Diabetes Management
• Wellness Workshop
• Group Fitness Program
• Nutrition Coaching
• Children's Health Improvement Program
• Well Mommy, Well Baby Program

Note:  For more information on these and other classes, see pages 80-83 or call the TakeCare Wellness Center at 671-300-7161 or via email at wellness@takecareasia.com.

Nothing. All health education classes are FREE to TakeCare members unless otherwise specified. Referral is required from your primary care physician. No referral is required for TakeCare's Group Fitness classes.

Nothing. All health education classes are FREE to TakeCare members unless otherwise specified. Referral is required from your primary care physician. No referral is required for TakeCare's Group Fitness classes.

Nicotine Cessation Program

• primary care physician referral required
• individual/group/telephone counseling
• over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence
  • Nicotrol Nasal Spray
  • Nicotrol Inhaler
  • Chantix
  • Zyban
  • Bupropion hydrochloride
  • Nicorette Gum
  • Nicorette DS Gum
  • Habitrol Transdermal film
  • Nicoderm CQ Transdermal system
  • Commit Lozenge
  • Nicorette Lozenge
  • Nicotine Film
  • Nicotine Polacrilex, Gum, Chewing; Buccal
  • Thrive (Nicotine Polacrilex) Gum, Chewing; Buccal
  • Nicotine Polacrilex, Trocher/Lozenge
  • Nicotine Patch
  • Varenicline

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

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

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

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

A comprehensive range of services are covered, 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
• Circumcision  
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Surgical treatment of morbid obesity  (bariatric surgery). Surgery is limited to Roux-en-Y bypass, laparoscopic gastric band placement, laparoscopic sleeve gastrectomy, and vertical banded gastroplasty.
  
  Concerning bariatric surgery, the following conditions must be met:
  • Eligible members must be age 18 or over
  • Eligible members must weigh 100 pounds or 100% over their normal weight according to current underwriting standards
  • Eligible members must meet the National Institute of Health Guidelines
  • We may require you to participate in a non-surgical multidisciplinary program approved by us for six months prior to your bariatric surgery
  • We will determine the provider for the non-surgical program and surgery based on quality and outcomes.
• Insertion of internal prosthetic devices.  See Section 5(a) – Orthopedic and prosthetic devices for device coverage information.
• Cardiac surgery for the implantation of stents, leads and pacemaker
• Cardiac surgery for the implantation of  valves (Plan pays for the cost of procedure only)
• 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.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $100 copayment per visit; Inpatient hospital - $100 copayment per day, up to $500 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $150 copayment per visit; Inpatient hospital - $150 copayment per day, up to $750 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot: see Foot care
• Services and supplies provided for circumcisions performed beyond thirty-one (31) days from the date of birth that are not determined to be medically necessary

Covered services include:

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

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.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $100 copayment per visit; Inpatient hospital - $100 copayment per day, up to $500 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $150 copayment per visit; Inpatient hospital - $150 copayment per day, up to $750 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

All charges

All charges

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

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $100 copayment per visit; Inpatient hospital - $100 copayment per day, up to $500 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $150 copayment per visit; Inpatient hospital - $150 copayment per day, up to $750 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

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

Gender affirming surgery is covered up to an annual maximum benefit of $50,000 per eligible member, including related Medical Travel Benefit charges (see page 134). Covered services are only available from in-network providers outside the service area. Benefit is limited to the following procedures and subject to the requirements listed below:

• For female to male surgery: mastectomy (including nipple reconstruction), hysterectomy, vaginectomy, salpingo-oophorectomy, metoidioplasty, phalloplasty, urethroplasty, scrotoplasty, electrolysis (hair removal at the covered operative site), and placement of testicular and erectile prosthesis
• For male to female surgery: penectomy, orchiectomy, vaginoplasty, clitoroplasty, labiaplasty, and electrolysis (hair removal at the covered operative site)

Prior authorization is required for gender affirming surgery.

Following WPATH Standards of Care Ver. 2 for gender affirming surgeries, TakeCare requires the member to meet all of the following requirements:

1. Must be at least 18 years of age at the time prior authorization is requested
2. Diagnosis of gender dysphoria rendered by a qualified healthcare professional
   • Member has a strong desire to be rid of primary and/or secondary sex characteristics because of a marked incongruence with the member’s identified gender
   • Member’s gender dysphoria is not a symptom of another mental disorder or chromosomal abnormality
   • Gender dysphoria causes clinical distress or impairment in social, occupational, or other important areas of functioning

In-network: Outpatient facility - $100 copayment per visit; Inpatient hospital - $100 copayment per day, up to $500 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: All charges.

In-network: Outpatient facility - $150 copayment per visit; Inpatient hospital - $150 copayment per day, up to $750 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: All charges.

Not covered:

• Reversal of gender reassignment surgery
• Any procedure not listed above

All charges

All charges

The following solid organ transplants are covered and subject to medical necessity and experimental/investigational review by the Plan. Pre-authorization is required. Solid organ transplants are limited to:

• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for those 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

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $100 copayment per visit; Inpatient hospital - $100 copayment per day, up to $500 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $150 copayment per visit; Inpatient hospital - $150 copayment per day, up to $750 maximum per admission. Copayment is waived at in-network facility in the Philippines.
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Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

The following tandem blood or marrow stem cell transplants for covered transplants are covered and subject to medical necessity review by the Plan. Pre-authorization is required.

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

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $100 copayment per visit; Inpatient hospital - $100 copayment per day, up to $500 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $150 copayment per visit; Inpatient hospital - $150 copayment per day, up to $750 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Blood or marrow stem cell transplants  

The Plan extends coverage for the diagnoses as indicated below. Not subject to medical necessity. Plan’s denial is limited to indicators for transplant such as refractory or relapsed disease, cytogenetics, subtype, staging or the  diagnosis.

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced neuroblastoma
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Hodgkin's lymphoma - relapsed
  • Infantile malignant osteopetrosis
  • Kostmann’s syndrome
  • Leukocyte adhesion deficiencies
  • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  •  Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s syndrome, Sanfillippo’s syndrome, Maroteaux-Lamy syndrome variants)
  • Myelodysplasia/Myelodysplastic syndromes
  • Non-Hodgkin's lymphoma - relapsed
  • 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)
  • Aggressive non-Hodgkin lymphomas
  • Amyloidosis
  • Breast Cancer
  • Ependymoblastoma
  • Epithelial ovarian cancer
  • Ewing’s sarcoma
  • Hodgkin's lymphoma - relapsed
  • Medulloblastoma
  • Multiple myeloma
  • Neuroblastoma
  • Non-Hodgkin's lymphoma - relapsed
  • Pineoblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $100 copayment per visit; Inpatient hospital - $100 copayment per day, up to $500 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $150 copayment per visit; Inpatient hospital - $150 copayment per day, up to $750 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) are covered for members with a diagnosis listed below, subject to medical necessity review by the Plan. There is no defined age limits for the use of RIC for an allogeneic stem cell transplant.

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

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

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $100 copayment per visit; Inpatient hospital - $100 copayment per day, up to $500 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $150 copayment per visit; Inpatient hospital - $150 copayment per day, up to $750 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

The following 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 subject to prior authorization by the Plan’s medical director in accordance with the Plan’s protocols.

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

• Allogeneic transplants for
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Beta Thalassemia Major
  • Chronic inflammatory demyelination polyneuropathy (CIDP) 
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Sickle Cell anemia
• Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning or RIC) for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Breast cancer
  • Chronic lymphocytic leukemia
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Colon cancer
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Myelodysplasia/Myelodysplastic Syndromes
  • Myeloproliferative disorders (MDDs)
  • Non-small cell lung cancer
  • Ovarian cancer
  • Prostate cancer
  • Renal cell carcinoma
  • Sarcomas
  • Sickle cell anemia
• Autologous Transplants for
  • Advanced childhood kidney cancers
  • Advanced Ewing sarcoma
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Aggressive non-Hodgkin lymphomas (Mantle Cell lymphoma, adult T-cell leukemia/lymphoma, peripheral T-cell lymphomas and aggressive Dendritic Cell neoplasms) 
  • Breast Cancer
  • Childhood  rhabdomyosarcoma
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Epithelial Ovarian Cancer
  • Multiple sclerosis
  • Small cell lung cancer
  • Systemic lupus erythematosus
  • Systemic sclerosis

Limited Benefits

• Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may be provided in an NCI- or NIH-approved clinical trial at a Plan-designated center of excellence subject to prior authorization by the Plan’s medical director in accordance with the Plan’s protocols.
• Bone marrow stem cell donor search and testing for compatible unrelated donors up to $15,000 per procedure at a National Preferred Transplant Facility when you are the intended recipient.

Transportation, food and lodging - the following benefits are provided on a reimbursement basis, if you live over 60 miles from the transplant center and the services are pre-authorized by us:

• Transportation limited to you and one escort to a National Preferred Transplant Network or other Company Approved Transplant Facility.
• A $125 per day allowance for housing and food.  This allowance excludes liquor and tobacco.

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

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $100 copayment per visit; Inpatient hospital - $100 copayment per day, up to $500 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

FHP Health Center: Primary Care - $5 copayment per visit; Specialist Care - $40 copayment per visit

In-network:  Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit; Outpatient facility - $150 copayment per visit; Inpatient hospital - $150 copayment per day, up to $750 maximum per admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

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

Professional anesthesia services provided in:

• Inpatient hospital
• Outpatient hospital
• Skilled nursing facility
• Ambulatory surgical center
• Physician's office

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Coverage includes room and board, such as

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

In-network: $100 copayment per day up to $500 maximum per inpatient admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: $150 copayment per day up to $750 maximum per inpatient admission. Copayment is waived at in-network facility in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests, x-rays and pathology tests
• Administration of blood and blood products
• Dressings, splints, casts and sterile tray services
• Medical supplies and equipment including oxygen
• Anesthetics, including nurse anesthetist services
• Rehabilitative therapies - See Section 5(a) for benefit limitations

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Any inpatient hospitalization for dental procedure
• Blood and blood products, whether synthetic or natural
• Custodial care
• Internal prosthetics except for those covered under Section 5(a) - Prosthetic and Orthopedic Devices.
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home
• Non-covered facilities, such as nursing homes, schools
• Personal comfort items, such as telephone, television, barber services, guest meals and beds
• Private nursing care
• Take-home items

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Administration of blood, blood plasma, and other biologicals
• 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:  $100 copayment per visit. Copayments waived when using in-network providers in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: $150 copayment per visit. Copayments waived when using in-network providers in the Philippines.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Blood and blood products, whether synthetic or natural

The Plan provides a comprehensive range of benefits when full-time skilled nursing care and confinement in a skilled nursing facility  is medically appropriate as determined by a Plan doctor and approved by the Plan.

Benefit Limits:

• Standard Option – up to 60 days confinement per calendar year
• High Option – up to 100 days confinement per calendar year

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: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered: 

• Custodial care
• Skilled nursing facility services in the Philippines

Supportive and palliative care for a terminally ill member is covered in the home or hospice facility when approved by TakeCare's Medical Referral Services department.

To be covered, services must be provided under the direction of a physician who certifies the patient is in the terminal stages of illness with a life expectancy of approximately six months or less.

Covered services include:

• Inpatient and outpatient care
• Family counseling

Note:  This benefit is limited to a maximum of up to 180 days per lifetime.

In-network: Nothing

Out-of-network: All charges

In-network: Nothing

Out-of-network: All charges

Not covered:

• Independent nursing, homemaker services
• Hospice-related services in the Philippines

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Transport that the Plan determined are not medically necessary
• Air ambulance services

All charges

All charges

• Urgent care services at the FHP Health Center
  • No appointment necessary
  • Including lab, x-ray, limited pharmacy services
  • Clinic is open from 8:00am – 8:00pm, Monday thru Saturdays. 10:00am – 6:00pm Sundays, except Christmas, New Year's, and one staff development day per year.

$15 copayment per visit

$15 copayment per visit

• Urgent care at a doctor's office other than FHP or at Guam Memorial Hospital (GMH).

In-network: Primary Care - $20 copayment per visit;  Specialist Care - $40 copayment per visit

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Primary Care - $25 copayment per visit;  Specialist Care - $40 copayment per visit

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

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

Note: We waive the ER copay if you are admitted to the hospital and inpatient copay will apply

In-network: $75 copayment per emergency room visit

Out-of-network: $75 copayment per emergency room visit 

In-network: $100 copayment per emergency room visit

Out-of-network: $100 copayment per emergency room visit

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

Note: We waive the ER copay if you are admitted to the hospital and inpatient copay will apply

If you are covered by Medicare on a primary basis, our coverage is secondary and will be dependent on what Medicare considers an eligible expense.

In-network: $100 copayment per visit

Out-of-network: $100 copayment per visit 

In-network: 20% coinsurance 

Out-of-network: 20% coinsurance 

• Elective care or non-emergency care and follow-up care recommended by out-of-network providers that has not received prior authorization by the Plan
• 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 that has not received prior authorization by the Plan

Nothing

Nothing

Not covered:

• Transport that the Plan determined are not medically necessary
• Air ambulance

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, in person or via phone, audio and video services using a computer, tablet or smartphone)
• Diagnosis and treatment of substance use disorders, including detoxification, treatment and counseling
• Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
• Electroconvulsive therapy

In-network: Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit ; Outpatient facility - $100 copayment per visit

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit ; Outpatient facility - $150 copayment per visit

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Applied Behavior Analysis (ABA) for the treatment of Autism Spectrum Disorder (ASD) is covered as any other condition, subject to prior authorization and benefit limitations.

ASD is a condition that begins early in life and typically affect areas of a person’s daily functioning. ASD is a group of developmental disabilities defined by uncharacteristic social interactions and communication (both verbal and nonverbal).

The following benefit limitations apply:

• Limited to children up to age 21
• Prior Authorization and treatment plan required
• An Autism Spectrum Disorder diagnosis meeting minimum criteria such as, but not limited to, impairment in social interaction, lack of social reciprocity, delay in the development of spoken language and inflexible adherence to specific non-functional routines
• Services must be performed by Qualified Autism Service Provider, Qualified Autism Service Professional, or Qualified Autism Service Paraprofessional
• Travel and/or lodging expenses are not covered

In-network: Specialist Care - $40 copayment per visit; Outpatient Facility - $100 copayment per visit; Inpatient hospital - $100 copayment per day, up to $500 maximum per admission. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Maximum Annual Benefit: $50,000 ages 9 and below, $25,000 ages 10 to 21

In-network: Specialist Care - $40 copayment per visit; Outpatient Facility - $150 copayment per visit; Inpatient hospital - $150 copayment per day, up to $750 maximum per admission. (Copayment is waived at in-network providers in the Philippines).

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Maximum Annual Benefit: $50,000 ages 9 and below, $25,000 ages 10 to 21

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

In-network: Primary Care - $20 copayment per visit; Specialist Care - $40 copayment per visit ; Outpatient facility - $100 copayment per visit

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Primary Care - $25 copayment per visit; Specialist Care - $40 copayment per visit ; Outpatient facility - $150 copayment per visit

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

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
• Preauthorization required

In-network: $100 copayment per day up to $500 maximum per inpatient admission

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: $150 copayment per day up to $750 maximum per inpatient admission

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

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
• Preauthorization required

In-network: $100 copayment

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: $150 copayment

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Evaluation or therapy on court order or as a condition of parole or probation, or otherwise required by the criminal justice system, unless determined by a Plan physician to be medically necessary

Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.

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

• Drugs and medicines that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered.
• Diabetic supplies limited to disposable needles and syringes for the administration of covered medications.
• Weight loss medication, subject to prior authorization and benefit coverage criteria such as but not limited to Body Mass Index (“BMI”) and/or co-morbidities.
• Drugs to treat gender dysphoria

Note: Insulin and other glucose-lowering agents for diabetes are covered as Preventive Medications (see below). 

Note: If there is no generic equivalent available, you will still have to pay the non-formulary copay if your physician did not specify "Dispense as Written" on the prescription.

In-network:
Retail Pharmacy Copay - (30-day supply)

Generic formulary: $10 copay 

Brand formulary: $25 copay

Non-formulary: $70 copay

Preferred Specialty drugs: $100 copay

Non-Preferred Specialty drugs: $200 copay

Mail Order Copay - (90-day supply)

Generic formulary: $0 copay

Brand formulary: $50 copay

Non-formulary: $100 copay

Specialty: Not covered

Out-of-network:
No coverage except for out-of-area emergencies or approved referrals

In-network:
Retail Pharmacy Copay - (30-day supply)

Generic formulary: $15 copay 

Brand formulary: $40 copay

Non-formulary: $100 copay

Preferred Specialty drugs: $100 copay

Non-Preferred Specialty drugs: $250 copay

Mail Order Copay - (90-day supply)

Generic formulary: $0 copay

Brand formulary: $80 copay

Non-formulary: $160 copay

Specialty: Not Covered

Out-of-network:
No coverage except for out-of-area emergencies or approved referrals 

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

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

• If the member chooses to use a branded product when a generic is available, the member will pay the difference between the brand and generic cost rather than paying "Nothing". 
  
  However, if a branded product is considered medically necessary by the prescribing physician, it will be covered the same as a generic with no cost sharing for the member.
• Reimbursement for over-the-counter contraceptives can be submitted by providing a copy of the payment receipt, which includes a description of the product purchased, to TakeCare Customer Service at customerservice@takecareasia.com 

• Growth hormone

• Generic Opioid Reversal (Rescue) Agents

Note: Coverage limited to generic naloxone-based injectables. Other opioid reversal (rescue) agents covered as any other covered medication.

In-network: Retail Pharmacy Copay - Generic naloxone-based injectables: $0 copay

Mail Order Copay: Generic naloxone-based injectables: $0 copay

Out-of-network: All charges

In-network: Retail Pharmacy Copay - Generic naloxone-based injectables: $0 copay

Mail Order Copay: Generic naloxone-based injectables: $0 copay

Out-of-network: All charges

• Drugs for sexual dysfunction are covered when Plan criteria is met. For information about these criteria and dose limits, please have the prescribing physician call Elixir, formerly Envision Pharmaceuticals, at 1-800-361-4542.
• Oral fertility drugs

Medications to promote better health as recommended by ACA.

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

• Aspirin (81 mg) for adults, ages 50-59, who have a 10% or greater 10-year cardiovascular risk, are not an increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years
• Aspirin (81 mg) for women of childbearing age, after 12 weeks gestation, who are at high risk for preeclampsia 
• Folic acid daily supplements (0.4 to 0.8 mg) for women ages 14-45 
• Liquid iron supplements for children age 6 months -1 year
• Vitamin D supplements (prescription strength) (400 & 1000 units) for members 65 or older
• Fluoride tablets, solution ( not toothpaste, rinses) for children age 0-5
• Formulary drugs and devices for the management of conditions as listed below:
  • Angiotensin Converting Enzyme (ACE) inhibitors for congestive heart failure, diabetes, and/or coronary artery disease
  • Anti-resorptive therapy for osteoporosis and/or osteopenia
  • Beta-blockers for congestive heart failure and/or coronary artery disease
  • Blood pressure monitor for hypertension
  • Inhaled corticosteroids and peak flow meters for asthma
  • Insulin and other glucose-lowering agents for diabetes
  • Opioid dependence treatments for opioid addiction
  • Selective Serotonin Reuptake Inhibitors (SSRIs) for depression
  • Statins for heart disease and/or diabetes

Note: Rather than paying "nothing" when using an In-network provider, if the member chooses to use a branded product when a generic is available, they will pay the difference between the brand and generic cost.

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

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

In-network:  Nothing

Out-of-network:
No coverage except for out-of-area emergencies or approved referrals

In-network:  Nothing

Out-of-network:
No coverage except for out-of-area emergencies or approved referrals

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies 
• Drugs or substances not approved by the Food and Drug Administration (FDA)
• Newly approved FDA drugs and medication within one year from the date of FDA approval. Coverage after the one year period is subject to the review, determination and approval of TakeCare’s pharmacy committee.
• Hospital take-home drugs
• Medical supplies (such as dressing, and antiseptics) 
• Non-prescription medications unless specifically indicated elsewhere
• Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them 
• Replacement of lost, stolen or destroyed medication

Note: Over-the-counter and prescription drugs approved by the FDA to treat tobacco dependence are covered under the Nicotine Cessation programs benefit. See page 49.

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

OFFICE VISIT
Oral examination and treatment plan; vitality test; and oral cancer exam. X-rays, including bitewings (once a year) and panoramic (once every three years).

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

RESTORATIVE DENTISTRY
Amalgam - one, two or three surfaces.
Composite - one or two surfaces, anterior only. Posterior composites are not covered; however, an allowance for a comparable silver amalgam restoration will be made. The difference in fees is the member's responsibility.

In-network: 20% coinsurance of covered charges

Out-of-network: 50% coinsurance of our allowance plus any difference between our allowance and billed charges.

All charges

In-network: 20% coinsurance of covered charges

Out-of-network: 50% coinsurance of our allowance plus any difference between our allowance and billed charges.

All charges

PROSTHODONTICS
Full and partial dentures; crowns and bridges; repair; relining and/or reconstruction of dentures.

In-network: 75% coinsurance of covered charges

Out-of-network: 95% coinsurance of our allowance plus any difference between our allowance and billed charges.

All charges

$1,500 per member per benefit year.

$1,500 per member per benefit year.

• Oral Surgery
• Prescription Drugs
• Orthodontics

All charges

All charges

Under the Flexible Benefits Option, we determine the most effective way to provide services.

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

TakeCare offers a Medical Travel Benefit to its FEHB members, making it easier to travel to the Joint Commission-accredited St. Luke’s Hospitals, The Medical City, or other in-network providers in the Philippines when they receive a pre-authorized, elective inpatient or outpatient procedure, excluding emergencies, screenings, executive checkups, primary care, dental, home health, hospice, mental health & substance misuse disorder treatment or maternity-related services.

The travel benefit provides up to $500 toward the cost of round-trip airfare between Guam and Manila, ground transportation between the airport and the hospital, and lodging in Manila. There is no limit to the number of times this benefit can be used during the year once all medical and pre-authorization requirements are met. 

Members can choose one of two options for airfare, transportation and lodging expenses:

• TakeCare will arrange and pay in advance up to $500 for the member’s airfare, transportation, and lodging,
  or
• The member can elect to receive a $500 travel allowance for expenses. The member will be responsible for their own travel arrangements and will be reimbursed by TakeCare, up to the $500 allowance.  Please note that documentation will be required as part of the reimbursement process. Frequent flyer mile points are not reimbursable.

For either option, the member is responsible for any airfare, transportation, and lodging expenses in excess of $500 and any penalties/fees associated with member-initiated travel changes or cancellations.

If the patient is an under age 18 dependent or a disabled individual, TakeCare will pay or reimburse up to $500 for the airline ticket for an adult escort, up to a maximum of $1,000 for two escorts when there are two or more patients on a single approved referral trip.

Approved escorts are limited to legal parents, legal guardians, or the individual caregiver responsible for the disabled member’s care. TakeCare will not extend the Medical Travel Benefit coverage to escorts not enrolled under the same TakeCare plan as the minor or disabled adult patient(s).

For the purposes of this benefit, a disabled individual is defined as a person who is dependent on a caregiver for all activities of daily living (eating, bathing, etc) as certified in writing by their attending physician.

Non-compliance with required treatment guidelines as defined by TakeCare’s provider and Medical Management will result in non-eligibility under the travel benefit.

Notes:

• Medical Travel Benefit claim payments, related to a pacemaker and related services, will accumulate towards the Pacemaker Annual Limit of $50K [See Sec 5 (a) Orthopedic and Prosthetic Devices]. 
• Medical Travel Benefit claim payments, related to Iatrogenic fertility preservation procedures, will accumulate towards the Iatrogenic fertility preservation procedures Annual Limit of $10K [See Sec 5 (a) Infertility Services].
• Medical Travel Benefit claim payments, related to gender affirming surgery, will accumulate towards the gender affirming surgery Annual Limit of $50K [See Sec 5 (b) Gender affirming surgery]. 

FEHB Members Covered by Medicare or Another Insurance Carrier
TakeCare-covered FEHB members with primary coverage through Medicare or another insurance carrier are not eligible for the Medical Travel Benefit.

To learn more about this benefit, contact TakeCare Customer Service at 671-647-3526.

All health education classes are FREE to TakeCare members unless otherwise specified. A referral is required from your primary care physician. No referral is required for TakeCare's Group Fitness Program.

For more information about these classes, call the TakeCare Wellness Center at 671-300-7161 or 671-300-7224 or email wellness@takecareasia.com.

Cardiac Risk Management Program is designed primarily to target members with high blood pressure and high cholesterol levels. It aims to prevent the onset and progression of heart and vascular disease through patient education. The purpose of the CRM Program is to reduce cardiac risks and complications such as stroke and heart attack. The program emphasizes adopting healthy lifestyle behaviors and promoting compliance with disease management treatment and medication adherence. The program includes weight, BMI, Blood pressure monitoring, lab tests and a one 2-hr workshop offered monthly. A 6-month telephonic follow-up with the Nurse Case Managers is part of the process for monitoring improvement and continuous support for the participants.

The program is facilitated by a fulltime nurse case manager and health educators who will assist patients with history of non-compliance in medication, exercise regime, diet and doctor’s follow up appointment. Support staff includes a wellness manager, a fitness expert and a nutritionist. Social workers and case managers will also help address the socioeconomic issues affecting patient’s healthcare. 

Diabetes Management Program is intended for members who are newly diagnosed with diabetes or members with diabetes who have not had a diabetic teaching in the past. It teaches members about the disease process, how to achieve or maintain a healthy blood sugar range and strategies on how to prevent complications. The program is designed to assist in making participants self-manage their condition and encourage them to make changes that will improve their over-all health and well-being.

The program provides one 2-hr class session that includes vitals screening on Weight, BMI, blood glucose, blood pressure and foot exam. Initial lab test for lipid profile, HbA1c and comprehensive metabolic profile, and a follow-up lab test after 6 months of participating the program is included as part of the assessment and management of the disease. The emphasis of the program is medication compliance, glucose monitoring, proper diet, regular physical activity and timely medical evaluation. Class sessions are offered monthly free to all TakeCare members.

Diabetes Prevention Program (DPP) is fully recognized and complies with the Centers for Disease Control and Prevention (CDC) nationally recognized structured in-person lifestyle change program—developed specifically to prevent type 2 diabetes. The TakeCare program has the unique distinction of being the only CDC-recognized DPP in the region. Lifestyle change programs are proven to work based on research led by the National Institutes of Health. It is designed for people who have pre-diabetes or are at risk for type 2 diabetes.

TakeCare’s trained and certified lifestyle coaches lead the program to help members with pre-diabetes change certain aspects of their lifestyle such as adopting a healthier eating habits, reducing stress, and getting more physical active. The DPP Lifestyle Change program is not a fad diet or a simple exercise class. It’s a year-long program focused on long-term changes and lasting results. It provides a long-term commitment to good health by learning new habits, gaining new skills, building confidence to make the change and support from other participants who share similar goals and struggles.

TakeCare’s DPP Lifestyle Change program is provided each year. Program enrollment begins the last quarter of the previous year to start the program the following year. Interested participants must complete a pre-diabetes testing and meet the pre-diabetes criteria before program enrollment. This is a year-long program with a 26-required sessions to be completed throughout the program year.

Wellness Workshop addresses prevention and management strategies for chronic diseases such as diabetes, high blood pressure, high cholesterol levels and obesity. The program includes an eight session class intended to improve the individuals’ health though plant-based nutrition. Members gain knowledge and understanding of their disease and learn to develop skills in managing their condition.   The program’s emphasis is on improving health with vital signs monitoring for blood pressure, random glucose, and weight and BMI measures as conducted during each class session. Initial comprehensive lab test is provided before the start of the program and a final lab test to measure improvement is also provided before the end of the program.

Nutrition Coaching is available through TakeCare’s trained nutritionists and health educators who work closely with our members to provide one-on-one, personalized coaching on the health and nutrition. Members are coached on various nutrition and healthy lifestyle related issues such as weight management, diabetes meal planning and other disease preventive healthful eating practices.

TakeCare's Group Fitness Program is a well-developed fitness program available to all TakeCare members. The program consists of various fitness activities in both indoor and outdoor settings that includes low to high impact, aerobic and muscle building exercises that are designed to meet individuals’ fitness level while keeping them engaged in their workout and improve their fitness abilities. Through TakeCare’s partnership with different fitness instructors, gym partners and other health organizations, members are able to choose from a variety of exercise activities that will appeal more to their needs, interests and lifestyle. View the current monthly calendar at www.takecareasia.com

Well Mommy-Well Baby Program is designed to provide educational support to pregnant women and their families, assist pregnant mothers to have a normal and healthy pregnancy. A Registered nurse will provide telephonic consult to identify and assess pregnancy risks and facilitate referrals to specialty case management services. In partnership with RGA (Reinsurance Group of America), The Well Mommy- Well Baby program provides access to trained perinatal case managers who can provide personalized (one-on-one) counseling and coaching to pregnant mothers.  A comprehensive assessment is done and for any identified risks, members are channeled to the right specialty for early intervention. Members are provided free educational materials and handouts as well as free access to Lamaze classes, Prenatal Yoga and other Prenatal Nutrition and Education classes. The program applies to eligible TakeCare members in their 2^nd trimester. Patients under network providers must send referral for enrollment to the program by e-mail at Wellness@takecareasia.com or fax at 647-3541 ATTN: Wellness. Enrollment to the program is free and self-referral from eligible members are also accepted.

Children's Health Improvement Program (CHIP) is a family-oriented health education program geared to those who are over the 85^th percentile with or without health risks aging 7 to 14 years old. Although this program is intended for overweight and obese children, we welcome all TakeCare Kids within the age range along with their parents/guardians to participate as preventative measures for childhood obesity.

The goal of the program is to provide a family-oriented nutrition education and physical fitness activities for children and young adolescents. The program encourages the participants to make healthy food choices and lifestyle changes; each class session includes 1-hour fitness session and 1-hour health education session that assumes the National Institutes of Health (NIH), Ways to Enhance Children’s Activity and Nutrition (WE CAN!) curriculum. 

Nicotine Cessation Program includes 4 one-hour weekly sessions designed to educate, empower, and assist individuals in quitting tobacco use or other nicotine delivery devices in conjunction with American Cancer Society’s Freshstart Program

The session topics touches on understanding the basic concepts of addiction, effects of tobacco and nicotine use, the benefits and methods of quitting and managing the first few days of cessation; it includes instructions on medications, support systems, and telephonic follow-up. Following the format of the Freshstart Program, participants are encouraged to identify a quit date followed by individual and group counseling sessions. Participants who failed to quit on the identified quit dates are encouraged to set another quit date and continuous telephonic counseling is done to ensure adequate follow-up. Prescription medication and over the counter nicotine patches are available free of charge for members needing assistance to wean off nicotine addiction.

Balanced Lifestyle Workshops focus on overall good health by combining prevention practices with the four key elements of wellness:  Be Active, Eat Right, Relax & Unwind, and staying Socially Connected. The program aims to provide members with an introduction to healthy living with the application of the four key elements of wellness. It encourages individual responsibility towards their health by assessing their readiness to change and adopt to a healthy lifestyle. Participants will learn the basics of creating S.M.A.R.T objectives to meet their personal health goals.

Workshop are scheduled throughout the year and can include cooking demo, meditation workshops, special fitness activities and socialization. Members are free participate and sign-up once schedule has been released.

Teen Talk Program provides health education for adolescence ages twelve (12) to seventeen (17). It's designed to build a foundation for healthy lifestyle behaviors that fosters self and social development. According to the Youth Risk Behavior Surveillance (2013), adolescences [ages 12 to 17] are vulnerable to engaging in health-risk behaviors. These health-risk behaviors can contribute to several health and social consequences such as 1) Behaviors leading to unintentional injuries and violence; 2) Substance abuse (nicotine, alcohol and drugs); 3) Sexual behaviors that contribute to unintended pregnancy and transmission of STIs and HIV; 4) Unhealthy dietary behaviors; and 5) Physical inactivity (CDC, 2013).

Group educational sessions include tools, resources and discussions relating to but not limited to Substance Abuse (nicotine, drug and alcohol use), Sexual Risk Behaviors and Unplanned Teenage Pregnancy, Violence Issues, Suicide Prevention, Nutrition and Physical Activity and various activities.

Members are encouraged to avail of the following services and screenings, most of which are covered at 100%:

• Flu Vaccination for Adults, ages 18-64.
• Biometric screening through the member’s TakeCare primary care provider or TakeCare Wellness health fairs.
• Pre natal visit to a TakeCare participating obstetrician gynecologist within the first trimester.
• Six or more Well-Child visits during the first 15 months of life.
• Compliance with insulin medication for at least 75% of their treatment period for adult members, ages 18-75, diagnosed with Type I or II Diabetes.
• Compliance with asthma controller medication for at least 75% of their treatment period for adult members, ages 19-50, with asthma.
• Annual Physical Exam through the member’s TakeCare participating primary care provider
• Annual Physical Exam and colorectal cancer screening for member ages 50 and above through TakeCare’s participating primary care provider with any of the following services: Colonoscopy; Sigmoidoscopy; and fecal occult blood test once per benefit year as part of the member’s annual physical examination
• Annual Physical Exam and breast cancer and screening mammogram for women between 40 to 69 through TakeCare’s participating primary care provider once per benefit year
• Annual Physical Exam and cervical cancer screening for ages 21 to 64 with pap smear through TakeCare’s participating primary care provider once per benefit year.
• Annual Dental Exam through TakeCare’s participating providers
• Annual Vision Exam through TakeCare’s participating providers

This 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 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 met the plan deductible, we pay benefits under traditional medical coverage described in this section.  The Plan typically pays 80% of covered charges for in-network care and 70% of our allowance 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 misuse treatment benefits
• Prescription drug benefits
• Dental benefits

Health Savings Accounts (HSA) or Health Reimbursement Arrangements (HRA) provide a financial means to save for current and future medical expenses while helping you pay out-of-pocket expenses (see the next Section for more details).

By law, HSAs are available to members who are not enrolled in Medicare, cannot be claimed as a dependent on someone else’s tax return, have not received VA (except for veterans with a service connected disability) and/or Indian Health Services (IHS) benefits within the last three months, or do not have other health insurance coverage other than another High Deductible Health Plan.  

In 2023, for each month you are eligible for an HSA premium pass through, we will contribute to your HSA $28.83 for a Self Only enrollment or $69.59 per month for a Self Plus One enrollment or $77.29 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 $3,850 for an individual and $7,750 for family coverage. See maximum contribution information on page 88.  You can use funds in your HSA to help pay your health plan deductible or other eligible medical expenses. 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:

• A choice of having your HSA administered by ASC Trust Fund or Bank of Guam or another qualified financial institution
• 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
• Your HSA is portable - it's 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 healthcare flexible spending account (see Section 11 - Other federal programs), 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 an HCFSA, we will establish an HRA for you.

If you are not eligible for an HSA (e.g., 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 $346.00 per year for a Self Only enrollment or $835.12 per year for a Self Plus One enrollment or $927.49 per year for a 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 ASC Trust Fund
• 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 HRA credit can be used to pay for qualified medical expenses for you and any individuals covered by this HDHP
• Unused HRA 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 Health Care Flexible Spending Account (HCFSA). However, you must meet FSAFEDS eligibility requirements.

Your in-network out-of-pocket maximum limit of $3,000 for Self Only enrollment, $6,000 for Self Plus One enrollment, or Self and Family enrollment. There is no out-of-pocket limit when using an out-of-network provider under this option. Separately, your in-network prescription drug out-of-pocket maximum limit is $3,000 for Self Only enrollment, $6,000 for Self Plus One enrollment, or $6,000 for Self and Family enrollment. An individual under Self Plus One or Self and Family enrollment will never have to satisfy more than what is required for the out-of-pocket maximum limit under a Self Only enrollment. 

Certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses even if you reach your out-of-pocket maximum (e.g., expenses in excess of the Plan’s allowable amount or benefit maximum). See page 25.

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)

You are responsible for establishing an HSA for yourself with ASC Trust, Bank of Guam, or another qualified financial institution as this HDHP’s fiduciary (an administrator, trustee or custodian as defined by Federal tax code and approved by IRS).

Upon establishing an HSA for yourself, you will need to inform us about your account information so we can coordinate the premium pass through deposits to your account. You can notify us by completing and submitting an HSA Pass Through form.

ASC Trust is the HRA fiduciary for this Plan.

The HSA set-up fee is paid by us.

$12.50 per quarter administrative fee charged by ASC Trust

$2.00 monthly administrative fee charged by Bank of Guam

Fees are subject to change and you may incur additional fees. Contact the financial institution for details.

$12.50 per quarter administrative fee charged by ASC Trust

Fees are subject to change and you may incur additional fees. Contact the financial institution for details.

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 care 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 Services (IHS) benefits in the last three months
• Complete and return all administrative 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 during the calendar year.

If you are eligible for HSA contributions, a portion of your monthly health plan premium is deposited to your HSA each month. This is called a Premium Pass Through. 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 1^st of the month, the earliest your HSA will be established is the 1^st 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 Express, MyPay, etc.).

Eligibility for the annual credit will be determined on the first day of the month and will be prorated for 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 $28.83 will be made by the HDHP directly into your HSA each month.

For 2023, your HRA annual credit is $346.00 (the amount will be prorated based on the length of enrollment during the calendar year).

For 2023, a monthly premium pass through of $69.59 will be made by the HDHP directly into your HSA each month.

For 2023, your HRA annual credit is $835.12 (the amount will be prorated based on the length of enrollment during the calendar year).

For 2023, a monthly premium pass through of $77.29 will be made by the HDHP directly into your HSA each month.

For 2023, your HRA annual credit is $927.49 (the amount will be prorated based on the length of enrollment during the calendar year).

For 2023, 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 an individual and $7,750 for a 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 ineligible to contribute 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 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 contributions are discussed on page 91.

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

You may make an annual maximum contribution of $3,504.00

You cannot contribute to the HRA

You may make an annual maximum contribution of $6,864.88

You cannot contribute to the HRA.

You may make an annual maximum contribution of $6,822.51

You cannot contribute to the HRA.

You can access funds in your HSA by the following methods:

• Visa® debit card (ASC only)
• ATM card (ASC only)
• Checks
• Direct cash withdraws 

For qualified medical expenses under your HDHP, you will be automatically reimbursed when claims are submitted through the HDHP. For expenses not covered by the HDHP (e.g., dental orthodontia), a reimbursement form will be sent to you upon your request.

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

See IRS Publication 502 for a list of eligible expenses.

You can pay eligible out-of-pocket 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 expenses. Physician prescribed over-the-counter drugs and Medicare premiums are also reimbursable. Most other types of medical insurance premiums are not reimbursable.

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.

When you turn age 65, distributions can be used for any reason without being subject to the 20% penalty, however they will be subject to ordinary income tax.

Not applicable – distributions will not be made for anything other than non-reimbursed qualified medical expenses.

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).
• We receive a completed Premium pass-through Form from you.
• We receive a record of your enrollment, initially establish your HSA account with the fiduciary you've chosen, and contribute the minimum amount required to establish an HSA.
• The fiduciary sends you HSA paperwork for you to complete and the fiduciary receives the completed paperwork back from you.

After TakeCare receives the enrollment and contributions from OPM and your HSA account  has been created and funded, you can withdraw funds up to the amount contributed for any eligible expenses incurred on or after the date the HSA was initially established.

Funds are not available until:

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

The entire amount of your HRA will be available to you upon your enrollment in the HDHP.

FEHB enrollee

TakeCare Insurance Company

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

If you do not enroll in another HDHP, you can no longer contribute to your HSA. See page 87 for HSA eligibility.

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

If you terminate employment or change health plans, only eligible expenses incurred while covered under the HDHP will be eligible for reimbursement subject to timely filing requirements. Unused funds are forfeited.

Yes, accumulates without a maximum cap.

Yes, accumulates without a maximum cap.

All contributions are aggregated and cannot exceed the maximum contribution amount set by the IRS. 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 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 date 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 per year. 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.

If you have not named a beneficiary and you are married, your HSA becomes your spouse's, otherwise, it becomes part of your taxable estate.

You can 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, 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 1-800-829-3676, or visit the IRS Website at www.irs.gov and click on "Forms and Publications."  Note: Effective January 1, 2020 the CARES Act added to the list of IRS-allowable expenses including menstrual care products, over the counter medications without a physician's prescription.

You may withdraw money from your HSA for items other than qualified expenses, but the withdrawal amount will be subject to income tax and, if you are under 65 years old, you will pay an additional 20% penalty tax on the amount withdrawn.

You will receive a periodic statement that shows the “premium pass through”, withdrawals, and interest earned on your account. In addition, you will receive an Explanation of Payment statement when you withdraw money from your HSA.

You can request reimbursement in any amount.  

If you don’t qualify for an HSA when you enroll in this HDHP, or later become ineligible for an HSA, we will establish an HRA for you. If you are enrolled in Medicare, you are ineligible for an HSA and we will establish an HRA for you.

You must tell us if you become ineligible to contribute to an HSA.

Please review the chart starting on page 87 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

• HRAs can only pay for qualified medical expenses, such as deductibles, copayments, and coinsurance expenses, for individuals covered by the HDHP. 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.

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. This includes follow-up colonoscopies after a positive non-invasive stool-based screening test or direct visualization test. 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, breast cancer screening, 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 - covered

Not subject to deductible

In-network – Nothing 

Out-of-network – 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule found at https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html.

Not subject to deductible

In-network – Nothing 

Out-of-network – 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

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

All charges.

• 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/hcp/imz/child-adolescent.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

Not subject to deductible

In-network – Nothing

Out-of-network –  30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

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

All charges.

The plan deductible applies to almost all benefits in this Section.  In the You pay column, we say “Not subject to deductible” when it does not apply.  When you receive covered services from in-network or out-of-network providers, you are responsible for paying the eligible charges until you meet the deductible. The Self and Family deductible can be satisfied when at least two (2) covered family members have met their individual deductible in a calendar year.

After you meet the deductible, we pay our portion of eligible charges (less your coinsurance or copayment) until you meet the annual catastrophic out-of-pocket maximum. Once you've met the out-of-pocket maximum, we pay eligible charges at 100% for the balance of the year for in-network services.

Please refer to Section 4 for your out-of-pocket maximum and services/expenses that do not count towards your out-of-pocket maximum.

Plan deductible: You are responsible for 100% of eligible charges until you meet the combined in-network and out-of-network plan deductible of $3,000 for Self Only or $6,000 for Self Plus One or $6,000 for Self and Family enrollment. You may choose to pay the deductible from your HSA or HRA, or you can pay it out-of-pocket.

After you meet your plan deductible, you pay the indicated coinsurance or copayments for covered in-network services until you have met your annual catastrophic out-of-pocket maximum.  

For out-of-network services, in addition to your indicated coinsurance or copayments, you are always responsible for the difference between our allowance and billed charges, even after you have met your annual catastrophic out-of-pocket maximum.

You may choose to pay the coinsurance and copayments from your HSA or HRA, or you can pay for them out-of-pocket.

Professional services of physicians

• In physician’s office
• Office medical consultations
• Second surgical opinion
• During a hospital stay
• In a skilled nursing facility

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered

• Off-island care for services received without prior authorization from TakeCare Medical Management department, except in the case of emergency.

Consultations via phone, audio/video services using a computer, tablet, or smartphone with in-network primary care or specialty providers, including behavioral health, on or off island. 

For specialty consultations, referral by primary care provider is required and coverage is limited to certain specialties.

Contact your provider regarding the availability of telehealth services and TakeCare for covered specialties.

FHP Health Center: 20% coinsurance

In-network: 20% coinsurance

Out-of-network: All charges

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine Pap tests
• Pathology
• Electrocardiogram and EEG

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• X-rays
• Non-routine mammograms
• CT Scans/MRI/Nuclear Medicine/Sleep Studies (prior authorization required)
• Ultrasound

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Complete maternity (obstetrical) care, such as:

• Prenatal care
• Screening for gestational diabetes 
• Delivery
• Postnatal care
• Breastfeeding support, supplies and counseling for each birth

Note: Here are some things to keep in mind:

• You do not need to have your vaginal delivery pre-authorized by TakeCare if in the service area. However, prior authorization is required for vaginal delivery services (i.e., prenatal care, delivery, and postnatal care) outside the service area.
• 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.
• 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   We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment.  Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

In-network: Primary care, Specialist - Nothing; Outpatient Facility, Inpatient Hospital - 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Routine sonograms to determine fetal age, size or sex
• Maternity-related services outside our service area unless pre-authorized by TakeCare's Medical Management Department.

Medical foods to treat physician-diagnosed Inborn Errors of Metabolism (IEM) including Phenylketonuria (PKU) as prescribed by a physician. 

Maximum Annual Benefit: $5,000 per covered individual

In-network: 20% coinsurance 

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered

• Special food items which can be routinely obtained in grocery stores at the same or at a minimally higher cost than similar items (e.g., gluten-free cookies, gluten-free pasta).

All charges

Contraceptive counseling on an annual basis

In-network: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

A range of voluntary family planning services, limited to:

• Voluntary sterilization (See Surgical procedures Section 5 (b)
• Surgically implanted FDA-approved contraceptives
• Injectable FDA-approved contraceptive drugs (such as Depo Provera)
• FDA-approved Intrauterine devices (IUDs)
• FDA-approved Diaphragms

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

Note: If the member chooses to use a branded product when a generic is available, the member will pay the difference between the brand and generic cost rather than paying "Nothing". 

However, if a branded product is considered medically necessary by the prescribing physician, it will be covered the same as a generic with no cost sharing for the member.

In-network:  20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing counseling 

Diagnosis and treatment of infertility such as:

• Artificial insemination: (up to three cycles per pregnancy attempt)
  • intravaginal insemination (IVI)
  • intracervical insemination (ICI)

In-network: Specialty Care - 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Injectable fertility drugs

Note: Oral fertility drugs are covered under Section 5(f) Prescription Drug Benefits.

In-network: $15 copayment in addition to the office visit coinsurance after you've met your deductible.

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Assisted reproductive technology (ART) procedures, such as:
  • in vitro fertilization
  • embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
  • Zygote transfer
• Intrauterine insemination (IUI)
• Services and supplies related to ART procedures
• Cost of donor sperm
• Cost of donor egg

Iatrogenic fertility preservation procedures (retrieval of and freezing of eggs or sperm) are covered for infertility caused by chemotherapy, pelvic radiotherapy, ovary or testicle removal and other gonadotoxic therapies for the treatment of disease as well as infertility associated with medical and surgical gender transition treatment.

Covered services include the following procedures, when provided by or under the care or supervision of a physician:

• Collection of sperm
• Ovarian simulation, retrieval of eggs and fertilization
• Sperm or egg cryo-preservation storage for up to one year

Fertility preservation procedures requires prior authorization. See Section 3, Other services

Iatrogenic fertility preservation, including related Medical Travel Benefit charges, is limited to $10,000 per member per benefit year

In-network: Specialty Care - 20% coinsurance

Out-of-network: Not covered 

Not covered:

• Embryo transfer
• Long-term storage costs (greater than one year)
• Egg harvesting or embryo implantation procedures beyond two attempts
• Elective fertility preservation, such as egg freezing due to natural aging

All charges

• Testing and treatment

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Allergy injections - Allergy serum

In-network: $150 copayment

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Provocative food testing and sublingual allergy desensitization

• Chemotherapy and Radiation therapy
  Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed on page 114.

• Organ/Tissue Transplants
• Respiratory and inhalation therapy
• Cardiac rehabilitation following qualifying event/condition is provided for up to 20 sessions per benefit period
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy
• Growth hormone therapy (GHT)
  Note: Growth hormone is covered under the prescription drug benefit. We only cover GHT when we prior authorize the treatment. We will ask you to submit information that establishes the GHT is medically necessary. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies we determine are medically necessary. See Other services under You need prior Plan approval for certain services on page 19.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Unlimited outpatient services and up to two (2) consecutive months per condition for the services of each of the following:

• qualified physical therapists
• qualified occupational therapists

Note: We only cover therapy when a physician:

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

We will only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury.

These therapies also apply to habilitation services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may also include speech pathology therapy and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Long-term rehabilitative therapy
• Exercise programs, lifestyle modification programs
• Equipment, supplies or customized devices related to rehabilitative therapies, except those provided under Section (a) Durable Medical Equipment
• Services provided by schools or government programs
• Developmental and Neuroeducational testing and treatment beyond initial diagnosis
• Hypnotherapy
• Psychological testing
• Vocational Rehabilitation

Inpatient cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is covered for up to 90 days per benefit period.

Outpatient cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is covered for up to 20 sessions per benefit period.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Unlimited visits for the services of a qualified Speech Therapist

Note: Speech therapy also applies to habilitation services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may also include physical/occupational therapies and other services for people with disabilities in a variety of inpatient and/or outpatient settings. All therapies are subject to medical necessity.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

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

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

In-network: Specialist Care - 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

• Hearing testing and treatment for adults when medically indicated for other than hearing aids 

Note: Hearing exams for children through age 17 covered under HDHP Preventive Care for Children

Note: for adult hearing device coverage information, see HDHP Sec. 5(a) - Orthopedic and prosthetic devices

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Hearing services that are not shown as covered

• Hearing aids, testing and examinations for children

Medical and surgical benefits for the diagnosis and treatment of diseases of the eye

• Annual eye examinations for adults

Note: See HDHP Preventive care for children for coverage of eye exams for children

In-network: 20% coinsurance 

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

In-network: All charges in excess of $100 per benefit year

Out-of-network: All charges

Refraction Exam

Refraction exams will be covered as part of the annual eye exam if member meets any of the following criteria:

• Fails a screening or risk assessment test;
• Reports a visual problem; or
• Cannot complete a screening (e.g. developmental delay)

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Eye exercises and orthoptics (vision therapy)
• Radial keratotomy and other refractive surgery such as LASIK
• Routine vision services outside the service area

Foot care and podiatry services

Note: When you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes, routine foot care may be covered.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Routine foot care including: 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 eyes
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy (up to (2) surgical bras per benefit year)
• Internal prosthetic devices, such as spinal implants, bone segments, artificial disks, artificial plates, stents, leads, intraocular lens implants, cochlear implants, and surgically implanted breast implant following mastectomy. 
• Single and dual pacemakers, biventricular pacemakers, pacemaker monitors, accessories such as pacemaker batteries and leads, including the cost of the devices, their placement, repair or replacement and related Medical Travel Benefit, hospital, and surgical charges will accrue towards the Pacemaker Annual Limit of $50,000 per member.
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants
• External hearing aids for adults (benefit limited to $300 per ear, every two (2) years)
• Orthopedic devices, such as braces

Note: See HDHP Section 5(b) for coverage of the surgery to insert the device. 

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

 Not covered:

• Orthopedic and corrective shoes
• Arch supports, foot orthotics, heel pads and heel cups 
• Artificial joints and limbs
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Lumbosacral supports
• Splints
• Over-the-counter (OTC) items
• Internal prosthetics such as heart valves, automatic implantable cardioverter defibrillator (AICD) and other implantable devices not specified above
• Prosthetic replacements provided less than 3 years after the last one we covered

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

• Manual hospital beds;
• Standard manual wheelchairs;
• Crutches/walk aids
• Oxygen Concentrators
• Portable Oxygen Tanks
• CPAP (Continuous Positive Airway Pressure)
• BPAP (Bi-Level Positive Airways Pressure)

Note: Pre-authorization is required. Contact us at 671-300-5995 or via email at tc.mrs@takecareasia.com as soon as your 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: Nothing

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

We will cover the following devices with a written prescription:

• Blood Glucose Monitors
• Continuous Glucose Monitor (CGM) System, including transmitter and sensors, if patient is actively participating in TakeCare’s Diabetes Management Program and meets criteria for coverage based on HbA1c level

In-network: Nothing. Not subject to deductible.

Out-of-network: All charges

Not covered:

• Motorized wheel chairs
• Motorized beds
• CPAP and BPAP supplies including masks other than those packaged by the manufacturer with a new machine
• Insulin pumps

Home healthcare ordered by a physician, pre-authorized by us, and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide while under an active treatment plan with a home health agency including services such as:  

• Oxygen therapy, intravenous therapy and medications.
• Services ordered by a physician for members who are confined to the home.
• Nursing
• Medical supplies included in the home health plan of care.
• Physical therapy, speech therapy, occupational therapy, and respiratory therapy.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

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.
• Home care services in the Philippines.

Chiropractic services - You may self refer to a in-network chiropractor for up to 20 visits per calendar year. Services are limited to:

• Manipulation of the spine and extremities
• Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application 
• Osteopathic Manipulative Treatment (“OMT”) when provided by a licensed, trained and credentialed practitioner.

In-network: All charges above $25 per visit and all charges after 20th visit

Out-of-network: All charges

• Consults and evaluations
• Ancillary services for chiropractic purposes (e.g., x-rays)

Acupuncture Services - You may self refer to a participating acupuncture practitioner for up to 20 visits per benefit year.

The Plan defines acupuncture as the practice of insertion of needles into specific exterior body locations to relieve pain, to induce surgical anesthesia, or for therapeutic purposes.

These providers are required to submit itemized bills and their Federal Tax I.D. Number (if a United States provider) as outlined in Section 7, Filing a claim for covered services.

In-network: All charges above $25 per visit and all charges after the 20th visit in a benefit year.

Out-of-network: All charges

Massage Therapy - You may self refer to a participating, licensed massage therapist for up to 20 visits per benefit year.

These providers are required to submit itemized bills and their Federal Tax I.D. Number (if a United States provider) as outlined in Section 7, Filing a claim for covered services.

In-network: $10 copayment per visit (up to 20 visits per benefit year).

Out-of-network: All charges

Not covered:

• Chelation therapy except for acute arsenic, gold, mercury or lead poisoning; or use of Desferoxamine in iron poisoning
• Naturopathic services and medicines
• Homeopathic services and medicines
• Rolfing

All charges

Programs are administered through the TakeCare Wellness Team include:

• Cardiac Risk Management Class
• Nicotine Cessation 
• Diabetes Management
• Wellness Workshop
• Group Fitness Program
• Nutrition Coaching
• Children's Health Improvement Program
• Well mommy, Well Baby Program

Note:  For more information on these and other classes, see pages 135-136 or call the TakeCare Wellness team at 671-300-7161 or via email at wellness@takecareasia.com.

All health education classes are FREE to TakeCare members unless otherwise specified. Referral is required from your primary care physician. No referral is required for TakeCare's Group Fitness classes.

Nicotine Cessation programs

• primary care physician referral required
• individual/group/telephone counseling
• over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence
  • Nicotrol Nasal Spray
  • Nicotrol Inhaler
  • Chantix
  • Zyban
  • Bupropion hydrochloride
  • Nicorette Gum
  • Nicorette DS Gum
  • Habitrol Transdermal film
  • Nicoderm CQ Transdermal system
  • Commit Lozenge
  • Nicorette Lozenge
  • Nicotine Film
  • Nicotine Polacrilex, Gum, Chewing; Buccal
  • Thrive (Nicotine Polacrilex) Gum, Chewing; Buccal
  • Nicotine Polacrilex, Trocher/Lozenge
  • Nicotine Patch
  • Varenicline

There is no charge for counseling for up to two quit attempts per year. Plan deductible does not apply.

There is no charge for OTC and prescription drugs approved by the FDA to treat tobacco dependence. Plan deductible does not apply.

A comprehensive range of services, such as:

• Operative procedures
• Anesthesia and related professional services
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Circumcision 
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Surgical treatment of morbid obesity (bariatric surgery). Surgery is limited to Roux-en-Y bypass, laparoscopic gastric band placement, laparoscopic sleeve gastrectomy, and vertical banded gastroplasty. Please note the following conditions must be met:
  
  • Eligible members must be age 18 or over
  • Eligible members must weigh 100 pounds or 100% over their normal weight according to current underwriting standards
  • Eligible members must meet the National Institute of Health guidelines
  • We may require you to participate in a non-surgical multidisciplinary program approved by us for six (6) months prior to your bariatric surgery
  • We will determine the provider for the non-surgical program and surgery based on quality and outcomes.
• Insertion of internal prosthetic devices. See 5(a) Orthopedic and prosthetic devices for device coverage information
• Cardiac surgery for the implantation of stents, leads and pacemaker
• Cardiac surgery for the implantation of valves
• 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. Plan pays for the cost of the insertion only.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot; see Foot Care on page 104.
• Services and supplies provided for circumcisions performed beyond thirty-one (31) days from the date of birth that are not determined to be medically necessary

• 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 (e.g., protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers and toes).
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • surgery to produce a symmetrical appearance of breasts 
  • treatment of any physical complications, such as lymphedema
  • 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.

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

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

Oral surgical procedures, limited to:

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

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Not covered:

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

Gender affirming surgery covered up to an annual maximum benefit of $50,000 per eligible member, including related Medical Travel Benefit charges (see page 134). Covered services are only available from in-network providers outside the service area. Benefit is limited to the following procedures and subject to the requirements listed below:

• For female to male surgery: mastectomy (including nipple reconstruction), hysterectomy, vaginectomy, salpingo-oophorectomy, metoidioplasty, phalloplasty, urethroplasty, scrotoplasty, electrolysis (hair removal at the covered operative site), and placement of testicular and erectile prosthesis
• For male to female surgery: penectomy, orchiectomy, vaginoplasty, clitoroplasty, labiaplasty, and electrolysis (hair removal at the covered operative site)

Prior authorization is required for gender affirming surgery.

Following WPATH Standards of Care Ver. 2 for gender affirming surgeries, TakeCare requires the member to meet all of the following requirements:

1. Must be at least 18 years of age at the time prior authorization is requested
2. Diagnosis of gender dysphoria rendered by a qualified healthcare professional
   • Member has a strong desire to be rid of primary and/or secondary sex characteristics because of a marked incongruence with the member’s identified gender
   • Member’s gender dysphoria is not a symptom of another mental disorder or chromosomal abnormality
   • Gender dysphoria causes clinical distress or impairment in social, occupational, or other important areas of functioning

In-network: Outpatient facility and Inpatient facility - 20% coinsurance. Coinsurance is waived at in-network facilities in the Philippines.

Out-of-network: All charges.

Not covered:

• Reversal of gender reassignment surgery
• Any procedure not listed above

All charges

These solid organ transplants are covered.  These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. Pre-authorization is required. 

Solid organ transplants are limited to:

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

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Pre-authorization is required.

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

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

Blood or marrow stem cell transplants  
The Plan extends coverage for the diagnoses as indicated below. Not subject to medical necessity. Plan's denial is limited to indicators for transplant such as refractory or relapsed disease, cytogenetics, subtype, staging or the diagnosis.

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced neuroblastoma
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Hodgkin's lymphoma - relapsed
  • Infantile malignant osteopetrosis
  • Kostmann’s syndrome
  • Leukocyte adhesion deficiencies
  • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  •  Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s syndrome, Sanfillippo’s syndrome, Maroteaux-Lamy syndrome variants)
  • Myelodysplasia/Myelodysplastic syndromes
  • Non-Hodgkin's lymphoma - relapsed
  • 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)
  • Aggressive non-Hodgkin lymphomas
  • Amyloidosis
  • Breast Cancer
  • Ependymoblastoma
  • Epithelial ovarian cancer
  • Ewing’s sarcoma
  • Hodgkin's lymphoma - relapsed
  • Medulloblastoma
  • Multiple myeloma
  • Neuroblastoma
  • Non-Hodgkin's lymphoma - relapsed
  • Pineoblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

In-network: 20% coinsurance

Out-of-network: 30% coinsurance of our allowance plus any difference between our allowance and billed charges.

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 and prior authorization by the Plan. There is no defined age limits for the use of RIC for an allogeneic stem cell transplant.

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